Public Health Research (Dec 2023)
Exploring the impact of housing insecurity on the health and well-being of children and young people: a systematic review
Abstract
Background Housing insecurity can be understood as experiencing or being at risk of multiple house moves that are (1) not through choice and (2) related to poverty. For example, due to short-term private rental tenancies, temporary or emergency housing, and homelessness. Housing insecurity has grown due to recent trends in the cost and availability of housing. The quality, affordability and stability of housing have all been shown to impact children’s health and well-being. However, the pathways linking housing and child health and well-being are complex and poorly understood. Objectives To identify, appraise and synthesise research evidence that explores the relationship between housing insecurity and the health and well-being of children and young people. Data sources MEDLINE via Ovid (searched 8 April 2022), EMBASE via Ovid (searched 8 April 2022), PsycINFO via Ovid (searched 8 April 2022). Review methods We undertook a systematic review synthesising qualitative data. We searched databases, reference lists and United Kingdom grey literature. We extracted and tabulated key data from the included papers, and appraised study quality. We synthesised the data qualitatively into an a priori conceptual framework using best-fit framework synthesis combined with thematic synthesis, and generated logic models to highlight links between specific exposures, impacts and outcomes. Results We included 59 studies and identified four populations: those experiencing housing insecurity in general (40 papers); associated with domestic violence (nine papers); associated with migration status (13 papers) and those forced to relocate due to demolition (two papers). Most published studies had an overall assessment of moderate-high quality, and most grey literature originated from known and valued sources. Housing insecurity took many forms and resulted from several, often inter-related, situations, including being evicted or having a forced move, living in temporary accommodation, exposure to problematic behaviour, overcrowded/poor-condition/unsuitable property, and making multiple moves. The resultant housing insecurity had multiple impacts, including school-related, psychological, financial and family well-being impacts, long-distance travel to attend school and see friends, living in a poor-condition or unsuitable property, all of which could further exacerbate housing insecurity. These experiences impacted health and well-being, in terms of mental health problems (often manifesting physically/behaviourally) and physical health problems related to poor housing conditions. Some factors lessened the impact of housing insecurity, including friendship and support, staying at the same school, having hope for the future and protective parenting. The negative impacts of housing insecurity on health and well-being may be compounded by specific situations and life circumstances, such as escaping domestic violence, migration status, or a forced relocation due to housing demolition. Limitations Many accounts were from parents or other informants, and more data directly from children and young people may give a more nuanced picture. Likewise, there was little information relating to outcomes, and it is difficult to know whether the current evidence has captured all relevant outcomes, and the links from impacts to health and well-being outcomes are less well understood. The complexity and diversity of the data added additional challenges to the synthesis process. Conclusions Our findings suggest that policies should focus on reducing housing insecurity among families, particularly in relation to reducing eviction, improving and reducing the need for temporary accommodation, minimum requirements for property condition, and support to reduce multiple moves and moves far from families’ desired location. Those working with children and families experiencing housing insecurity should give them optimal choice and control over situations that affect them. Future work Future qualitative research should focus explicitly on the health and well-being of children and young people experiencing housing insecurity, and how it links with the impacts identified in the current review, foregrounding the accounts of children and young people themselves, including specific groups of young people who are likely to be marginalised. Qualitative research focusing on the impact of interventions to address housing insecurity among families in the United Kingdom is also needed. Study registration This study is registered as PROSPERO CRD42022327506. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (Award ref: NIHR135455) and is published in full in Public Health Research; Vol. 11, No. 13. See the NIHR Funding and Awards website for further award information. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Plain language summary Introduction Housing insecurity is being at risk of moving house many times, due to poverty and having no choice, for example, due to a short-term rental house/flat, emergency housing and homelessness. Children’s health and well-being are known to be affected by how suitable, affordable and stable their housing is. However, the reasons for this are poorly understood. Methods We looked for studies exploring how housing insecurity can affect the health and well-being of children and young people (aged 0–16) in the United Kingdom. We included the views of children, parents/close family members and professionals (e.g. teachers). We searched for studies published in academic journals, searched relevant websites and received suggestions from experts. Results We included 59 studies on the impact of housing insecurity on young people. We found that children are affected in many ways including their social life (e.g. being far from friends), schooling (e.g. joining a new school), health, financial and family well-being. This led to anxiety/stress, trouble eating and sleeping, wetting the bed and health problems, such as asthma, due to poor living conditions. Some things can help to protect children experiencing housing insecurity, including friendship and support, staying at the same school, and support from parents. The problems of housing insecurity may be made worse by life circumstances, including domestic violence, being a migrant/refugee/asylum seeker and a forced relocation. Most studies included parents/professionals, with few seeking the views of the children and young people themselves. Conclusions Our review suggests that it is important to reduce housing insecurity among families. All those working with children and families experiencing housing insecurity should give them as much choice and control over situations that affect them as possible. Future studies should gather the views of children and young people themselves. Scientific summary Introduction Housing insecurity can be understood as experiencing or being at risk of multiple house moves that are (1) not through choice and (2) related to poverty. This may include a range of precarious housing situations (e.g. private rental accommodation with short-term or insecure tenancy agreements; temporary or emergency housing and homelessness). Housing insecurity has grown as a result of a number of trends in the cost and availability of housing, reflecting in particular the rapid increase in the number of low-income families with children in the private rental sector. The evidence from cohort studies that show a relationship between housing insecurity, homelessness or frequent moves in childhood and health-related outcomes can usefully quantify the proportion of children and families at risk of poorer health associated with housing instability. Such evidence, however, cannot determine causal associations, and the complex pathways linking housing and child health and well-being have not been synthesised. Objectives The current review aimed to identify, appraise and synthesise research evidence that explores the relationship between housing insecurity and the health and well-being of children and young people (CYP). We aimed to highlight the relevant factors and causal mechanisms. Methods We undertook a systematic review synthesising qualitative data, employing elements of rapid review methodology. Database searches [of MEDLINE, EMBASE, PsycINFO, Applied Social Sciences Index and Abstracts (ASSIA), International Bibliography of the Social Sciences (IBSS) and the Social Sciences Citation Index] were accompanied by scrutiny of reference lists of included papers and relevant systematic reviews, and grey literature searching of key websites, including those identified by stakeholders. We extracted and tabulated key data from the included papers. Data extraction was performed by one reviewer, with a 10% sample checked by a second reviewer. We appraised study quality of the published literature using the Critical Appraisal Skills Programme (CASP) qualitative checklist, and the quality of grey literature sources using the authority, accuracy, coverage, objectivity, date, significance (AACODS) checklist. Before commencing the review, we developed an initial a priori conceptual framework in consultation with stakeholders and topic experts, to inform and guide the review and synthesis. The framework consisted of: the policy context, population, exposures, impacts (i.e. interim outcomes) and outcomes (health and well-being outcomes in childhood/youth). We synthesised the data qualitatively into the conceptual framework using best-fit framework synthesis combined with thematic synthesis, and generated logic models to highlight the links between specific exposures, impacts and outcomes by population. Inclusion criteria Population The population included families with children aged 0–16 experiencing or at risk of housing insecurity, living in a family unit, in the UK. This could include, but not be limited to, those on low incomes, lone parents and ethnic minority groups including migrants, refugees and asylum seekers. Informants could include the children themselves, parents/close family members (e.g. grandparents, if the children live with them), or other informants with insight into the child’s/children’s experiences (e.g. teachers, clinicians). Children outside a family unit (i.e. who had left home or who were being looked after by the local authority) and traveller families were excluded. Exposure We defined ‘housing insecurity’ according to the Children’s Society (3) definition: those experiencing and at risk of multiple moves that are (1) not through choice and (2) related to poverty. This included actual or perceived insecurity related to housing situations, which may include the following: private rental accommodation with short-term or insecure tenancy agreements; temporary emergency housing; homelessness (including ‘hidden’ homelessness). We also aimed to include research related to interventions that have the specific aim of reducing housing insecurity and/or mitigating the impact of housing insecurity on the health and well-being of children, where identified. Context The current UK policy context shows exacerbation of factors that can lead to housing insecurity. These include the following: trends in poverty and inequality exacerbated by the COVID pandemic; changes in the housing market (an increase in investment properties, loss of social housing); increased numbers of low-income families living in the private rental sector; insecure or short-term tenancies; increasing housing costs (and fuel/food costs) and lack of affordable properties (see Background). Outcomes Any reported immediate and short-term outcomes related to childhood mental and physical health and well-being (up to the age of 16) were included. Studies reporting on the long-term outcomes and impacts in adulthood of housing insecurity experienced in childhood were excluded, as were short-term outcomes reported by adults. Studies We included studies reporting qualitative data on the views of young people and/or parents with young children on how housing insecurity has impacted on their (or their children’s) well-being. Books (with the exception of searchable e-books) and dissertations were excluded. Conference abstracts were only included if they contained relevant data unavailable elsewhere. Results In total, 59 studies were included in the review, which included 16 from database searches, 37 from grey literature searches, and 6 from reference lists of included studies and relevant reviews. Most published studies had an overall assessment of moderate-high quality, although few reported reflexivity. Most of the grey literature included originated from known and valued sources, and although methodologies and methods were often poorly described, primary data in the form of quotations were usually available. We identified four distinct populations for which research evidence was available during the process of study selection and data extraction: general population (housing insecurity in general) (reported in 40 papers) domestic violence population (housing insecurity associated with domestic violence) (reported in nine papers) migrant, refugee and asylum seeker population (housing insecurity associated with migration status) (reported in 13 papers) relocation population (families forced to relocate due to planned demolition) (reported in two papers). We detected all elements of the conceptual framework in the data from the included studies and identified an additional element through thematic synthesis: protective factors. We included this new element in our logic models and constructed a separate logic model for each population. Although we anticipated potentially different experiences of housing insecurity and its impacts and outcomes across the four populations, the evidence reviewed suggests many similarities across all the populations in terms of impacts, exposures, outcomes and protective factors. Common exposures included being evicted or having a forced move, living in temporary accommodation, experiencing overcrowding, exposure to problematic behaviour, poor-condition/unsuitable property and making multiple moves. Common impacts included social, school-related, psychological, financial and family well-being impacts, having to travel long distances to attend school and see friends, having to live in a property that was unsuitable or in a poor state of repair, overcrowded and often noisy, all of which could then further exacerbate housing insecurity. Common outcomes reported were mental health problems (which could manifest in physical ways, e.g. trouble eating and sleeping, or wetting the bed) and physical health problems, such as skin complaints and asthma related to poor housing conditions. Protective factors common to several populations included friendship and support, staying at the same school, having hope for the future, and protective parenting. Pervasive throughout all populations and accounts was an overall lack of choice or control over the housing situation. In addition, some considerations specific to certain populations were identified. In the domestic violence population, there was an additional consideration of the family choosing to remain in the property or leave the property, but both options came with insecurity attached, as those who stayed were not sure if they would be evicted due to the perpetrator defaulting on the mortgage. Some positive results were reported in relation to an intervention that helped families to feel safe if they chose to stay in their property (the Sanctuary Scheme), which reduced fear related to the perpetrator returning. Housing insecurity negatively impacted on friendships in all populations, with CYP reporting greater difficulty in forming close bonds and a peer network in each new location. However, this could be potentially more challenging for those escaping domestic violence, due to the need to keep information about themselves confidential to keep the family safe. In the migrant, refugee and asylum seeker population, parents and children spoke of having very little notice before having to move out of a property, in some cases only 48 hours. This could lead to a housing emergency for the family, and in this population there were several accounts of families becoming homeless and having to sleep in unsuitable places, such as the accident and emergency (A&E) waiting room and on a night bus. In some families, parents had no recourse to public funds, so even in cases where a child or children were born in the UK, the family still ended up destitute and homeless. This situation caused significant worry for the parents, which in turn was perceived and experienced by the children. A key commonality across everyone in the relocation population was that they were forced to move by a particular date, as their property (a flat in a high-rise block) was scheduled for demolition. Many families desired a move, due to a lack of space, overcrowding and unsafe outdoor spaces; however, many did not want to leave behind social networks and schools in the community, and even some who wanted to move had difficulty finding a property that was suitable (e.g. for their family size). In synthesising the evidence, a key challenge was the complexity of the data, in particular of the relationships between exposures and impacts. Factors that were exposures in the first instance could then become impacts, and particular impacts could then drive housing insecurity. Another key challenge in synthesising the qualitative evidence was that many elements of the experience of housing insecurity have been separated out in the logic models, but are likely to have been experienced simultaneously by the CYP, such that the experience of these elements may have been conflated and difficult to separate out. It has been particularly challenging to highlight this complexity in our synthesis. Policy-makers and practitioners should consider that the logic models presented here may be somewhat simplified, and that conflation of the factors represented as well as complexity in relationships is likely to occur among families experiencing housing insecurity. Conclusions Housing insecurity among CYP in families in the UK can take many forms and result from several, often inter-related, situations including being evicted or having a forced move, living in temporary accommodation, experiencing overcrowding, exposure to problematic behaviour, poor-condition/unsuitable property, and making multiple moves. The resultant housing insecurity can have multiple (often simultaneous) impacts, including school-related, psychological, financial and family well-being impacts, having to travel long distances to attend school and see friends, having to live in a property that was unsuitable or in a poor state of repair, overcrowded and often noisy, all of which could then further exacerbate housing insecurity. These experiences can impact on health and well-being, in terms of mental health problems (which could manifest in physical ways) and physical health problems related to poor housing conditions. Some experiences and situations can lessen the impact of housing insecurity, including friendship and support, staying at the same school, having hope for the future and protective parenting; and in some groups, as the relocation population, influencing the decision was also a protective factor. The negative impacts of housing insecurity on health and well-being may be compounded by specific situations and life circumstances, such as escaping domestic violence, being a migrant, refugee or asylum seeker (or having a parent with that status), or a forced relocation due to housing demolition. Our review findings suggest that policies should focus on reducing housing insecurity among families, particularly in relation to reducing eviction, improving and reducing the need for temporary accommodation, minimum requirements for property condition, and support to reduce multiple moves and moves far from families’ desired location. All those working with children and families experiencing housing insecurity should give them optimal choice and control over situations that affect them, as far as possible. Study registration This study is registered as PROSPERO CRD42022327506. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR135455) and is published in full in Public Health Research; Vol. 11, No. 13. See the NIHR Funding and Awards website for further award information. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
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