Project-based housing linked to reductions in uncontrolled diabetes
U.S. adults living in project-based, federally subsidized housing were less likely to have uncontrolled diabetes than their peers wait-listed for the housing program, according to study data.
The findings were published in JAMA Network Open.
The catalyst for the study was to assess whether stable and affordable housing would allow individuals to maintain complex treatment regimens to reduce HbA1c and prevent diabetes or manage diabetes outcomes, according to Andrew Fenelon, PhD, assistant professor of public policy and sociology at Penn State University.
“We used a unique nationally representative data source that links survey and biomarker data — including direct HbA1c measurements — with participation in federal rental assistance programs,” Fenelon told Healio.
Specifically, Fenelon and colleagues used data from the National Health and Nutrition Examination Survey, which they linked with U.S. Department of Housing and Urban Development records of rental assistance participation. The study included adults aged at least 45 years who received two types of rental assistance — project-based housing or housing vouchers — at the time of the NHANES interview, as well as those receiving rental assistance within the subsequent 2 years (the waitlist group).
The researchers collected data from 1999 to 2016.
Level of continuous HbA1c served as the primary outcome. An HbA1c cut point of 5.7% to 6.5% served as prediabetes, greater than 6.5% as diabetes and 9% or greater as uncontrolled diabetes.
Overall, the study included 1,050 adults (41.6% aged at least 65 years; 70.1% women), of whom 795 were receiving rental assistance at time of the interview (project-based housing, n = 450; housing vouchers, n = 345), and 255 received rental assistance within 2 years after the interview.
Researchers observed nonstatistically significantly lower HbA1c levels among participants in project-based housing compared with those on the waitlist. There was no significant difference in HbA1c levels between those receiving housing vouchers and those on the waitlist (beta = 0.051; 95% CI, 0.182 to 0.284).
Compared with adults on the waitlist, those in project-based housing had a lower likelihood of uncontrolled diabetes (3.7 percentage points; 95% CI, 7 to 0).
“The results indicate that rental assistance can be a platform to improve diabetes outcomes, but effects are limited to project-based programs,” Fenelon said. “Although this may seem counterintuitive, it is consistent with much existing evidence on the effects of rental assistance on life course health.”
For more information:
Andrew Fenelon, PhD, can be reached at afenelon@psu.edu; Twitter: @andyfenelon.
Perspective
Back to Top
Housing is a social determinant of health, which is why diabetes learning health systems, such as the T1D Exchange QI Collaborative, have prioritized screening for housing insecurity and other social determinants of health, partnering with the community to ensure people are housed in a clean and safe environment.
As a population health researcher, I congratulate Fenelon and colleagues for a critical examination into the critical topic of the association between rental assistance programs and HbA1c levels, using a representative sample of U.S. adults. The study found that adults receiving rental assistance through project-based housing were less likely to have an uncontrolled HbA1c level, which is good news; a similar association was not found for patients receiving housing vouchers, which was surprising.
The researchers described several other studies that have previously demonstrated that diabetes outcomes are impacted by structural and social inequities, such as housing. However, this study adds to the growing evidence in the field in a novel manner.
There are numerous limitations to the study, many of which were well described by the authors in the article. An additional limitation, in my opinion, which should have been discussed given the ongoing COVID-19 pandemic, is that the analyzed data were collected before the ongoing pandemic (1999-2016). I will be curious on how outcomes might differ with more recent data considering how COVID-19 has disproportionately impacted people with diabetes and people of color and the impact of public health emergency federal policies.
Another limitation is limited discussion of other potential systemic programs/policies during the study period by federal, state or community organizations that might have contributed to the observed association for adults receiving project-based assistance as opposed to those on voucher-based assistance. For example, there were a few major programs to improve community-clinical partnerships for public housing residents and several smaller programs happening across the U.S. similar to one my colleagues and I led for five public housing developments in Boston, which was associated with improved HbA1c outcomes.
Finally, as to why studies exploring associations and contributions to inequities are important, I argue there needs to be stronger emphasis on innovative studies testing innovative solutions across different levels. Many groups across the U.S. are exploring these kinds of initiatives, including ongoing health equity work at the T1D Exchange QI Collaborative.
Collapse