Association Between Housing Insecurity, Psychological Distress, and Self-rated Health Among US Adults During the COVID-19 Pandemic

Economic hardship due to the COVID-19 pandemic has exacerbated concerns about the threat of evictions and foreclosures.^1,2 While prior research has documented an association between housing insecurity and health,³ the magnitude of this relationship has not been examined during the COVID-19 pandemic. Understanding the association between housing insecurity and health in a nationally representative sample during the pandemic is critical to inform efforts to support people harmed by the economic downturn.

This survey study was deemed nonhuman participants research by the institutional review board at Johns Hopkins Bloomberg School of Public Health, and informed consent was waived. This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline and the Survey Reporting Guideline (SURGE).

Data were from wave 3 of the Johns Hopkins COVID-19 Civic Life and Public Health Survey, conducted online November 11 to November 30, 2020, using the National Opinion Research Center’s probability-based AmeriSpeak panel. With a panel recruitment rate of 34%,⁴ AmeriSpeak is representative of the US civilian, noninstitutional adult population and covers 97% of households. A total of 1468 US adults participated in wave 1 (April 2020), which had a response rate of 70.4%. Among wave 1 respondents, 1337 responded to wave 2 (July 2020), and 1222 responded to wave 3 with completion rates of 91% and 92%, respectively.

Housing insecurity was defined as being currently behind on rent or mortgage or having no or low confidence in their ability to pay the next rent or mortgage payment vs having moderate or high confidence. Outcomes included psychological distress symptoms measured using Kessler 6 Psychological Distress Scale⁵ and dichotomized as moderate or severe vs lower psychological distress based on a score of 5 or more and self-rated health dichotomized as fair or poor vs good, very good, or excellent.

Covariates based on prior research^2,3,6 included gender, race and ethnicity, age, household income in 2019, employment status, housing tenure, household structure, and urbanicity (eMethods in the Supplement). We separately estimated predicted probabilities of each outcome by status of housing insecurity, controlling for covariates. Analytic sample excluded 4 participants missing outcome data. Analyses were weighted to be nationally representative. Stata version 15 (StataCorp) was used for data analysis. Predicted probabilities were estimated from logistic regression models. Tests were 2-tailed and statistical significance was set at P < .05. Statistical analysis was performed between February to March 2021.

This survey study included 1218 participants (623 [51%] female; 560 [46%] aged 30 to 54 years; 549 [45%] aged 55 years or older; 161 [13%] self-identified as being Hispanic; 157 [13%] self-identified as being non-Hispanic Black; 841 [69%] self-identified as being non-Hispanic White). Overall, 128 participants (12%) reported housing insecurity in November 2020. Among participants experiencing housing insecurity, 42 participants (34%) reported being behind on housing payments, 55 participants (38%) reported having little to no confidence in their ability to make the next housing payment, and 31 participants (28%) reported both (Figure). Housing insecurity vs housing security was disproportionately higher among participants who rented their homes (78 [64%] vs 281 [27%]; P <.001); non-Hispanic Black race (44 [37%] vs 113 [8%]), were aged 30 to 54 years (88 [64%] vs 472 [38%]), earned less than $35 000 in 2019 (64 [52%] vs 268 [27%]), lived with children (58 [47%] vs 279 [29%]), or resided in metropolitan counties (116 [92%] vs 914 [84%]) (Table).

Forty-six percent (95% CI, 43%-50%) of participants reported severe to moderate psychological distress; 18% (95% CI, 15%-21%) reported fair to poor health. Compared with participants with housing security, participants experiencing housing insecurity reported higher distress (69 [57%] vs 467 [45%]) and lower self-rated health (33 [30%] vs 157 [16%]). After covariate adjustment, the association between housing insecurity and lower self-rated health was statistically significant. The association between housing insecurity and higher distress was no longer statistically significant. Fifty-seven percent (95% CI, 44%-69%) of participants experiencing housing insecurity reported moderate or severe distress relative to 45% (95% CI, 41%-49%) of participants with housing security (P = .09), and 26% (95% CI, 15%-37%) of participants experiencing housing insecurity reported fair or poor health, relative to 15% (95% CI, 12%-18%) of participants with housing security (P = .03) (Figure).

In this nationally representative sample of US adults, housing insecurity was associated with higher psychological distress and lower self-rated health during the COVID-19 pandemic. The survey was conducted after the United States Centers for Disease Control and Prevention’s nationwide eviction moratorium, which may have attenuated these associations. Interventions that reduce housing insecurity during the COVID-19 pandemic will promote the health of the US population, and those interventions that consider equity in their implementation may mitigate entrenched health disparities resulting from structural racism and exacerbated by the pandemic. Results may be vulnerable to sampling biases, including the underrepresentation of adults experiencing homelessness. The cross-sectional design of this study precludes identifying causality; the survey did not assess prepandemic housing needs.

Accepted for Publication: July 30, 2021.

Published: September 30, 2021. doi:10.1001/jamanetworkopen.2021.27772

Correction: This article was corrected on November 4, 2021, to fix the colors of the bars in Panel B of the Figure.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Linton SL et al. JAMA Network Open.

Corresponding Author: Sabriya L. Linton, PhD, MPH, Assistant Professor, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Room 882, Baltimore, MD 21205 (slinton1@jhu.edu).

Author Contributions: Drs Linton and Leifheit had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Linton, Barry.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Linton, Leifheit, Barry.

Obtained funding: Linton, McGinty, Pollack.

Administrative, technical, or material support: Linton, Leifheit, McGinty, Pollack.

Supervision: Linton, McGinty, Pollack.

Conflict of Interest Disclosures: Dr Pollack reported owning stock in Gilead Pharmaceuticals and being an unpaid member of Enterprise Community Partners’ Health Advisory Council. Dr Pollack reported receiving personal fees as a consultant to the Open Communities Alliance and working on a temporary assignment with the United States Department of Housing and Urban Development. Dr McGinty reported receiving grants from Johns Hopkins University Alliance for a Healthier World 2020 COVID-19 Launchpad during the conduct of the study and receiving grants from the National Institute on Drug Abuse, National Institute of Mental Health, the United States Centers for Disease Control and Prevention (CDC), and Arnold Ventures outside the submitted work. Dr Leifheit reported giving expert testimony to legislative bodies regarding the public health impacts of eviction. Drs Pollack, Leifheit, and Linton reported signing on as amici to amici curiae briefs supporting the CDC’s national moratorium on eviction. No other disclosures were reported.

Funding/Support: Funding for survey data collection came from Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, the Alliance for a Healthier World, and the Robert Wood Johnson Foundation. Dr Leifheit was supported by grant T32HS000046 from the Agency for Healthcare Research and Quality.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent those of the US Department of Housing and Urban Development or other government agencies.