Is Housing a Neglected Social Determinant of Health?
Is housing a neglected social determinant of health? A recent Lancet editorial seems to think so, highlighting how improved housing is rarely prioritised in public and global health narratives.1 In contrast, research on the topic of “neighbourhood” has increased substantially since the 2000s, as seen in the trends in the citation of “housing” or “neighborhood/neighbourhood” in PubMed listed publications (see Figure 1 below).
Figure 1: Citations of “housing” and “neighborhood/neighbourhood” in the titles of PubMed listed publications since 1945.
One of the reasons for doing research is to discover new factors or new insights. It comes as no surprise to anyone that we spend much of our day indoors at home, although the actual amount may be surprising for some people. On average, around 60%–70% of our day as adults is spent at home indoors in most countries.2 Furthermore, the time we spend at home has been increasing since 2000. U.S. adults increased their time spent at home on a typical day from 2003 to 2022 by one hour and 39 minutes.3 This was increasing well before the COVID-19 pandemic, and the increases in time spent at home during the pandemic has remained high after the COVID-19 lockdowns.
There is also a strong age patterning with the very young and older adults spending more time at home indoors. Adults aged 65 and over in the US spend more than 20 hours day at home.4 So, in terms of the amount of exposure to health-related risks and benefits, the home environment is absolutely key, given the amount of time we spend at home. So why is it that research on housing gets comparatively less attention as a topic than the neighbourhood since the 2000’s? There could be a few reasons.
There are new sources of neighbourhood data (including green space, transport and pollution data) and types of analytical methods (such as multilevel models) since the early 2000s have enabled a much greater focus on neighbourhood level factors in health than before. While this is largely true, a greater focus on the neighbourhood should not mean we ignore housing related factors as a determinant of health. Moreover, poor quality housing is an important confounding factor when analysing neighbourhood effects on health.
Housing research could be viewed as a bit unfashionable, as there is not much new research needed for housing factors in relation to health, given that housing is a well-established social determinant of health. Existing conceptual models have highlighted the importance of housing as a social determinant of health in terms of the physical health effects of toxins within the home, damp and mould, excessively cold or hot indoor temperatures, overcrowding, indoor safety factors/home hazards and the negative mental health effects arising from poor quality and insecure housing. However, despite these well-established models, existing reviews of interventions to improve healthy ageing5 or risk factors for disability6 fail to mention any specific role for housing interventions.
The relatively lack of research into housing as a social determinant of health becomes more urgent when it comes to understanding healthy ageing and related interventions. Given that older adults tend to spend only 4 hours each day outside their home, most of the social determinants of healthy ageing cannot ignore the role of the home environment. There are increasing amounts of high-quality data on housing and health available through household surveys of older adults from around the world. Researchers on the social determinants of healthy ageing should not ignore the role of housing as a social determinant of health.
References:
The Lancet. Housing: an overlooked social determinant of health. The Lancet. 2024 May;403(10438):1723.
Khajehzadeh I, Vale B. How New Zealanders distribute their daily time between home indoors, home outdoors and out of home. Kōtuitui: New Zealand Journal of Social Sciences Online. 2017 Jan 2;12(1):17–31.
Sharkey P. Homebound: The Long-Term Rise in Time Spent at Home Among U.S. Adults. SocScience. 2024;11:553–78.
Spalt EW, Curl CL, Allen RW, Cohen M, Adar SD, Stukovsky KH, et al. Time–location patterns of a diverse population of older adults: the Multi-Ethnic Study of Atherosclerosis and Air Pollution (MESA Air). J Expo Sci Environ Epidemiol. 2016 Jun;26(4):349–55.
Michel JP, Dreux C, Vacheron A. Healthy ageing: Evidence that improvement is possible at every age. European Geriatric Medicine. 2016 Jul;7(4):298–305.
White H, Saran A, Kuper H. Evidence and gap map of studies assessing the effectiveness of interventions for people with disabilities [Internet]. Centre for Excellence and Development Impact and Learning (CEDIL); 2018 [cited 2025 Feb 5]. Available from: https://policycommons.net/artifacts/3785429/cedil-inception-paper-12-egm-report/4591191/
