Hidden costs of unaffordable housing: Exploring the multidimensional and intersecting health effects on Black Americans

Abstract

Background:

Housing, a key health determinant, is increasingly unaffordable. Black/African-American communities are disproportionately affected due to a long, documented history of structural racism in housing. To date, much unaffordable housing research is economically focused, leaving holistic health consequences underexplored.

Design and methods:

We used a multidisciplinary lens to explore potential effects of unaffordable housing (30%+ of income) on mental, emotional, physical, and social well-being. In-depth, semi-structured interviews were conducted with 33 individuals who were residents and/or staff members of organizations that provide housing or support resources in three historic, Black neighborhoods in westside Atlanta. Thematic analysis identified key themes.

Results:

Unaffordable housing can have direct and indirect adverse effects on health and wellbeing. Participants described ways that rising housing costs can increase stress, worsening mental health (e.g. depression, anxiety) and negatively impacting relationships within one’s household (e.g. spouse/partner, children) and outside of the home (e.g. friends, neighbors). Spending a disproportionate amount of income on housing can make other basic necessities unaffordable, such as food and medication. Working overtime or additional jobs to cover expenses can lead to mental and/or physical exhaustion and increase opportunities for injury for physically demanding jobs, and may also decrease time available to adequately care for oneself and their family or to invest in relationships.

Conclusion:

This qualitative study helps increase the breadth and depth of knowledge regarding potential effects of unaffordable housing on mental, emotional, physical, and social well-being that should be considered in the development of health-promoting housing practice, policy, and funding allocation.

Introduction

Housing is a central determinant of health, ¹ yet it remains increasingly unaffordable and inaccessible to millions of Americans. Black/African Americans (referred to hereafter as Black), a resilient segment of the United States population with a long, well-documented history of exclusion from full and fair participation in the housing system, are particularly vulnerable to housing insecurity.^2–4 The ability to find housing and remain in it becomes increasingly difficult when costs become unaffordable, commonly defined as spending 30% or more of income on housing costs, including utilities ⁵ ; unaffordability can result in displacement (e.g. eviction, foreclosure), in some instances repeatedly. Despite the existence of the Fair Housing Act of 1968, Black Americans continue to experience the lowest homeownership rates and lowest housing equity wealth across the life span. ⁶ Recent estimates from national data show 45% of Black Americans are homeowners, which is notably lower than their white (72%), Asian (63%), and Hispanic (51%) counterparts. ⁷ Because home ownership is a primary means for wealth accumulation in the United States, markedly lower rates of homeownership contribute to long-term financial and housing insecurity among Black Americans. Moreover, Black people consistently experience disproportionately high rates for eviction filings and evictions, with Black women and children being among the most affected. ⁸ Consequently, despite making up roughly 14% of the US population, approximately one in three people who experienced homelessness in 2024 was Black. ⁹ It is important to note that disparate rates are most accurately explained by population-level patterns of discrimination that were established in the past (e.g. formerly enslaved persons emancipated with no property or capital, revocation of Special Field Order 15), ¹⁰ institutionalized by policies and practices for many generations (e.g. redlining, racial covenants),^3,4 and persist today (e.g. predatory lending, disproportionately higher loan denials, lower home appraisals).^4,11,12

A growing body of research has linked housing insecurity and housing instability to physical, mental, and social well-being. For example, recent reviews reported mostly harmful associations between housing instability and hypertension, overweight/obesity, and diabetes, ¹³ as well as cardiovascular disease.^13,14 Other studies have linked housing insecurity or housing instability to physical and physiological health consequences, including poorer sleep quantity and quality measures, physical inactivity, kidney disease, and increased substance use and sexual risk behaviors,^15–18 as well as delayed medical care. ¹⁹ Housing instability has also been associated with increased risks of preterm delivery and other adverse perinatal outcomes, ²⁰ health outcomes that disproportionately impact Black mothers and babies.^21,22 Studies of national survey data showed severe housing cost burden increased the likelihood of declining health in a sample of older adults. ²³ Similarly, housing insecurity predicted poorer physical health, especially among Black adults, in analyses of national survey data from midlife and older adults. ²⁴ Thus, housing insecurity can affect Black Americans across the life course, from gestation through older adulthood. Beyond physical health, researchers have highlighted significant mental health effects of housing insecurity, such as higher rates of depression, anxiety, and severe psychological distress among people who have been displaced.^25–27 Others have emphasized how displacement, a common outcome when housing becomes unaffordable, disrupts social networks, damaging social cohesion and social support.^28,29

However, much of the existing research is quantitative and focuses on a single dimension of health, which does not provide depth of understanding nor permit exploration of interrelationships, both of which are necessary for developing nuanced, health-promoting programs and policies. Unlike quantitative approaches where a statistical model is constructed to explore hypothesized relationships, a qualitative approach allows participants to share detailed accounts of their experiences, including time-order sequences that help illuminate potential cause-and-effect relationships, resulting in a nuanced and contextualized understanding of multiple dimensions of health and how factors in one dimension may interact with another. Additionally, much attention is focused on what happens after displacement, largely ignoring the period leading to displacement as housing costs become increasingly unaffordable. Therefore, the aim of this study was to answer the following research question: How does increasingly unaffordable housing affect health, holistically? This qualitative study uses a social ecological lens ³⁰ that considers individual (e.g. cognitive processes), interpersonal (e.g. relationships), and policy (e.g. property tax, housing assistance) factors and a multidimensional lens (informed by social epidemiology, psychology, and sociology) to more comprehensively explore the potential effects of unaffordable housing on mental, emotional, physical, and/or social well-being and the interrelationships between these dimensions.

Design and methods

Participants

The sample of 33 participants consisted of individual residents (85%; n = 28) and staff members (15%; n = 5, 3 of whom were also residents) from organizations that provide housing and/or support resources for residents of three historic, Black neighborhoods in westside Atlanta. Most resided in the largest neighborhood in the area (73%; n = 24) or adjacent neighborhoods (24%; n = 8), including three of the five (60%) organizational staff members. The two participants who were not westside residents had close ties to the communities and had been working for nonprofit organizations in the area for several years. Slightly more than one-third (36%; n = 12) of participants owned their homes.

Nearly all of the participants were Black (94%; n = 31); two were White staff members who spoke about the challenges faced by the Black residents they served, recounting experiences shared with them in their professional capacity and personal relationships (without providing residents’ names). Sixty-four percent (n = 21) of the sample was female. To bolster participation in the study, individuals were not asked to report their exact age or income. Instead, they provided their age range and occupation. Participants’ ages ranged from the early 20s to mid-70s. Occupations for this primarily working-class sample included bus drivers, independent construction contractors, security officers, health care staff, and food service or retail workers, for example. Four (12%) were self-employed, while a few were unemployed, disabled, or retired (18%; n = 6). All of the participants who were staff members at organizations providing housing and/or support services in the area worked for small nonprofit organizations in the neighborhood, one of whom also held a leadership position at a neighborhood church.

Recruitment

Participants were recruited between May 2021 and August 2022. A combination of methods was employed to maximize recruitment, including neighborhood canvassing, sharing digital flyers with two nonprofit housing organizations for circulation via email and/or social media, and making an announcement at a neighborhood meeting open to visitors. Interested individuals were screened in person, by phone or email, and completed the interview or scheduled an appointment for a later date. Nearly all (97%; n = 33) of the 34 eligible participants completed an interview. To be eligible, individuals had to be 18 years of age or older, live in a westside Atlanta neighborhood, and have experienced residential displacement or fear being displaced due to unaffordable housing. Individuals were not eligible if they did not meet the aforementioned inclusion criteria or if they were unable to speak and understand English (alternative language options were not available).

Data collection

Private, semi-structured interviews were conducted by the principal investigator (PI), a public health researcher and professor trained in qualitative and quantitative methods (EB); interviews were completed by November 2022. The PI was familiar with some of the participants because of time spent establishing a connection with a nonprofit affordable housing organization in the area, but did not have a close relationship with them. The interview guide was developed by the PI, based on the literature review and study aims, and included three broad questions and related probes. The PI also had a nuanced understanding of the topic based on personal and professional experiences. Participants responded to open-ended questions about their home and neighborhood (e.g. length of residence, ownership, neighborhood pros and cons, connectedness to neighborhood and residents); how they perceived being displaced in the past or potential displacement because of unaffordable housing at the time of the interview affected their health (mental, emotional, physical, social well-being); and desired action from local leaders, policymakers, developers, or others regarding the health effects of unaffordable housing.

Before being interviewed, participants provided written (in person) or oral (video call, phone call) consent. To build trust through transparency, the PI shared the written consent form, an infographic summarizing the consent form, as well as the interview questions before the interview, and answered any questions. As a part of the consent process and to build a rapport with participants before starting the interview, the PI shared an overview of the study aims, as well as reasons for interest in the community and the topic. Interviews were conducted in person (participant’s home or the conference room of a community space) or remotely via video call or phone call based on the participant’s preference. Although the interviews were recorded, the PI took notes during the conversation. Most (79%; n = 26) were conducted remotely (39%; n = 13 each for video and phone). On average, interviews lasted 30–45 min, with long-time residents’ interviews sometimes exceeding 1 hour. Although saturation appeared to be reached at approximately 25 participants, interviews continued until everyone who expressed interest had the opportunity to participate, resulting in a final sample size of 33. One participant rescheduled multiple times but was unable to be interviewed before the data collection window closed. Participants received $25 upon completion. Agnes Scott College’s Institutional Review Board approved all study protocols and materials.

Data analysis

Thematic analysis was used to analyze participant narratives. The audio-recorded interviews were transcribed verbatim and checked for accuracy by the interviewer (PI) before being imported into Nvivo 14, a qualitative data analysis software program. Using a deductive approach, two authors (JMM, JN) developed initial codes based on the semi-structured interview guide and sensitizing concepts from an extensive literature search; an inductive process was used to refine the codes. The final codes reflected the multidimensional concept of health, accounting for mental, emotional, physical, and social well-being, and factors at the individual (e.g. thoughts and emotions), interpersonal (e.g. relationship tension), and policy (e.g. rising property taxes) levels of the social ecological model that influenced each dimension of health. After reaching a reliability score of 80%, which indicated consistency between coders (percent agreement, Cohen’s kappa, Krippendorf’s alpha), the two coders divided and coded the transcripts independently. Upon completion, the research team met several times to review and discuss the coded data and memos and identified key themes. A preliminary version of the findings was shared with interested research participants to assess the accuracy of the interpretations and the extent to which our narrative resonated with them and adequately represented their experiences.

Results

Unaffordable housing that displaces or threatens to displace renters or homeowners can have direct and indirect adverse effects on health and well-being. Participants described interrelated consequences of stress on mental and emotional (e.g. anxiety, depression, fear), physical (e.g. high blood pressure, exhaustion, and injury from overworking to increase income), and social well-being (e.g. limited capacity to connect with family, friends, neighbors, others). High housing costs also reduced income available to spend on other basic necessities, as well as time needed to adequately care for oneself and one’s family or to invest in relationships among those who must earn additional income to meet expenses (Figure 1).

Figure 1.

Multidimensional and intersecting health effects of unaffordable housing.

Themes synthesizing participants’ experiences shared during their interviews are discussed below. This qualitative research aimed to extend the breadth and depth of understanding regarding the health effects of unaffordable housing by expanding the range of potential health effects that have been identified and illuminating relationships between them. Although some qualitative research includes counts as an indicator of salience, the authors chose not to do so because counts can inadvertently convey a weighting or relative importance of each health consequence, ³¹ which is more appropriately established by subsequent quantitative research and is not the purpose of this endeavor.

Unaffordable housing increases stress, which can directly harm mental and physical health

“Stress” was a broad term that described psychological and sometimes physical strain. Participants discussed experiencing psychological stress as a direct result of rising housing costs. Stress was rooted in fears that unaffordable spikes in their rent or in their property taxes would cause them to be displaced from their homes. Beyond typical anticipated cost-of-living increases, more recent cost spikes were commonly attributed to new home construction or extensive renovations to existing rental homes that increased their and surrounding properties’ values. Residents feared having to relocate farther outside of the city and away from their current neighborhoods. A Black male Atlanta native and father in his 30s expressed a common frustration regarding this trend: “. . .it is stressing me out all the time. I think about it every day. . .it bothers me a lot. I think of every day what I’m going to do. I’m actually thinking that the only solution that I’m coming up with is to move on the outskirts of the city.” Although this strategy is a common practice, the Atlanta metropolitan area has become so unaffordable that moving to another city or state to find affordable housing is the most viable option for some, especially for people in the lowest income brackets. A married mother in her 20s who was also an Atlanta native dreaded the disruption associated with potentially uprooting her family: “The people who are born and raised [in Atlanta], I’m scared to move to another state. . .the ones who are already here and have made a life and have families and kids, our feet are already planted here.”

Beyond personal experiences, some participants also reported vicarious psychological stress about the consequences of rising housing costs for neighbors who are elderly and/or live on a fixed income. These residents were viewed as the most socially and economically vulnerable people, who may be less able or unable to afford increases in their rent or property taxes. Legacy residents (individuals and families who own homes that have been passed down for generations) have experienced unique stress regarding the devastation of losing their family home due to unaffordable property taxes. A retired Black longtime homeowner in his 70s shared his concern for his peers: “You got some folks been there since the early 1960s, early 50s. So of course their homes are paid for, but then you come in and you put what I call mega mansions in the neighborhood, then it affects them greatly. Everybody wants to stay in their homes until they pass away in order to be able to pass it down to their offspring. And sometimes it’s not possible because you have to sell to survive.” He discussed the potential mental effect of losing one’s home at that stage in life: “If you go to a high rise, that’s just like going from the hospital to the hospice. . .that’s how some seniors feel when they go from their home to a high rise. I don’t have this freedom to just walk out my door, walk in my backyard, sit on my front porch. You don’t have that kind of freedom. And so, to some degree, I guess that would affect their overall mental state. I know it would affect mine because I’m used to just having that freedom. And once your freedom is taken from you, then that changes you altogether.” Taxes are not the only financial burden that can result in the loss of generational family homes. Some legacy residents experience financial strain when they must take out loans to cover costly maintenance or unexpected repairs and psychological stress when they struggle to repay or subsequently default on those loans. A Black longtime resident in his 60s reflected on several recent examples of people he grew up with who recently lost their family homes because of what he believed to be predatory lending practices as a gentrification strategy.

The threat or reality of imminent displacement can increase stress on the mind and/or body as residents strategize to avoid homelessness. A Black mother in her 20s discussed the mental and physical costs of preparing for displacement: “It’s scary because it’s like, ‘Where do you go?’. . .‘What if we got to move in the shelter because we can’t find a place in time for the lease to go up?’ I really don’t know. . .trying to save for a deposit which I know is going to be needed when we move. So that’s more stress. And I’m probably going to have to pick up another gig soon because it’s almost time for us to get ready to move. . .Like I said, mentally stressful. . .Physically, makes you feel older than what you are, because you working like a dog. . .just getting desperate and finding whatever fits and that’s really not a way to live.” While negative effects of experiencing displacement may seem obvious, it is important to recognize that the onset of negative effects can occur long before actual displacement, as people face uncertainty regarding their housing stability and everything connected to it (e.g. work, school, place of worship).

Psychological stress induced by unaffordable housing manifested in mental and/or physical health concerns, such as depression, anxiety attacks, suicidal thoughts, high blood pressure, heart palpitations, poor sleep (lack of sleep or inconsistent sleep schedules caused by overworking or ruminating on displacement), decreased or inconsistent appetite, overeating, low energy/exhaustion, muscle tension, and skin conditions such as stress-induced rashes or hives. In more extreme accounts, participants shared having to seek healthcare for health problems stemming from housing-related financial stress. A Black mother in her 20s disclosed repeated, anxiety induced hospitalizations as a result of working multiple jobs to keep up with rising housing costs: “. . .I was working two jobs and it did affect my health. . .I was admitted to the hospital. It felt like a heart attack. It was actually an anxiety attack. This was three different times and that was this year, so I recently let that second job go at the end of March, and I’ve been doing this one job for a while.” Another participant, a Black woman in her 50s, described her experience: “. . .In the last six months, I actually had to go see a dermatologist, because I bit my nails down to the skin, and they’re bleeding. And so I can’t really use my hands because of the stress. I was breaking out in anxiety rashes where there are literally big red blotches on your skin, and they were all over my body. They itch and they burn. It’s like big welts. And I’ve had those a few times. . .I went to the hospital, and they was like, “You need to calm down.” Since all this happened, I’ve had to get on blood pressure medication. I’ve never had high blood pressure until recently. . .It started this year. I mean, when the rent was raised.”

Negative emotions such as sadness and hopelessness that stem from psychological stress of housing costs can disrupt health-promoting behaviors, such as regular eating, sleeping, and exercising. A Black woman in her 40s articulated the interrelationship well: “It’s already stressful with the prices that we have right now and if things go up, that’s even more stressful. . .sometimes the stress turns into depression and then sometimes when people are depressed, you don’t eat as much. So you’re not eating healthy. You’re not eating the way you should be eating. You’re not getting up and getting exercise, because depression will cause you to stay in the house and worry about your problems.”

Awareness of the role of social and economic power structures also surfaced as a source of psychological stress. A lifelong neighborhood resident in her 60s articulated the lack of control regarding the impending neighborhood changes that are viewed as strategic gentrification efforts because of most residents’ social and economic positioning: “. . .It got worse when these houses [newly constructed, higher priced] started coming up. And then that had a lot to do with us stressing whether we were going to be able to stay here or not. . .You get angry. . .And, you see, people can’t do nothing, it hurts. And that just throws you into a depression. It really does. . .when I try to tell the people that can do it [leaders who can enact change], and don’t nothing get done, it hurts.” This sentiment was expressed by other residents who referred to feeling helpless or ignored by people in positions of power. A Black male long-time resident in his 60s explained how corporations, developers, politicians, or others repeatedly engaged residents in private or public meetings or focus groups/listening sessions regarding revitalization plans, yet promises did not materialize and plans did not adequately reflect their feedback.

Social well-being can be indirectly impacted by unaffordable housing

Social well-being is a vital but often overlooked aspect of health as perspectives of health in the United States often emphasize physical health and, to a lesser extent, mental health. Residents’ experiences suggest more attention to this dimension of health is essential. Working overtime or additional jobs to pay for expenses can create mental, emotional and physical exhaustion that affects people’s desire, ability, or time to socialize. One resident’s remark captured the sentiment of others: “The way it affects the relationship is. . .you don’t really want to socialize because it’s not nothing against the person, it’s just the focus of your mind, your mental state. And you really don’t have time to socialize, or reach out, or be friends” (Black woman in her 20s). Some residents stopped or reduced the frequency of activities that contributed to their social well-being such as going on dates or participating in “get-togethers” or vacations with family or friends because they didn’t have the mental and emotional capacity or financial resources. Housing affordability issues can also create or exacerbate interpersonal tension. The physical and emotional toll can reduce patience with partners, roommates, children, and neighbors, resulting in strained relationships. Consequently, lost or diminished social connections can make people feel isolated, which can worsen mental health.

Displacement caused by unaffordable housing also disrupts social networks. Residents described the loss of companionship and emotional support when people were forced to relocate: “You try to stay in touch. But if they was in the neighborhood, you can just walk across the street or whatever. But going all the way out there, that’s draining. And then all of a sudden, this friendship dwindles” (Black woman in her 60s). Importantly, residents also described the loss of tangible support such as childcare, transportation, meal sharing, and other practical ways neighbors care for one another. Residents who repeatedly experienced displacement discussed their and/or their child’s difficulty developing new relationships due to fear of losing those in the future, which can be particularly detrimental to a child’s social and emotional development and related areas such as academic achievement.

Unaffordable housing directly or indirectly decreases money for other basic necessities and indirectly decreases time to properly care for oneself or others

Participants noted that rising housing costs reduce their ability to afford essentials that impact health and quality of life. When a disproportionate amount of income is spent on housing, it is difficult to purchase essential items such as food, medications, toiletries, and clothing for themselves or their children or to pay for other important expenses such as auto payments, fuel, or repairs. When people fall too far behind on expenses and are ultimately evicted from their homes, displacement creates additional financial burdens and the stress that accompanies them. Moving costs, such as paying an application fee, security deposit, and the first and last months’ rents for a new living space, as well as renting a moving truck and/or storage space, are expensive. People who are forcibly evicted from their homes also experience loss of property that must be replaced (e.g. furniture, clothing). People who cannot secure a new home because they do not qualify based on their credit score or prior evictions can also pay exorbitant rental costs to live in a motel or extended-stay hotel, for example. Rates for safe, clean lodging typically meet or exceed the cost of their rent at the location from which they were displaced, especially for households with multiple members, making this a costly and unsustainable solution.

In addition to direct financial effects, a key indirect effect of housing costs that exceed income surfaced. Residents who worked overtime or multiple jobs to keep up with expenses noted increased opportunities for injury when performing physically demanding jobs. For example, a Black woman in her 40s discussed her and her husband’s predicament: “. . .We have to literally be able to keep a full-time job and a part-time job, as he [husband] works full-time and I work a part-time job. . .we having to work overtime, lifting up refrigerators, washers and dryers all day long. It puts wear and tear on your body.” Injury can present additional financial challenges due to loss of income when an individual is unable to work or medical expenses associated with seeking care for the injury. Physical exhaustion can also make it difficult or impossible for people to complete normal daily activities such as exercising or cooking healthy meals for themselves or their families. For example, a Black resident in her 20s expressed difficulty creating work-life balance and made connections to her physical and mental well-being: “I got to work my bones off just to keep afloat. . .It messed up my mental state of knowing that I need to be more healthy or working out. . . I don’t have time for this. . .I got to try to work a double [shift] two, three times this week to make sure I make ends meet.” A Black mother in her 20s also described her struggle to achieve work-life balance: “Two physical jobs, they bring in income, and this job as a parent. So that’s three jobs technically, but working those two jobs, the kids would get what I had left, which wasn’t much. . .me working more than one job, it has taken away from their nutrition. . .I can’t even make a good wholesome meal because I don’t have the time to do it because I’m steady trying to scrape together my pennies to make rent for the month.” Financial assistance from longer-term rental assistance programs (e.g. federal HUD programs), short-term rent relief programs (e.g. county-or state-level emergency rent assistance), or less formal sources (e.g. family, friends, church) provided opportunities to prevent detrimental effects of overworking described above.

Discussion

In this qualitative study designed to explore how unaffordable housing can affect health, holistically, experiences shared by residents reflect a range of mental, emotional, physical, and social consequences that can occur for renters and homeowners alike when housing becomes increasingly unaffordable. Applying a social ecological lens permitted exploration of factors beyond the individual (e.g. thoughts, emotions) that influence one’s health status (e.g. interactions with others, policies and programs), which is essential for developing a more accurate, contextualized understanding of health that can be used to inform the development of health-promoting housing policy and practice. It is important to emphasize that people can experience adverse health effects of displacement resulting from affordable housing long before displacement occurs. The experience of unaffordable housing in and of itself, which often does but may not necessarily result in displacement, poses a significant threat to one’s well-being. “Stress” from uncertainty about or experiencing displacement can harm mental health (e.g. anxiety, depression, fear, anger, frustration), which can produce psychosomatic responses for some (e.g. elevated blood pressure, inability to sleep) or affect relationships with people within one’s household and with others. People experiencing high levels of stress may not have the mental or emotional capacity to engage with others in healthy ways and may disengage partially or entirely. Overworking to earn enough to meet financial obligations can contribute to increased opportunity for injury for physically demanding jobs, potentially increasing financial strain during recovery (e.g. costs of medical care, limited earning potential), and can decrease time and energy to spend properly caring for oneself or others (e.g. exercise, nutrition, social connection). These findings are consistent with previous studies linking housing instability or insecurity to mental health conditions such as depression or anxiety,^25–27 hypertension, ¹³ poor health-related behaviors such as inadequate sleep ¹⁵ and physical inactivity, and disruption of relationships and social networks.^28,29 Our findings also expand the literature by highlighting relational tension and/or disengagement as an effect on social wellbeing, underscoring the severity of some physiological responses (e.g. hospitalization), and illuminating potential physical consequences such as exhaustion or injury from overworking to meet financial obligations, as well as emphasizing unique concerns such as seniors fearing the loss of their independence if they can no longer afford to stay in their homes or long-time residents losing a family home that has been passed down for generations. Diminished mental, emotional, physical, or social well-being attributed to unaffordable housing warrants serious consideration as it can contribute to a lower quality of life.

Additionally, our findings support Bhat et al.’s conceptual model, developed based on a recent narrative review, that proposes potential pathways to illustrate how housing insecurity (e.g. instability, unaffordability) can produce epigenetic and physiological manifestations of stress via mediators (e.g. health behaviors, psychosocial resources, and structural resources). ¹⁶ While our study did not have an epigenetic component, heart palpitations, high blood pressure, or anxiety rashes were identified as physiological manifestations of stress. Further, our findings suggest another potential pathway may exist. Mental health is treated as a mediator of stress in Bhat and colleagues’ conceptual model. For example, when encountering unaffordable housing as a stressor, a physiological response is influenced by psychosocial resources such as mental health. In essence, one processes their experience with unaffordable housing through a mental health “filter.” If someone already has poorer mental health and housing expenses become unaffordable, they are more likely to have a negative physiological response or to have a relatively stronger response than someone whose housing expenses become unaffordable but the experience is filtered through a healthier mental state. This is consistent with our findings. Being hospitalized for heart palpitations or a rash because of anxiety were more extreme physical responses experienced by individuals with preexisting anxiety that was exacerbated by rising housing costs. Yet, findings from our study suggest that, in addition to considering the mediating role of mental health in producing distal physiological manifestations of stress, it could be useful to consider psychological manifestations as another type of distal manifestation of stress (pathway with mental health as an outcome). For example, chronic depression or anxiety that was not present at baseline can be the result of one’s experience with housing unaffordability. Similar to obesity research, where obesity is appropriately considered a mediator in some instances but an outcome of interest in others, future research of relationships between housing insecurity, instability, or unaffordability and health that includes mental health as a dimension of holistic health should carefully consider whether it is most appropriate to treat mental health as an outcome or whether it lies in a proposed causal pathway (mediator), perhaps exploring both options, depending on the study aims. The strongest approach to clarify the pathway would likely be a mixed methods design (e.g. exploratory sequential design) where qualitative methods are used to gain a nuanced understanding of the specific role of mental health factors in that population before relying on statistical models to quantify the strength of relationships in the proposed pathways.

Bhat et al.’s narrative review and conceptual model also proposes factors such as financial assistance and chronic discrimination/unfair treatment as potential moderators of stress. Similar to previous research, residents discussed the role of financial support from formal sources, such as housing assistance programs ³² and benefits such as Social Security, ¹⁶ but they also noted financial assistance from informal sources, such as family, friends, or church members, in decreasing psychological stress caused by financial strain. While discrimination and unfair treatment were not the focus of this study, these topics surfaced in reference to displacement of residents as housing became increasingly unaffordable. It is possible that psychological stress from housing unaffordability may be magnified for residents who identified gentrification as the sole or primary reason for unaffordable housing. This finding warrants further investigation, for example, in studies examining the detrimental health effects of an increased allostatic load from prolonged stress.^33–36 Therefore, future research could explore potential moderating effects of each of the aforementioned factors in more detail.

It is important to note potential study limitations. Although candid accounts from residents representing a range of ages, occupations, and lived experiences can provide a more nuanced understanding of potential health consequences of unaffordable housing and connections between factors, findings from this small, qualitative study should be considered in the appropriate context. The semi-structured interview guide for the study was developed by the research team, not an existing validated measure, and was not pilot tested. It is possible that different questions could have yielded different responses. Additionally, respondents discussed perceived causal relationships that could not be verified. For example, regarding temporality, someone may have become more aware of a condition such as high blood pressure, but it was not possible to verify that the condition developed after housing costs became unaffordable. Additionally, although probes were used to attempt to rule out other factors, it is possible that a respondent was not fully aware of potential confounding factors that could have contributed to new or worsening mental, emotional, physical, or social well-being. The authors aim only to highlight potential effects on mental, emotional, social, and physical health identified by our sample that deserve further attention in studies with larger samples from other populations and with study designs that permit generalizability.

Conclusions

Reducing housing cost burden is a public health imperative, evidenced by its inclusion as a Healthy People 2030 objective. ³⁷ Consistent, high-quality, affordable housing has the potential to improve the well-being of millions, especially among Black Americans. As a result of historical and contemporary exclusionary housing policies and practices in the United States, not individual-level factors, a relatively higher proportion of Black people rely on a form of rental assistance to make their housing more affordable. ³⁸ Analyses of national data underscore better self-reported overall health and less psychological distress for people enrolled in housing assistance programs compared to eligible people awaiting enrollment, ³² emphasizing an important link between health and housing affordability. Public health researchers are uniquely positioned to develop a more robust body of evidence that includes multidimensional (e.g. exploring physical, mental, emotional, and social well-being in the same study) and intersectional (e.g. exploring how one dimension of health overlaps and influences another) research to inform a Health in All Policies ³⁹ approach regarding housing. Effectively disseminating findings that provide a more complete understanding of the detrimental health effects of unaffordable housing may persuade policy makers or other key decision makers to allocate funding, pass legislation, or employ other tools that bolster existing or create new means for housing affordability (e.g. expand eligibility for rental assistance programs, create paths to home ownership), which could make housing security and stability a reality for more Black Americans.

Supplemental Material

sj-pdf-1-phj-10.1177_22799036251388582 – Supplemental material for Hidden costs of unaffordable housing: Exploring the multidimensional and intersecting health effects on Black Americans

Supplemental material, sj-pdf-1-phj-10.1177_22799036251388582 for Hidden costs of unaffordable housing: Exploring the multidimensional and intersecting health effects on Black Americans by Erin L. P. Bradley, Jayla Norman, Jordan Mackenzie Mitchell, Claire Moore and Asmiya Kazmin in Journal of Public Health Research