World Diabetes Day 2023 | Housing Insecurity and Diabetes Care: Leaping the Diabetes Intervention Chasm

Our paper discusses the challenge that having unmet basic needs poses to health and one’s ability to care for and manage their diabetes. The paper is part of a series of articles highlighted by BMC for World Diabetes Day 2023.
World Diabetes Day 2023 | Housing Insecurity and Diabetes Care: Leaping the Diabetes Intervention Chasm
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Relationship between housing insecurity, diabetes processes of care, and self-care behaviors - BMC Health Services Research

Background The aim of this analysis was to examine the influence of housing insecurity on diabetes processes of care and self-care behaviors and determine if that relationship varied by employment status or race/ethnicity. Methods Using nationally representative data from the Behavioral Risk Factor Surveillance System (2014-2015), 16,091 individuals were analyzed for the cross-sectional study. Housing insecurity was defined as how often respondents reported being worried or stressed about having enough money to pay rent/mortgage. Following unadjusted logistic models testing interactions between housing insecurity and either employment or race/ethnicity on diabetes processes of care and self-care behaviors, stratified models were adjusted for demographics, socioeconomic status, health insurance status, and comorbidity count. Results 38.1% of adults with diabetes reported housing insecurity. Those reporting housing insecurity who were employed were less likely to have a physicians visit (0.58, 95%CI 0.37,0.92), A1c check (0.45, 95%CI 0.26,0.78), and eye exam (0.61, 95%CI 0.44,0.83), while unemployed individuals were less likely to have a flu vaccine (0.84, 95%CI 0.70,0.99). Housing insecure White adults were less likely to receive an eye exam (0.67, 95%CI 0.54,0.83), flu vaccine (0.84, 95%CI 0.71,0.99) or engage in physical activity (0.82, 95%CI 0.69,0.96), while housing insecure Non-Hispanic Black adults were less likely to have a physicians visit (0.56, 95%CI 0.32,0.99). Conclusions Housing insecurity had an influence on diabetes processes of care and self-care behaviors, and this relationship varied by employment status and race/ethnicity. Diabetes interventions should incorporate discussion surrounding housing insecurity and consider differences in the impact by demographic factors on diabetes care.

"Available Home" by compujeramey is licensed under CC BY 2.0./Cropped from original

First, I’d like to take this opportunity to recognize the tireless work my much more accomplished co-authors engage in every day. Health disparities researchers face an increasingly maddening paradox – the simplest and probably most effective solutions to preventing unnecessary death are going to be the most difficult to implement. Additionally, I’m grateful for the invitation to write a corresponding blog post to our paper because the recommendations within I felt warrant some discussion about the lack of affordable housing in the US.

Researching this paper topic was of interest to the co-authors and myself because housing is a basic need and providing evidence that people’s health is negatively impacted when their housing is not stable is a prerequisite for advocating for change at a policy level in modern society. Our study findings added some new insights to the evidence base; we found those who reported housing insecurity had a lower likelihood of several self-reported diabetes processes of care and self-care behaviors, and this relationship was moderated by both employment and race/ethnicity in some interesting ways.

We highlighted prior research indicating individuals with diabetes who are housing insecure need to invest more resources and personal energy into getting around barriers to managing their diabetes, and clinicians find maintaining regular standards of care challenging for these patients (Henry et al, 2020). It’s not hard to imagine how the stress of potentially losing your home can be all consuming, leaving one with very little capacity to deal with a chronic disease like diabetes that requires so much daily effort from the individual affected to keep it in check.

With or without diabetes, human health is inextricable from basic needs for healthy food, clean water, and safe shelter – who would disagree? However, even in high-income economies like the U.S., basic needs are heavily regulated, unevenly allocated, and incessantly debated. In modern societies, accessing basic needs is not something an individual can do without engaging in the infrastructure and economies we’ve built around basic needs. An unhoused person in the U.S. cannot just build a house for themself to live in, they must seek out someone appointed with housing resources who can find the appropriate housing for their situation, and the appointed person has a dual obligation to ensure the unhoused person meets the criteria and follows the rules for living in that house/apartment/room/sleeping pod. Our basic needs are subject to conditions, and the worse off you are, likely the more conditions.

While many diabetes interventions at the individual, organizational, or provider level have the evidence behind them to be successful, they are not equipped to address gaps in basic needs for vulnerable people; providers cannot connect patients with material needs when they are unobtainable. This may be a reason why, as noted in our paper, only 2% of nationally representative sample of adults with diabetes who were unstably housed reported receiving help with housing in a clinical setting (Berkowitz et al, 2018). I recognize this poses a challenge to our paper’s concluding recommendation:

“To minimize the impact of housing insecurity on diabetes outcomes, housing insecurity questions should be included in standardized assessments used within the clinical setting to further tailor diabetes care interventions to patients and connect those facing housing insecurity to a social service provider with housing resources.”

The recommendation is valid. However, it is dependent on an individual who has access to a resource that must be readily available to the patient. This is exactly the point where individual and organizational level interventions fall short, where there exists a chasm between the basic needs of the patient and the capacity of their environment to meet those needs. In other words, it’s difficult to put these types of recommendations into practice in places that need community level interventions that directly target community level determinants of health.

Consider the current housing crisis in the City of Milwaukee where our team conducts research on diabetes interventions. For context, Milwaukee is one of the most segregated cities in the U.S. and most Black residents are concentrated in the central city where, not surprising, there is a lack of affordable and safe housing. Milwaukee County has a diabetes prevalence rate of 11%, however, 29% of Black residents participating in a national survey in the City of Milwaukee reported having diabetes (Ryff et al, 2018).

Wisconsin state statutes require municipalities to produce yearly housing affordability reports. The 2022 report from the City of Milwaukee states that there are 38,900 households that earn less than $20,000 per year and pay more than half of their income on housing, and they expect this number of severely cost burdened households to grow. In total, 95,900 Milwaukee households report cost burdens (42% of all households). Households of lower income and of persons of color tend to be disproportionately affected by housing cost burden and are subject to housing insecurity associated with lower home ownership rates, greater risk of foreclosure, and higher eviction rates. Most severely cost burdened households are renting, indicating there are very few rental units available that are appropriately priced. Despite the lack of affordable units, the city reports having a more than adequate supply of housing units. To remedy the issue, housing policy experts recommend providing housing assistance in the form of public housing, subsidized housing, or a housing voucher. The report acknowledges that the number of resources required to meet the needs of severely cost burdened households alone is far beyond the scope of local government to do at a meaningful scale in Milwaukee.

Now, I bet it’s not hard to figure out what a community level intervention for affordable housing in Milwaukee might look like with this knowledge. Simple solutions, right? Well, not quite – but I hope the health disparities researchers are taking note. People are in dire need of community level interventions to adequately address health disparities and the time to do them is now.

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