Prevalence and Correlates of Food and/or Housing Instability among Men and Women Post-9/11 US Veterans.

Food and/or housing instability (FHI) has been minimally examined in post-9/11 US veterans. A randomly selected nationally representative sample of men and women veterans (n = 38,633) from the post-9/11 US veteran population were mailed invitation letters to complete a survey on health and well-being. Principal component analysis and multivariable logistic regression were used to identify FHI's key constructs and correlates for 15,166 men and women respondents (9524 men, 5642 women). One-third of veterans reported FHI; it was significantly more likely among women than men (crude odds ratio = 1.31, 95% CI:1.21-1.41) and most prevalent post-service (64.2%). "Mental Health/Stress/Trauma", "Physical Health", and "Substance Use" were FHI's major constructs. In both sexes, significant adjusted associations (p < 0.01) were found between FHI and homelessness, depression, adverse childhood experiences, low social support, being enlisted, being non-deployed, living with seriously ill/disabled person(s), and living in dangerous neighborhoods. In men only, posttraumatic stress disorder (adjusted odds ratio (AOR) = 1.37, 95% CI:1.14-1.64), cholesterol level (elevated versus normal, AOR = 0.79, 95% CI:0.67-0.92), hypertension (AOR = 1.25, 95% CI:1.07-1.47), and illegal/street drug use (AOR = 1.28, 95% CI:1.10-1.49) were significant (p < 0.01). In women only, morbid obesity (AOR = 1.90, 95%CI:1.05-3.42) and diabetes (AOR = 1.53, 95% CI:1.06-2.20) were significant (p < 0.05). Interventions are needed that jointly target adverse food and housing, especially for post-9/11 veteran women and enlisted personnel.

Examining Excess Mortality Associated With the COVID-19 Pandemic for Renters Threatened With Eviction.

Importance: Residential evictions may have increased excess mortality associated with the COVID-19 pandemic. Objective: To estimate excess mortality associated with the COVID-19 pandemic for renters who received eviction filings (threatened renters). Design, Setting, and Participants: This retrospective cohort study used an excess mortality framework. Mortality based on linked eviction and death records from 2020 through 2021 was compared with projected mortality estimated from similar records from 2010 through 2016. Data from court records between January 1, 2020, and August 31, 2021, were collected via the Eviction Lab's Eviction Tracking System. Similar data from court records between January 1, 2010, and December 31, 2016, also collected by the Eviction Lab, were used to estimate projected mortality during the pandemic. We also constructed 2 comparison groups: all individuals living in the study area and a subsample of those individuals living in high-poverty, high-filing tracts. Exposures: Eviction filing. Main Outcomes and Measures: All-cause mortality in a given month. The difference between observed mortality and projected mortality was used as a measure of excess mortality associated with the pandemic. Results: The cohort of threatened renters during the pandemic period consisted of 282 000 individuals (median age, 36 years [IQR, 28-47]). Eviction filings were 44.7% lower than expected during the study period. The composition of threatened renters by race, ethnicity, sex, and socioeconomic characteristics during the pandemic was comparable with the prepandemic composition. Expected cumulative age-standardized mortality among threatened renters during this 20-month period of the pandemic was 116.5 (95% CI, 104.0-130.3) per 100 000 person-months, and observed mortality was 238.6 (95% CI, 230.8-246.3) per 100 000 person-months or 106% higher than expected. In contrast, expected mortality for the population living in similar neighborhoods was 114.6 (95% CI, 112.1-116.8) per 100 000 person-months, and observed mortality was 142.8 (95% CI, 140.2-145.3) per 100 000 person-months or 25% higher than expected. In the general population across the study area, expected mortality was 83.5 (95% CI, 83.3-83.8) per 100 000 person-months, and observed mortality was 91.6 (95% CI, 91.4-91.8) per 100 000 person-months or 9% higher than expected. The pandemic produced positive excess mortality ratios across all age groups among threatened renters. Conclusions and Relevance: Renters who received eviction filings experienced substantial excess mortality associated with the COVID-19 pandemic.

The association between incarceration and housing insecurity and advanced immune age during late life.

Emerging evidence suggests that psychosocial stress ages the immune system. Accordingly, immune aging may be an important potential mechanism linking psychosocial stress to aging-related decline and disease. Incarceration and housing insecurity represent severe and complex experiences of a multitude of psychosocial stressors, including discrimination, violence, and poverty. In this study, we investigated the association between incarceration and/or housing insecurity and advanced immune age in adults aged 55 and older. Our sample was derived from the Health and Retirement Survey (HRS), with n = 7003 individuals with valid housing insecurity data and n = 7523 with valid incarceration data. From 2016 Venous Blood Study data, we assessed immune aging using a comprehensive set of immune markers including inflammatory markers (IL-6, CRP, s-TNFR1), markers of viral control (CMV IgG antibodies), and ratios of T cell phenotypes (CD8+:CD4+, CD+ Memory: Naïve, CD4+ Memory: Naïve, CD8+ Memory: Naïve ratios). We found that both incarceration and housing insecurity were strongly associated with more advanced immune aging as indicated by increased inflammation, reduced viral control, and reduction in naïve T cells relative to memory T cells. Given that those who experienced incarceration, housing insecurity, and/or are racialized minorities were less likely to be included in this study, our results likely underestimated these associations. Despite these limitations, our study provided strong evidence that experiencing incarceration and/or housing insecurity may accelerate the aging of the immune system.

Examining second-stage shelters: insights into housing instability and tailored support for IPV survivors.

BACKGROUND: Intimate Partner Violence (IPV) exposes women and children to a wide range of challenges across housing, employment, social connections, and child well-being and is a public health issue. IPV survivors are at heightened risk of housing insecurity and homelessness. Emergency shelters have historically offered respite and support, but the emergence of second-stage shelters provides longer-term solutions. Despite their significance, there has been a lack of comprehensive research on second-stage shelters. This study focuses on understanding the needs of IPV survivors accessing second-stage shelters, aiming to illuminate unexplored aspects of support. To examine the current published peer-reviewed literature and gray literature on second-stage shelters, a scoping review was conducted. METHODS: This scoping review used the method suggested by Arksey & O'Malley (2005) and considered all studies that focused on women who had experienced IPV and were accessing transitional housing/second-stage shelters. RESULTS: Sixteen articles, mainly from the USA and published between 1985 and 2022, were included in the analysis. The findings highlighted themes of (1) a safe(r) place, with the subtheme of 'gated' communities, and (2) programming and services, with the subtheme of does one size fit all? and (3) insider support, with subthemes of paid insider support and peer insider support. CONCLUSIONS: Housing instability was evident, and the need for multiple and individualized tailored options of programming and support along with housing security was identified. Second-stage housing policy and practice implications are addressed which illuminate unexplored aspects of support.

Housing insecurity among black women surviving intimate partner violence during the COVID-19 pandemic: an intersectional qualitative approach.

BACKGROUND: Housing instability is highly prevalent among intimate partner violence (IPV) survivors, and the coupling consequences of structural racism, sexism, classism, and the COVID-19 pandemic, may create more barriers to safe and adequate housing, specifically for Black women IPV survivors. In particular, the consequences of the COVID-19 pandemic had the potential to amplify disadvantages for Black women IPV survivors, yet very little research has acknowledged it. Therefore, the current study sought to assess the experiences of housing insecurity among Black women experiencing intimate partner violence (IPV) while navigating racism, sexism, and classism during the COVID-19 pandemic. METHODS: From January to April 2021, we conducted in-depth interviews with 50 Black women experiencing IPV in the United States. Guided by intersectionality, a hybrid thematic and interpretive phenomenological analytic approach was used to identify sociostructural factors shaping housing insecurity. RESULTS: Our findings demonstrate the various ways in which the COVID-19 pandemic shaped Black women IPV survivors' ability to obtain and sustain safe housing. We derived five themes to capture factors contributing to housing experiences: challenges with separate and unequal neighborhoods; pandemic-related economic inequalities; economic abuse limitations; and strategies to maintain housing. CONCLUSIONS: Obtaining and maintaining safe housing during the COVID-19 pandemic was difficult for Black women IPV survivors who were also navigating racism, sexism, and socioeconomic position. Interventions are needed to reduce the impact of these intersecting systems of oppression and power to facilitate the resources necessary for Black women IPV survivors to identify safe housing.

Opportunities for Nurses to Decrease the Stigma Associated with Housing Instability and Homelessness.

The number of people experiencing homelessness (PEH) in the United States has increased in the past 5 years. PEH have a higher disease burden and early mortality compared to people who are housed. Stigma adds to the burden of disease and disease management for PEH. In this article the authors review stigma, define housing and homelessness, describe the health and health care disparities PEH experience, and using the socio-ecological model as a framework, offer opportunities for nurses to intervene in efforts to decrease the stigma that PEH and housing instability encounter to improve health outcomes.

Risk of dementia among veterans experiencing homelessness and housing instability.

BACKGROUND: In the United States, nearly 85,000 Veterans experienced homelessness during 2020, and thousands more are experiencing housing instability, representing a significant proportion of the population.1 Many Veterans experiencing homelessness are aging and have complex co-occurring medical, psychiatric, and substance use disorders. Homelessness and older age put Veterans at greater risk for age-related disorders, including Alzheimer's disease and related dementias (ADRD). METHODS: We examined the rate of ADRD diagnosis for Veterans experiencing homelessness and housing instability compared to a matched cohort of stably housed Veterans over a nine-year period using cox proportional hazard models. RESULTS: In the matched cohort, 95% (n = 88,811) of Veterans were men, and 67% (n = 59,443) were White and were on average 63 years old (SD = 10.8). Veterans with housing instability had a higher hazard of 1.53 (95% confidence interval (CI) 1.50, 1.59) for ADRD compared to Veterans without housing instability. CONCLUSIONS: Veterans experiencing housing instability have a substantially higher risk of receiving an ADRD diagnosis than a matched cohort of stably housed Veterans. Health systems and providers should consider cognitive screening among people experiencing housing insecurity. Existing permanent supportive housing programs should consider approaches to modify wraparound services to support Veterans experiencing ADRD.

Association of Antenatal Housing Instability with Perinatal Care Utilization and Outcomes.

Background: Social determinants of health are important contributors to maternal and child health outcomes. Limited existing research examines the relationship between housing instability during pregnancy and perinatal care utilization. Our objective was to evaluate whether antenatal housing instability is associated with differences in perinatal care utilization and outcomes. Materials and Methods: Participants who were surveyed during their postpartum hospitalization were considered to have experienced housing instability if they answered affirmatively to at least one of six screening items. The primary outcome was adequacy of prenatal care measured by the Adequacy of Prenatal Care Utilization index. Maternal, neonatal, and postpartum outcomes, including utilization and breastfeeding, were also collected as secondary outcomes. Multivariable logistic regression models were adjusted for sociodemographic and clinical covariates. Results: In this cohort (N = 490), 11.2% (N = 55) experienced housing instability during pregnancy. Participants with unstable housing were more likely to have inadequate prenatal care (17.3% vs. 3.9%; odds ratio [OR] 5.11, 95% confidence interval [CI] 2.15-12.14, p < 0.001), but findings were not significant after adjustment (aOR 1.72, 95% CI 0.55-5.41, p = 0.35). Similarly, postpartum visit attendance was lower for individuals with unstable housing (79.6% vs. 91.2%), but there was no difference in the odds of the postpartum visit attendance after adjustment (OR 0.69, 95% CI 0.29-1.66, p = 0.14). Conclusions: There were no statistically significant association with the maternal, neonatal, and other postpartum secondary outcomes. Housing instability appears to be a risk marker that is related to other social determinants of health. Given the range of housing instability experiences, future research must account for specific types and degrees of housing instability and their potential perinatal consequences.

Housing Insecurity and Asthma Outcomes.

Asthma is a chronic respiratory disease with widespread prevalence that affects children, adolescents, and adults. Asthma morbidity and mortality can be exacerbated in the setting of housing insecurity. In this Grand Rounds Review article, we present a case and discuss the implications that housing insecurity has on asthma outcomes in the United States. We then highlight ways in which providers can advocate for patients with asthma and housing insecurity.

Housing Insecurity and Other Syndemic Factors Experienced by Black and Latina Cisgender Women in Austin, Texas: A Qualitative Study.

Austin, Texas emerged as one of the fastest-growing cities in the U.S. over the past decade. Urban transformation has exacerbated inequities and reduced ethnic/racial diversity among communities. This qualitative study focused on housing insecurity and other syndemic factors among Black and Latina cisgender women (BLCW). Data collection from 18 BLCW using in-depth interviews guided by syndemic theory was conducted three times over three months between 2018 and 2019. Four housing insecurity categories emerged: (a) very unstable, (b) unstable, (c) stable substandard, and (d) stable costly. Participants who experienced more stable housing, particularly more stable housing across interviews, reported fewer instances of intimate partner violence (IPV), less substance use, and a reduced risk of acquiring HIV. Results identified the importance of exploring housing insecurity with other syndemic factors among BLCW along with determining structural- and multi-level interventions to improve housing circumstances and other syndemic factors. Future research should explore these factors in other geographic locations, among other intersectional communities, and among larger sample sizes and consider using a mixed methods approach.

Associations Between Different Types of Housing Insecurity and Future Emergency Department Use Among a Cohort of Emergency Department Patients.

Housing insecurity can take multiple forms, such as unaffordability, crowding, forced moves, multiple moves, and homelessness. Existing research has linked homelessness to increased emergency department (ED) use, but gaps remain in understanding the relationship between different types of housing insecurity and ED use. In this study, we examined the association between different types of housing insecurity, including detailed measures of homelessness, and future ED use among a cohort of patients initially seen in an urban safety-net hospital ED in the United States between November 2016 and January 2018. We found that homelessness was associated with a higher mean number of ED visits in the year post-baseline. Other measures of housing insecurity (unaffordability, crowding, forced moves, and multiple moves) were not associated with greater ED use in the year post-baseline in multivariable models. We also found that only specific types of homelessness, primarily unsheltered homelessness, were associated with increased ED use.

Access to COVID-19 testing by individuals with housing insecurity during the early days of the COVID-19 pandemic in the United States: a scoping review.

Introduction: The COVID-19 pandemic focused attention on healthcare disparities and inequities faced by individuals within marginalized and structurally disadvantaged groups in the United States. These individuals bore the heaviest burden across this pandemic as they faced increased risk of infection and difficulty in accessing testing and medical care. Individuals experiencing housing insecurity are a particularly vulnerable population given the additional barriers they face. In this scoping review, we identify some of the barriers this high-risk group experienced during the early days of the pandemic and assess novel solutions to overcome these barriers. Methods: A scoping review was performed following PRISMA-Sc guidelines looking for studies focusing on COVID-19 testing among individuals experiencing housing insecurity. Barriers as well as solutions to barriers were identified as applicable and summarized using qualitative methods, highlighting particular ways that proved effective in facilitating access to testing access and delivery. Results: Ultimately, 42 studies were included in the scoping review, with 143 barriers grouped into four categories: lack of cultural understanding, systemic racism, and stigma; medical care cost, insurance, and logistics; immigration policies, language, and fear of deportation; and other. Out of these 42 studies, 30 of these studies also suggested solutions to address them. Conclusion: A paucity of studies have analyzed COVID-19 testing barriers among those experiencing housing insecurity, and this is even more pronounced in terms of solutions to address those barriers. Expanding resources and supporting investigators within this space is necessary to ensure equitable healthcare delivery.

Housing Instability Associated with Return to Stimulant Use among Previously Abstaining Women.

Stimulant use among unstably housed individuals is associated with increased risks of psychiatric co-morbidity, violence, HIV transmission, and overdose. Due to a lack of highly effective treatments, evidence-based policies targeting the prevention of stimulant use disorder are of critical importance. However, little empirical evidence exists on risks associated with initiating or returning to stimulant use among at-risk populations. In a longitudinal cohort of unstably housed women in San Francisco (2016-2019), self-reported data on stimulant use, housing status, and mental health were collected monthly for up to 6 months, and factors associated with initiating stimulants after a period of non-use were identified through logistic regression. Among 245 participants, 42 (17.1%) started using cocaine and 46 (18.8%) started using methamphetamine. In analyses adjusting for demographics and socio-structural exposures over the preceding month, experiencing street homelessness was associated with initiating cocaine use (AOR: 2.10; 95% CI: 1.04, 4.25) and sheltered homelessness with initiating methamphetamine use (AOR: 2.57; 95% CI: 1.37, 4.79). Other factors-including race, income, unmet subsistence needs, mental health, and treatment adherence-did not reach levels of significance, suggesting the paramount importance of policies directed toward improving access to permanent supportive housing to prevent stimulant use among unstably housed women.

A developmental formative evaluation of a pilot participatory music program for veterans with housing insecurity.

BACKGROUND: Interventions are needed to improve well-being and promote community reintegration among Veterans with housing insecurity. The objective was to conduct a developmental formative evaluation of a participatory music program. METHODS: This single-site, pilot study implemented a participatory music program at a U.S. Department of Veterans Affairs (VA) Homeless Domiciliary that included one-hour sessions (group music instruction and ensemble playing), 3 times per week for 3 months. Intervention development was guided by the Model of Human Occupation (MOHO). Evaluation was guided by the MOHO and the Consolidated Framework for Implementation Evaluation (CFIR). Qualitative data were collected via semi-structured interviews from participants and non-participants, and were analyzed using an interdisciplinary, constant comparison qualitative analysis technique. RESULTS: Sixteen program participants and 8 non-participants were enrolled, age range 26-59 (mean 41; standard deviation, 11) years; 75% were White. The sample for this study (N = 12) included five participants and seven non-participants. Semi-structured interview responses produced three salient themes illuminating Veterans' perspectives: (1) key characteristics of the intervention (the relative advantage of the participatory program over other problem-focused programs; the importance of a supportive, encouraging teaching; the group setting; the role of music); (2) the therapeutic power of the program (based on it being enjoyable; and serving as an escape from preoccupations); and (3) the context and culture (which included Veterans supporting each other and the Domiciliary setting). CONCLUSIONS: Veterans described the benefits of a participatory music intervention compared to problem-based groups, which included enjoyment, skill acquisition facilitating pride, escape, reconnecting with their identity prior to current problems, and experiencing positive aspects of Veteran culture such as mutual support and discipline. These data support ongoing research about participatory music programs to support Veterans with housing insecurity.

What is prenatal stress? A scoping review of how prenatal stress is defined and measured within the context of food insecurity, housing instability, and immigration in the United States.

BACKGROUND: Stress during pregnancy can lead to significant adverse outcomes for maternal mental health. Early evaluation of prenatal stress can help identify treatment needs and appropriate interventions. Disparities in the social determinants of health can contribute to stress, but what constitutes stress during pregnancy within the social determinants of health framework is poorly understood. OBJECTIVE: To scope how prenatal stress is defined and measured among pregnant people exposed to three prominent social stressors in the United States: insecurity pertaining to food, housing, and immigration. ELIGIBILITY CRITERIA: We included all studies that focused on stress during pregnancy in the context of food insecurity, housing instability, and immigration, given their recent policy focus due to the COVID-19 pandemic and ongoing political discourse, in addition to their importance in American College of Obstetricians and Gynecologists (ACOG's) social determinants of health screening tool. SOURCES OF EVIDENCE: We searched PubMed, Scopus, and Web of Science for articles published between January 2012 and January 2022. CHARTING METHODS: Using a piloted charting tool, we extracted relevant study information from the selected articles and analyzed the content pertaining to stress. RESULTS: An initial search identified 1,023 articles, of which 24 met our inclusion criteria. None of the studies defined prenatal stress, and only one used the Prenatal Distress Questionnaire, a prenatal stress-specific tool to measure it. The Perceived Stress Scale was the most common instrument used in seven studies. Fifteen studies measured over 25 alternative exposures that researchers theorized were associated with stress, and 4 of the 15 studies did not explain the association between the measure and stress. CONCLUSIONS: Our findings demonstrate a fundamental inconsistency in how prenatal stress is defined and measured in the context of social determinants of health, limiting the comparison of results across studies and the potential development of effective interventions to promote better maternal mental health.

Systems Analysis by a Cross-sector Workgroup to Address Housing Insecurity in Cancer Survivorship.

BACKGROUND: Cancer survivors face many financial burdens that generate additional stress such as housing insecurity or homelessness. Because this leads to worse health outcomes, it is essential for health care and housing organizations to begin mobilizing resources to support this vulnerable population. OBJECTIVES: Create a "Housing in Cancer" workgroup to conduct systems-led analysis of housing insecurity in cancer survivorship in the Greater New Orleans area. METHODS: A cross-sector workgroup employed a systems analysis toolkit to explore the system. The group engaged in systems analysis exercises and generated observations on the current system. RESULTS: The problem was discerned into three components. Through reflection, the group created a new focus to support housing policies in cancer survivors and one group member was awarded a grant to provide financial assistance to cancer survivors. CONCLUSIONS: The workgroup's insights identified systemic policies and additional funding for sponsoring organizations who expressed authority over this issue.

A Novel Framework to Address the Complexities of Housing Insecurity and Its Associated Health Outcomes and Inequities: "Give, Partner, Invest".

The association between housing insecurity and reduced access to healthcare, diminished mental and physical health, and increased mortality is well-known. This association, along with structural racism, social inequities, and lack of economic opportunities, continues to widen the gap in health outcomes and other disparities between those in higher and lower socio-economic strata in the United States and throughout the advanced economies of the world. System-wide infrastructure failures at municipal, state, and federal government levels have inadequately addressed the difficulty with housing affordability and stability and its associated impact on health outcomes and inequities. Healthcare systems are uniquely poised to help fill this gap and engage with proposed solutions. Strategies that incorporate multiple investment pathways and emphasize community-based partnerships and innovation have the potential for broad public health impacts. In this manuscript, we describe a novel framework, "Give, Partner, Invest," which was created and utilized by the University of Pittsburgh Medical Center (UPMC) Insurance Services Division (ISD) as part of the Integrated Delivery and Finance System to demonstrate the financial, policy, partnership, and workforce levers that could make substantive investments in affordable housing and community-based interventions to improve the health and well-being of our communities. Further, we address housing policy limitations and infrastructure challenges and offer potential solutions.