AIDS Behav (2007) 11:S1–S6 DOI 10.1007/s10461-007-9302-z
ORIGINAL PAPER
Why Housing? Angela A. Aidala Æ Esther Sumartojo
Published online: 21 August 2007 Ó Springer Science+Business Media, LLC 2007
Abstract Housing/lack of housing and HIV are powerfully linked. Housing occupies an important place in the causal chains linking poverty and inequality, and HIV risk and outcomes of infection. The articles in this Special Supplement of AIDS and Behavior confirm the impact of homelessness, and poor or unstable housing, on HIV/AIDS, and challenge scientists to test and policy makers to implement the promise of housing as an innovative response to the epidemic. In order to influence the development of policies on housing to benefit at-risk or HIVinfected persons, however, proponents must justify why this association exists, and how housing can help end the epidemic as well as improve the care and health of persons living with HIV/AIDS. We introduce this supplement with a discussion of the ‘‘why’’ question. Keywords Housing HIV/AIDS Structural factors Mechanisms Prevention Health care The underlying premise of this special supplement to AIDS and Behavior is that housing is powerfully linked with the risk for HIV exposure and transmission, and with the care
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. A. A. Aidala (&) Mailman School of Public Health, Columbia University, 722 W 168th St., R503, New York, NY 10032, USA e-mail:
[email protected] E. Sumartojo National Center on Birth Defects and Developmental Disabilities, Coordinating Center for Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
and health of persons living with HIV/AIDS. Many of the articles provide empirical evidence of this association, while others compel us from local observations and a national public health perspective. In order to influence the development of policies on housing to benefit at-risk or HIV-infected persons, however, proponents must justify why this association exists. In the absence of experimental verification that stable housing leads to reduced risk and stronger health for HIV affected persons and communities, a compelling explanation for the association is needed. We introduce this supplement with our perspective on the ‘‘why’’ question. A starting point is to direct attention to the crucial role of housing within a nested set of contexts, which shape vulnerabilities to HIV infection and poor outcomes among the infected. Awareness is increasing that health is shaped by ‘‘upstream’’ or fundamental causes—macro (societal or global) economic, political, and social arrangements and resources that shape differential access to knowledge, money, prestige, and power which can be used to avoid or buffer exposure to health risks (Anderson et al., 2003; Berkman & Kawachi, 2000; WHO, 2005). Housing occupies a strategic position as an intermediate structural factor, linking these broader societal processes to the more immediate physical and social environments within which we carry out day-to-day life. Housing can be seen as a ‘‘vector’’ or ‘‘vehicle’’—an intermediary by which the pathogenic inequality that inheres in broader economic and political structures is carried to susceptible hosts: those born to poverty, race/ethnic minorities, persons affected by mental illness or drug addiction, and those victimized by persons or circumstance, who have insufficient resources to carry them through prolonged or repeated periods of crisis. Housing is a manifestation of and contributes to the generation of social and economic inequalities. Income and
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race, the two factors most consistently associated with differential health are also the factors that determine access to good housing in good neighborhoods and the variety of threats or enhancements of well-being provided by different residential contexts (Acevedo-Garcia et al., 2004; Saegert & Evans, 2003). Housing warrants more focused attention as a structural factor which directly or indirectly affects an individual’s ability to avoid exposure to HIV, or for HIV positive individuals to avail of health promoting and risk reducing resources (Blakenship, Friedman, Dworkin, & Mantell, 2006; Shriver, Everett, & Morin, 2000; Sumartojo, 2000). Health impact of environments produced by housing (or lack of housing) were a core concern in the early history of public health (Krieger & Higgins, 2002; Shaw, 2004). Contemporary attention, however, including HIV research, has turned away from analysis of community housing conditions as a factor influencing population health, to a focus on ‘the homeless’ as a special risk group and the characteristics of individuals that put them at risk for both homelessness and poor health outcomes (Schwartz & Carpenter, 1999). However, as the United Nations has codified in the Universal Declaration of Human Rights, adequate housing encompasses more than basic shelter (United Nations, 2007). As several articles in this issue demonstrate, literal homelessness is but the most extreme among a range of unstable and inadequate living arrangements which can compromise health (Aidala, Lee, Abramson, Messeri, & Siegler, 2007; German, Davey, & Latkin, 2007; Kipke, Weiss, & Wong, this issue; Weir, Bard, O’Brian, Casciato, & Stark, 2007). Further, having a secure and appropriate place to live is affected by the existing stock of affordable housing, and the political, economic, taxation, credit and other policies and institutional practices that shape the availability of housing to community members. It follows that a focus on individual level characteristics associated with unstable housing and its health correlates examines factors that actually operate within a context that influences opportunities and outcomes largely outside of any specific individual’s control. The tendency to consider homelessness as an attribute of individuals rather than a situation or condition within which individuals may find themselves is consistent with the risk factor or ‘‘risky person’’ paradigm that predominates in health and public health research (Susser, 1998). To explain observed correlations between homelessness and HIV infection and treatment outcomes, the ‘‘risky person’’ model looks for individual personality dispositions or other ‘‘traits’’ that may lead persons to drug use, risky sex and illegal activities which would have both health (increased risk for HIV infection) and housing (limited economic resources to purchase conventional housing) consequences. Risky person arguments are also common in
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the substance abuse and deviance literature (e.g., Jessor, 1984; Zuckerman, 1994) and echo a range of ‘‘trait versus state’’ arguments in social psychology (Spielberger, 1972; Shinn, 1997). In contrast to an emphasis on the individual, a structural or ‘‘context of risk/pervasive stress’’ model would seem appropriate, similar to the ‘‘nexus of risk’’ approach described by O’Leary and colleagues (O’Leary, 2001). In this model, broader processes of inequality lead to the deterioration of housing situations and neighborhood environments for members of excluded groups. Economic marginalization triggers social exclusion and negative psychosocial states. Individuals can find themselves in contexts marked by pervasive risk, competing needs, few personal resources, and few community resources—situations that can that, in turn, lead to unstable housing (one lacks financial resources, faces housing discrimination) as well as risky behaviors (e.g., exchanging sex for money, or using drugs to self-medicate emotional distress) which both contribute to increased risk for HIV infection or transmission of HIV to others. Arguing for an independent causal role for housing factors does not deny the role of individual dispositions and characteristics. It may be that housing and neighborhood contexts potentiate individual dispositions, facilitating enactment of some behaviors, making others unnecessary, more difficult, or impossible. There are multiple causes for HIV events and reciprocal causation is possible (Rothman & Greenland, 2005). Nonetheless, studies that show independent effects associated with the more directly malleable ‘‘state’’ of housing situation are likely to hold more promise for effective intervention than a focus on mechanisms far antecedent in psychological development or closer to biological bases of disease. Articles in this Special Supplement on Housing and HIV/AIDS add to the accumulating evidence that supports the implication of housing in the HIV epidemic. The risky person model assumes that behavior is driven by individual choice and a person’s relatively enduring traits, rather than shaped by situations or environments, such as being homeless or unstably housed. In this view, the oncehomeless person who receives housing would be expected to continue engaging in risky behaviors which would contribute to a return to homelessness. However, a number of studies show a contrasting pattern. Longitudinal research shows that formerly homeless individuals who obtain housing are more likely to cease or reduce both drug related and sexual risk behaviors (Aidala, Cross, Stall, Harre, & Sumartojo, 2005; Elifson, Sterk, & Theall, 2007; Shah et al., 2006; Valencia, Sohler, Saez , Conover, & Susser, 2004; Weir, Bard, O’Brian, Casciato, & Stark, 2007). Interventions to provide rental assistance to HIV positive persons or other help with securing housing keeps
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them housed regardless of history of homelessness or psychosocial vulnerabilities (Aidala & Lee, 2000; Dansinger & Speiglman, 2007; Scott, this issue). Also relevant are positive outcomes associated with ‘‘housing first’’ interventions that place homeless persons with substance abuse and/or mental health problems directly into housing without prior demonstration of sobriety, treatment adherence, or other criteria as a condition of receiving or maintain housing (Burt et al., 2002; Tsemberis, Gulcur, & Nakae, 2004). On the other hand, HIV risk reduction interventions that do not address housing issues have found that participants in unstable housing conditions are much less likely to change risky behavior than their stably housed counterparts (DesJarlais, Braine, Friedmann, 2007; Elifson, Sterk, & Theall, 2007). In addition, there appears to be a dose-response relationships between housing status and HIV risk with the literally homeless or those in the worse housing situations tending to be at greater risk than those in unstable or less problematic housing, and both of these groups at greater risk than persons in stable and secure housing (Aidala, Cross, Stall, Harre, & Sumartojo, 2005; Elifson, Sterk, & Theall, 2007; Weir, Bard, O’Brian, Casciato, & Stark, 2007). A full discussion of possible mechanisms that may directly or indirectly link housing status to drug and sexual behaviors and/or medical care outcomes is beyond the scope of this essay. Several explanations are offered in the attempt to encourage appropriate empirical explorations. A structural perspective would be mindful of the fact that housing effects carry neighborhood effects. Housing includes broader aspects of the surrounding residential setting (Dunn and Hayes, 1999; Fitzpatrick and LaGory, 2003). The homeless and unstably housed are not randomly distributed throughout a city or geographic area but concentrated in the most devastated neighborhoods, characterized by limited economic opportunities, high rates of crime and violence, and poor service infrastructure. Both housing situation and neighborhood can be sources of comfort and protection, or environments where a variety of factors exogenous to the individual interact to increase risk and vulnerability (Anderson et al., 2003; Miller & Neaigus, 2001; Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005; Yen & Syme, 1999). Research investigating entrants to emergency homeless shelters has found that prior addresses are concentrated in areas with higher rates of unemployment, housing crowding, property abandonment, and higher rent-to-income ratios than other areas. Culhane and colleagues found the same pattern in New York and Philadelphia with 3–4 areas accounting for over 60% of shelter admissions in each city. These few geographic areas were also among those with the highest rates of HIV infection (Culhane, Lee, & Wachter, 1996; Hudson Planning Group, 2005).
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Housing researchers have identified a number of dimensions of housing relevant to health (Dunn, 2000; Shaw, 2004). The materiality of housing refers to the direct physical aspects of housing which confer a protected space and facilities for maintaining physical well-being (to sleep, wash, prepare food, etc.). Homeless individuals, of course, lack even this resource. Homelessness as well as substandard housing, especially in high crime neighborhoods, poses direct health risks but also have psychosocial consequences and serve to limit social interaction as discussed below. For the homeless, the press of daily survival needs limits time, energy, and attention to all but the most immediate health concerns (Cunningham et al., 1999). The material aspect of housing also refers to economic considerations. High housing costs relative to income are a source of chronic stress for many persons and also restrict income availability for other potentially health-promoting uses (Anderson et al., 2003; Scott, this issue). Housing markets are important factors for wealth accumulation and intergenerational transmission of economic resources and status that relate back to broader processes of exclusion and disadvantage (Boehm & Schlottmann, 1999). As Dunn (2000) and others (Evans, Wells, & Moch, 2003; Hartig, Johansson, & Kylin, 2003; Shaw, 2000) have emphasized, housing has meaning as well as material dimensions that affect health and well-being. Home and neighborhood are for most people a positive source of identity and belonging. Experiencing a ‘‘sense of home’’ contributes to ontological security—a sense of order, continuity, and meaning with regard to an individual’s experiences (Dupis & Thorns, 1998; Padgett, 2007) and may lead to a sense of personal and social identity and agency that helps build resistance to risky behaviors. As Henry Cisneros reminds us, secure housing is a place to be safe, to rest, to pray, to study, and to ‘‘gather one’s thoughts for the challenges ahead’’ (Cisneros, 2007). On the other hand, those in sub-standard housing, in ‘‘bad’’ or ‘‘wrong’’ neighborhoods, or in transient housing arrangements, can experience a reduced sense of safety, personal efficacy, and personal value (Blacksher, 2002; Despres, 1991), psychosocial responses that affect a range of health-related behaviors, from avoiding risk of exposure or transmission to accessing and using preventive and treatment services (Fishbein, 2000; Ickovics et al., 2006; Latkin, Curry, Hua, & Davey, 2007). Being literally homeless is a mark of failure at the most basic level of adult role functioning (Goffman, 1963; Takahashi, 1997). Social rejection as well as internalized shame and lack of self-esteem may further contribute to risky behaviors. Substance use as ‘‘self-medication’’ can be a response to stress and/or untreated symptoms of depression or anxiety, increasing risk for HIV infection (Khantzian, 1997; McEwen, 2001). Sexual escape is also an option for some
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(McKirnan, 2001). A number of studies in the current issue have found housing status differences in psychological and psychsocial variables that other research has shown to affect health-related decisions, intentions, and behavior (Eastwood & Birnbaum, 2007; Elifson, Sterk, & Theall, 2007; Wenzel, Tucker, Elliot, & Hambarsoomians, 2007). Another causal dynamic to consider is the role of housing as it provides the necessary social and physical space to develop and maintain social ties and positive social relations which are strongly associated with a variety of health behaviors and outcomes. Social networks can provide emotional support which buffers negative effects of stress, and information and practical assistance for positive coping (Taylor; Repetti, & Seeman, 1997). The lack of stable, adequate housing limits opportunity for regular social interaction; housing transience disrupts existing networks. Homeless, unstably or inadequately housed individuals tend to be socially isolated or involved in social ties and networks that support risky behaviors (substance use, sex exchanges). Being stably housed in a reasonably stable neighborhood allows participation in wider social networks and can lead to community identification and health benefits associated with collective efficacy and neighborhood social capital or the normative and associational properties of communities (Kawachi, Kennedy, Lochner, Prothrow-Stith, 1997; Sampson, Raudenbush, & Earls, 1997; Szreter & Woolcock, 2004). Social capital effects appear to be influenced by area racial composition, itself influenced by housing policies and patterns (Semaan, Sternberg, Zaidi, & Aral, 2007). Particularly important for understanding relationships between housing and HIV is the extent to which access to housing structures intimate relations. The lack of housing, transient living conditions, and the communal sleeping arrangements in most homeless shelters pose a formidable barrier to forming stable intimate relationships. Lack of a stable ‘‘home’’ and community ties has long been associated with multiple sexual partners, casual liaisons, sex exchanges, and low rates of marriage or stable partner relationships (Browning & Olinger-Wilson, 2003; Castel, 2000; Goode, 1963; Huston, 2000). It is clear that access to stable, affordable housing is influenced by factors far beyond any single individual’s control. Housing provides a clear example of the ways in which broader economic and political factors shape the context of health. Many societal factors seem far beyond the reach of public health—e.g., restructuring occupational opportunities, or removing racism or gender inequality. We can however address a more proximal manifestation of these influences by addressing the day to day context of human behavior shaped by housing/lack of housing, particularly since much of this context has been shaped by deliberate laws, policies, and regulations.
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For example, laws and policies influence who is likely to experience housing instability and who among the homeless or unstably housed is eligible for housing assistance (Scott Tax, zoning, community development, credit and other policies produce or limit affordable housing. Government bodies define a homeless person in very specific terms, and some programs exclude persons who are in substandard or overcrowded housing (HUD, 2002). In most jurisdictions, individuals are ineligible for housing supports because of behavioral problems such as drug use or criminal records (Lazzarini & Klitzman, 2002). Migrants to a city will be excluded from local housing and social services because they do not meet residency requirements (Montoya, Bell, Richard, Goodpastor, & Carlson, 1998). Laws designed to prevent commercial sex work or illicit drug use often target the homeless because homeless persons may trade sex for a place to sleep or use drugs in street settings. Some local ordinances, referred to as anti-homeless laws, ban camping, loitering, or panhandling and can increase risks associated with trading sex or drug use since these activities are now more likely to be hidden from public view and participants less accessible to outreach or providers of harm reduction resources (Lee, Ross, Mizwa, & Scott, 2000; Takahashi, 1997). Incarceration for any offence is disruptive to the often fragile supports created by individuals attempting to sustain life at the margins. Jail or prison represents another risk environment. We have argued that people are homeless or unstable housed not simply because of their individual traits or characteristics, but because of a confluence of interacting environmental influences. The same ‘‘fundamental causes’’ put persons at risk for both homelessness and HIV infection: economic and political contexts, inequality of opportunities and conditions, social processes of discrimination and exclusion. Articles in this issue contribute to the growing accumulation of research findings demonstrating the association of housing status with HIV risk behaviors and differential rates of HIV infection—among women and men, drug users, formerly incarcerated, young men who have sex with men (Elifson, Sterk, & Theall, 2007; German, Davey, & Latkin, 2007; Kipke, Weiss, & Wong, this issue; Salazar et al., 2007; Weir, Bard, O’Brian, Casciato, & Stark, 2007; Wenzel, Tucker, Elliot, & Hambarsoomians, 2007). Research has also documented that for persons with HIV, those with stable and adequate housing are significantly more likely to access appropriate health care and to adhere to medications than those without housing (Aidala, Lee, Abramson, Messeri, & Siegler, 2007; Eastwood & Birnbaum, 2007; Leaver, Bargh, Dunn, & Hwang, this issue) Several studies have shown that improvements in housing are associated with reduced risk and improved health care outcomes (Elifson, Sterk, & Theall, 2007; Weir, Bard, O’Brian, Casciato, & Stark, 2007). Existing studies
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based on randomized designs are scarce but those that report general health outcomes are promising (AcevedoGarcia et al., 2004). Kidder et al. (2007) will soon release findings from a randomized trial that examines provision of housing as a structural intervention to HIV positive persons. Cost analyses have already demonstrated such interventions are likely to be cost effective (Holtgrave et al., 2007). Broader structural processes sustaining poverty and inequality would seem beyond the immediate reach of HIV interventions. Fortunately, however, changing housing and neighborhood environments is both possible and promising. We want to thank all the contributing authors and reviewers for making this Special Supplement such a valuable contribution to our understanding of the role of housing/lack of housing for individuals and communities most affected by HIV/AIDS. Note that a number of additional articles addressing housing issues appear in the regular November, 2007 issue of AIDS and Behavior.
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