The Social Determinants of Health:
Housing as a Determinant of Health

This summary is primarily based on papers and presentations by Toba Bryant, Post-doctoral fellow, Centre for Health Studies, York University and presentations by Sharon Chisholm, Executive Director, Canadian Housing Renewal Association, Ottawa, and Cathy Crowe, Street Nurse, Toronto. The presentations were prepared for The Social Determinants of Health Across the Life-Span Conference, held in Toronto in November 2002.

The opinions expressed in this publication are those of the authors and do not necessarily reflect the views of Health Canada.

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Current Situation

In recent years, a housing crisis has arisen in Canada, marked by increases in homelessness and a lack of affordable rental accommodations. Analysts attribute this to several factors:

• In the 1990s, the federal government and many provinces stopped providing social housing.

• At the same time, some provinces reduced social assistance rates (e.g., by 22% in Ontario).

• The private sector has not moved to replace the role of government by providing affordable rental housing (Layton, 2000; Hulchanski, 2001).

These factors are exacerbated in Ontario where new legislation introduced two other significant changes. The Tenant Protection Act amended the Ontario Human Rights Code to allow the use of income to screen prospective tenants. This increased the risk of homelessness for vulnerable groups such as immigrants and refugees who may be unable to provide credit and other references. The second change was the elimination of rent controls. This contributed to a 17% increase in rents in Toronto and a significant increase in the number of evictions (Shapcott, 2002).

Shelter use has increased across Canada. In 1998, Layton reported one million overnight stays in emergency shelters in Ontario communities alone. On an average night in 2000, shelter use was approximately 300 people in Vancouver, 1,200 in Calgary, 460 in Ottawa and 4,000 in Toronto (Layton, 2000).

CMHC (2000) found that the over one million tenant households in Canada who live in core need situations have average incomes of $14,600. On average, these households spend 47% of their income on rent. Thus, after-rent income available is about $7,738 to cover all other expenses such as food, health products, education, transportation, and other living costs. The Federation of Canadian Municipalities (1996) reported that two out of five Canadian households spent more than 30%, and one out of five spent more than 50% of their income on rent - an increase of 43% since 1991 (Layton, 2000).

Another CMHC survey (2001) showed that renters in Toronto who were on social assistance were left with less than $100 to cover food and other expenses after paying their rent each month. The Daily Bread Food Bank (2002) in Toronto found that after paying their monthly rent, households with children that are dependent on food banks have only $3.65 per day per person for all living expenses, not only food. Low-income households with children live in overcrowded and often unsafe housing conditions. Among their users, 60% of households with children considered at least one aspect of their housing as poor, an increase of 57% over the previous year. The Daily Bread survey also found that 25% of all households with children who use their services could afford only a bachelor or one bedroom apartment; and that 8% of all households with children shared a kitchen, while 7% lacked a private bathroom.

There is a widening gap in income and wealth between homeowners and renters. In the late 1960s, homeowner wealth was about 20 times that of renters. Homeowner wealth increased in 1984 to 29 times and in 1999 to 70 times that of renters (Statistics Canada, 1984, 1999).

In the last five years, the federal government has responded to the housing crisis by:

• appointing a minister responsible for housing and homelessness

• providing additional funding for the rehabilitation of substandard housing through the Residential Rehabilitation Assistance Program and program design changes (1999)

• developing the federal homelessness strategy in 1999 ($753 million for services and temporary shelter over three years)

• establishing the Affordable Housing Framework Agreement in 2001 ($680 million for new affordable housing over five years).

As part of the 2001 agreement, the federal and provincial governments committed themselves to building more social housing units. One year later, the National Housing and Homeless Network (2002) reported that, outside of Quebec, less than 200 new housing units had been built. Over half of the provincial governments have yet to fulfil their commitments to build more social housing units. In addition, three provinces have yet to sign a bilateral housing agreement with the federal government, although they committed to doing so one year ago. Quebec and the three territories have taken action to match the federal commitment of $680 million over five years. The Network expressed concern that the definition of "affordable housing" has been undermined in the bilateral housing agreements. The weakening of this term will render low and moderate-income households unable to afford the rents of many new units.

Factors that Affect the Issue

When rents are unaffordable, it is difficult to cover other necessities such as food, thereby contributing directly to food insecurity. When families spend more than 50% of income on housing, it significantly reduces amounts that can be spent on recreation, food, and other social determinants of health.

Epidemiological studies have tended to focus on isolated aspects of housing and health such as the presence of mould and the development of respiratory infections in children, or overcrowding and its impact on mental health. Most have used models that search for the association between the material aspects of housing independent of personal characteristics and other health determinants. These models fail to explain how people end up in poor housing and to consider the effects of income and the correlations between housing and the other determinants of health. They also tend to focus on individuals, instead of considering the effects of various policies and programs on groups within society. This may lead to pathologizing individuals who live in poor housing conditions, instead of addressing larger structural issues, such as housing policy, that may contribute to their housing circumstances (Bryant, 2002).

Effects of Housing on Health

Many studies have found that homeless populations experience a much greater incidence of a variety of negative health conditions and ailments (Bryant, 2002). Wendy Bines (1994) in the U.K. showed that people who used hostels, bed and breakfast accommodation, day centres and soup runs were more likely than the general population to have musculoskeletal and chronic breathing problems, headaches and seizures. Those who sleep on the street had even higher rates for a variety of illnesses. A survey in Toronto found that homeless people had a much higher risk than the general population for many chronic conditions, including respiratory diseases, arthritis, rheumatism, high blood pressure, asthma, epilepsy and diabetes (Ambrosio et al., 1992). Homeless populations frequently do not receive the services they need to address these health problems.

Homeless people are also at greater risk of premature death compared to the general population. In the United States, being homeless can shorten life expectancy by 20 years (Wright et al., 1998). City of Toronto data show that young homeless men in Toronto are eight times more likely to die prematurely than men of the same age in the general population (Kushner, 1998).

Using longitudinal data from the National Child Development Study to examine the link between housing and health, Marsh and colleagues found housing played a significant and independent role in health outcomes. Greater housing deprivation showed a dose-response relationship to severe/moderate ill health at age 33. Living in substandard housing and poor neighbourhoods affected children directly and indirectly, since increased stress is related to their parents' financial and psychosocial distress. For those who experienced overcrowded housing conditions in childhood to age 11, there was an increased likelihood of experiencing infectious disease. In adulthood, overcrowding is linked to an increased likelihood of respiratory disease (Marsh, 1999).

Other studies have shown the negative effect of inadequate heating and dampness on health, particularly for children and older people (Savage, 1988; Strachan, 1998; Platt et al., 1989). Studies like these that examine relationships between housing conditions and specific health problems may oversimplify the relationship between housing and health and the other broad social determinants of health.

A lack of adequate, affordable housing can aggravate other problems associated with low income. As discussed above, individuals and families who are forced to spend a disproportionate amount of their income on rent often face food insecurity and possible malnutrition, and are unable to participate in healthy community activities such as active recreation and children's social programs. There is little or no money left for transportation to work and for clothing and school supplies.

Living in disadvantaged housing circumstances clusters with a variety of other indicators of disadvantage. Indeed, Shaw and colleagues argue in The Widening Gap: Health Inequalities and Policy in Britain (1999), that: "Health inequalities are produced by the clustering of disadvantage - in opportunity, material circumstance, and behaviours related to health across people's lives."

Implications for Policy, Practice and Research

Housing affordability does not occur in a vacuum. Policy decisions in income support combine with those related directly to housing to contribute to housing insecurity, and increased stress, morbidity, mortality, social exclusion, illness and disease.

Housing is especially sensitive to political ideologies that favour a pro-privatization and free market agenda since there is no motivation for the private sector to provide affordable housing to Canadians with low incomes who are likely to be lifelong renters. When governments make radical policy shifts in the overall goals of a policy area, vulnerable groups suffer the most. For example, until 1995, tenant protection referred to protecting tenants from high rent increases through rent controls and the provision of social housing to those unable to afford market rents. Policy changes by several governments since then have made low-income renters consumers in a market that greatly increases their vulnerability to housing insecurity and homelessness (Bryant, 2002).

The housing situation in Canada can be improved by developing a policy approach that includes a national housing strategy, and recognizes housing as a basic human right that affects the other social determinants of health. By definition, the social determinants of health require intervention by all three levels of government, but particularly by senior governments that have the revenues to support action. The private market cannot be expected to meet the needs of citizens who cannot afford to purchase private goods and services.

The Toronto Disaster Relief Committee (TDRC) (1999) developed the One Per Cent Solution to end the housing and homelessness crisis. The TDRC argues that if all governments increased their spending on housing by 1% of overall spending, the homelessness crisis could be eliminated in five years. The One Per Cent Solution calls for three actions by governments:

1. annual funding for housing of $2 billion federally, and another $2 billion among provinces and territories

2. restoring and renewing national, provincial and territorial programs to resolve the housing crisis and homelessness disaster

3. extending the federal homelessness strategy (Supporting Community Partnerships Initiative) with immediate funding for new and expanded shelter and services across the country.

Layton (2000) outlines several strategies. He stresses the need for coordinated action among all levels of government, community groups and the private sector. Based on his work with the Federation of Canadian Municipalities (FCM), he suggests that a healthy housing sector should have four components: rental housing; ownership housing; social housing with mixed incomes; and support for people with special needs to enable them to live independently. The FCM team devised a framework for a National Affordable Housing Strategy to promote affordable, new and existing housing. The strategy consists of the following programs:

• A flexible capital grant program: a locally designed and administered program of housing initiatives financed by federal or joint federal/provincial/ territorial capital fund

• A private rental program to stimulate private rental production

• Investment pools of money to create affordable housing by attracting new funding for the development, acquisition or rehabilitation of affordable housing

• Provincially administered income supplement programs to assist tenants who cannot afford private market rents. The program would complement capital grants to reach those most in need.

There is also a need for a body independent of government to monitor the social determinants of health. The proposed Health Council recommended by Commissioner Romanow could be mandated to do this. With respect to housing, this could entail monitoring the state of housing, recommending policies to address the housing crisis, and monitoring the activities of federal, provincial and territorial governments to ensure accountability and the implementation of appropriate policies and programs.

The health sector has an obligation to address the health and long-term care needs of individuals and families who are homeless or live in inadequate housing. This is particularly important for Canadians with mental health, substance abuse and chronic health problems. More importantly, the sector needs to convince political systems to consider the social determinants of health in general and housing in particular as essential components of the policy making process. Social and health policy analysts and others concerned with these issues must work with leaders in housing and use every opportunity to present policy solutions. Partnerships among health, housing, social services, finance and urban development need to ensure a collaborative strategy that:

• optimizes a continuum of affordable housing and supports

• prevents people from becoming homeless

• supports people when they are homeless

• helps homeless people obtain appropriate housing (City of Ottawa, 2002).

Researchers need new ways of thinking about housing and its relationship to health. Dunn provides one framework for studying housing as a socioeconomic determinant of health from a population health perspective. He proposes measuring material dimensions of housing (physical integrity and costs), meaningful dimensions (housing as an expression of social status, identity, control and sense of belonging), and spatial dimensions (proximity to school, work, recreation and services, and exposure to health hazards such as toxins and pollution). This model suggests the need for ethnographic studies of people's housing experiences, as well as the need to understand geographic aspects of neighbourhoods. Longitudinal studies with very large numbers can yield understanding of the relationship between housing and health and the pathways that lead to poor housing and deprivation. But these studies (and the use of Dunn's model) usually say little about how life situations interact with policy environments to create situations of disadvantaged housing.

There is both an opportunity and need to make better use of existing data sources (e.g., improved indicators and questions on the National Population Health Survey, Survey of Consumer Finances) and to make linkages with data sources such as provincial/territorial administrative health records.

Emergent research needs include a better understanding of the links between health, socioeconomic status and housing related to:

• exposure to physical hazards and healthy environments, e.g., green spaces, supportive neighbourhoods

• supportive initiatives in the home such as the installation of grab bars and ramps

• psychological and social effects

• financial support, e.g., comparison of government support to home owners and renters

• political dimensions, e.g., support for housing industry versus social housing

• location, e.g., effect of neighbourhood on early childhood development and other determinants of health

• gender, age, (dis)ability, ethnicity and mental health.

Networking and partnerships between researchers in housing and health may help focus the use of data from "natural experiments" to evaluate housing as a health intervention. This would involve studying the everyday effects of housing interventions on health status and health care use among individuals and families over time.

References

Ambrosio E., Baker D., Crowe C. and Hardill K. (1992). The Street Health Report: A Study of the Health Status and Barriers to Health Care of Homeless Women and Men in the City of Toronto. Toronto: Street Health.

Bines W. (1994). The Health of Single Homeless People. Centre for Health Policy, York University.

Bryant T. (2002). The Current State of Housing in Canada as a Social Determinant of Health. Paper given at The Social Determinants of Health Across the Life-Span Conference, Toronto, November 2002.

Canada Mortgage and Housing Corporation (2001 October). Welfare Income Versus Current Average Market Rent, Toronto. Ottawa: Canada Mortgage and Housing Corporation.

Canada Mortgage and Housing (2000). Housing Market Survey, Statistics Canada Small Area Data, Special Tabulations Calculations. Ottawa: The Advocate Institute.

Chisholm S. (2002). Presentation given at The Social Determinants of Health Across the Life-Span Conference, Toronto, November 2002.

Crowe C. (2002). Presentation given at The Social Determinants of Health Across the Life-Span Conference, Toronto, November 2002.

City of Ottawa. (2002). Ottawa's Community Action Plan to Prevent and End Homelessness, 2002-2005. Ottawa: People Services Department, Housing Branch.

Daily Bread Food Bank. (2002 October). Fact Sheet: Turning our Backs on our Children: Hunger + Decrepit Housing = Unhealthy, Unsafe Children. Toronto: Daily Bread Food Bank.

Dunn J.R. (2002). A Population Health Approach to Housing: A Framework for Research. Ottawa: National Housing Research Committee and Canada Mortgage and Housing Corporation.

Hulchanski J.D. (2001 August). A Tale of Two Canadas: Homeowners Getting Richer, Renters Getting Poorer: Income and Wealth Trends in Toronto, Montreal and Vancouver, 1984 and 1999. Toronto: Centre for Urban and Community Studies, University of Toronto.

Kushner C. (1998). Better Access, Better Care: A Research Paper on Health Services and Homelessness in Toronto. Toronto: Mayor's Homelessness Action Task Force, City of Toronto.

Layton J. (2000). Homelessness: The Making and Unmaking of a Crisis. Toronto: Penguin Books.

Marsh A., Gordon D, Pantazis C. and Heslop P. (1999). Home Sweet Home?: The Impact of Poor Housing on Health. Bristol: The Policy Press.

National Housing and Homelessness Network. (2002 November 22). More Than Half Provinces Betray Commitments: NHHN "Report Card" on Anniversary of Affordable Housing Framework Agreement. Toronto: National Housing and Homelessness Network.

Platt S., Martin C., Hunt S. and Lewis C. (1989). Damp housing, mould growth and symptomatic health state. British Medical Journal, 298:1673-8.

Savage A. (1988). Warmth in Winter: Evaluation of an Information Pack for Elderly People. Cardiff: Cardiff University of Wales College of Medicine Research Team for the Care of the Elderly.

Shapcott M. (2002 June). The Ontario Alternative Budget 2002. Ottawa: Canadian Centre for Policy Alternatives.

Shaw M., Darling D., Gordon D. and Davey Smith G. (1999). The Widening Gap: Health Inequalities and Policy in Britain. Bristol: The Policy Press.

Statistics Canada (1984, 1999). Survey of Financial Security. Ottawa: Statistics Canada.

Strachan D. (1988). Damp housing and childhood asthma: validation of reporting of symptoms. British Medical Journal, 297:1223-6.

Toronto Disaster Relief Committee. (1998). The One PerCent Solution. Toronto: TDRC. http://www.tdrc.ca

World Health Organization (1986). Ottawa Charter on Health Promotion. Geneva: WHO.

Wright J.D., Rubin B.A. and Devine J.A. (1998). Beside the Golden Door, Policy, Politics and the Homeless. New York: Aldine De Gruyter.