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Association Between Rental Assistance Programs and Undiagnosed Diabetes Among U.S

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Abstract

Background

Rental assistance programs have been linked to better housing quality, stability, healthcare access, and reduced likelihood of uncontrolled diabetes. However, its direct association with diabetes screening is uncertain.

Objective

To determine whether federal rental assistance programs are associated with lower odds of undiagnosed diabetes.

Design

We used a quasi-experimental approach, comparing outcomes among adults receiving rental assistance to those who entered assisted housing within 2 years after their health data were collected. We test the a priori hypothesis that rental assistance will be associated with decreased odds of undiagnosed diabetes.

Participants

Participants in the National Health and Nutrition Examination Survey 1999–2018 who received rental assistance and who had diabetes.

Intervention

Current rental assistance participation, including specific housing programs.

Main Measures

Undiagnosed diabetes based on having hemoglobin A1c ≥ 6.5% but answering no to the survey question of being diagnosed with diabetes.

Key Results

Among 435 eligible adults (median age 54.5 years, female 68.5%, non-Hispanic white 32.5%), 80.7% were receiving rental assistance programs at the time of the interview, and 19.3% went on to receive rental assistance within 2 years. The rates of undiagnosed diabetes were 15.0% and 25.3% among those receiving rental assistance programs vs. those in the future assistance group (p-value = 0.07). In an adjusted logistic regression model, adults receiving rental assistance had lower odds of undiagnosed diabetes (OR 0.52, 95% CI 0.28–0.94) than those in future assistance groups. Sex, race and ethnic group, educational level, and poverty ratio were not significantly associated with having undiagnosed diabetes, but individuals aged 45–64 years had significantly lower odds of undiagnosed diabetes (OR 0.21, 95% CI 0.08–0.53) compared with those aged 18–44.

Conclusions

Rental assistance was linked to lower odds of undiagnosed diabetes, suggesting that affordable housing programs can aid in early recognition and diagnosis, which may improve long-term outcomes.

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References

  1. Ogurtsova K, Guariguata L, Barengo NC, et al. IDF diabetes Atlas: Global estimates of undiagnosed diabetes in adults for 2021. Diabetes Res Clin Pract. Jan 2022;183:109118. doi:https://doi.org/10.1016/j.diabres.2021.109118

    Article  PubMed  Google Scholar 

  2. Mosley-Johnson E, Walker RJ, Thakkar M, et al. Relationship between housing insecurity, diabetes processes of care, and self-care behaviors. BMC Health Service Res. 2022/01/13 2022;22(1):61. doi:https://doi.org/10.1186/s12913-022-07468-7

    Article  PubMed  PubMed Central  Google Scholar 

  3. Incidence of Newly Diagnosed Diabetes. Updated September 2022. Accessed July 6, 2023. https://www.cdc.gov/diabetes/data/statistics-report/newly-diagnosed-diabetes.html

  4. Whicher CA, O’Neill S, Holt RIG. Diabetes in the UK: 2019. Diabet Med. Feb 2020;37(2):242-247. doi:https://doi.org/10.1111/dme.14225

    Article  CAS  PubMed  Google Scholar 

  5. Housing Instability. Accessed July 7, 2023. https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/housing-instability

  6. Keene DE, Henry M, Gormley C, Ndumele C. ‘Then I Found Housing and Everything Changed’: Transitions to rent-assisted housing and diabetes self-management. Cityscape. 2018;20(2):107-118. doi:https://doi.org/10.2307/26472170

    Article  PubMed  PubMed Central  Google Scholar 

  7. Bernstein RS, Meurer LN, Plumb EJ, Jackson JL. Diabetes and hypertension prevalence in homeless adults in the United States: a systematic review and meta-analysis. Am J Public Health. Feb 2015;105(2):e46-60. doi:https://doi.org/10.2105/AJPH.2014.302330

    Article  PubMed  PubMed Central  Google Scholar 

  8. Stewart A, Sandel M. Housing Instability and Quality. In: Alter HJ, Dalawari P, Doran KM, Raven MC, eds. Social Emergency Medicine: Principles and Practice. Springer International Publishing; 2021:255-271.

  9. GARTLAND E. Chart Book: Funding Limitations Create Widespread Unmet Need for Rental Assistance. 2023. https://www.cbpp.org/research/housing/funding-limitations-create-widespread-unmet-need-for-rental-assistance#:~:text=Only%205.3%20million%20(1%20in,fraction%20of%20renters%20in%20need.

  10. Schapiro R, Blankenship K, Rosenberg A, Keene D. The effects of rental assistance on housing stability, quality, autonomy, and affordability. Hous Policy Debate. 2022;32(3):456-472. doi:https://doi.org/10.1080/10511482.2020.1846067

    Article  PubMed  Google Scholar 

  11. Fenelon A, Mayne P, Simon AE, et al. Housing assistance programs and adult health in the United States. Am J Public Health. Apr 2017;107(4):571-578. doi:https://doi.org/10.2105/AJPH.2016.303649

    Article  PubMed  PubMed Central  Google Scholar 

  12. Denary W, Fenelon A, Schlesinger P, Purtle J, Blankenship KM, Keene DE. Does rental assistance improve mental health? Insights from a longitudinal cohort study. Soc Sci Med. Aug 2021;282:114100. doi:https://doi.org/10.1016/j.socscimed.2021.114100

    Article  PubMed  PubMed Central  Google Scholar 

  13. Simon AE, Fenelon A, Helms V, Lloyd PC, Rossen LM. HUD Housing assistance associated with lower uninsurance rates and unmet medical need. Health Aff (Millwood). Jun 1 2017;36(6):1016-1023. doi:https://doi.org/10.1377/hlthaff.2016.1152

    Article  PubMed  PubMed Central  Google Scholar 

  14. Fenelon A, Lipska KJ, Denary W, et al. Association between rental assistance programs and hemoglobin A1c levels among US adults. JAMA Netw Open. Jul 1 2022;5(7):e2222385. doi:https://doi.org/10.1001/jamanetworkopen.2022.22385

    Article  PubMed  PubMed Central  Google Scholar 

  15. Fain JA. Nhanes. Diabetes Educ. Apr 2017;43(2):151. doi:https://doi.org/10.1177/0145721717698651

    Article  PubMed  Google Scholar 

  16. The Linkage of the National Center for Health Statistics (NCHS) Survey Data to U.S. Department of Housing and Urban Development (HUD) Administrative Data: Linkage Methodology and Analytic Considerations chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cdc.gov/nchs/data/datalinkage/NCHS-HUD-Linked-Data-Methodology-and-Analytic-Considerations.pdf

  17. Lloyd PC, Helms VE, Simon AE, et al. Linkage of 1999-2012 national health interview survey and national health and nutrition examination survey data to U.S. department of housing and urban development administrative records. Vital Health Stat 1. 2017;(60):1-40.

  18. Boudreaux M, Fenelon A, Slopen N. Misclassification of rental assistance in the national health interview survey: evidence and implications. Epidemiology. Sep 2018;29(5):716-720. doi:https://doi.org/10.1097/EDE.0000000000000861

    Article  PubMed  PubMed Central  Google Scholar 

  19. Schwartz AE, Horn KM, Ellen IG, Cordes SA. Do housing vouchers improve academic performance? evidence from New York City. J Policy Anal Manage. 2020;39(1):131-158. doi:https://doi.org/10.1002/pam.22183

    Article  Google Scholar 

  20. Elwert F, Pfeffer FT. The Future Strikes Back: Using future treatments to detect and reduce hidden bias. Sociol Methods Res. Aug 2022;51(3):1014-1051. doi:https://doi.org/10.1177/0049124119875958

    Article  MathSciNet  PubMed  Google Scholar 

  21. Picture of Subsidized Households. 2023. https://www.huduser.gov/portal/datasets/assthsg.html

  22. Nwaneri C, Cooper H, Bowen-Jones D. Mortality in type 2 diabetes mellitus: magnitude of the evidence from a systematic review and meta-analysis. The British Journal of Diabetes & Vascular Disease. 2013;13(4):192-207. doi:https://doi.org/10.1177/1474651413495703

    Article  Google Scholar 

  23. Sinha DD, Williams RC, Hollar LN, et al. Barriers and facilitators to diabetes screening and prevention after a pregnancy complicated by gestational diabetes. PLoS One. 2022;17(11):e0277330. doi:https://doi.org/10.1371/journal.pone.0277330

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Vijayaraghavan M, Jacobs EA, Seligman H, Fernandez A. The association between housing instability, food insecurity, and diabetes self-efficacy in low-income adults. J Health Care Poor Underserved. Nov 2011;22(4):1279-91. doi:https://doi.org/10.1353/hpu.2011.0131

    Article  PubMed  Google Scholar 

  25. Berkowitz SA, Meigs JB, DeWalt D, et al. Material need insecurities, control of diabetes mellitus, and use of health care resources: results of the measuring economic insecurity in diabetes study. JAMA Intern Med. Feb 2015;175(2):257-65. doi:https://doi.org/10.1001/jamainternmed.2014.6888

    Article  PubMed  PubMed Central  Google Scholar 

  26. Swope CB, Hernandez D. Housing as a determinant of health equity: A conceptual model. Soc Sci Med. Dec 2019;243:112571. doi:https://doi.org/10.1016/j.socscimed.2019.112571

    Article  PubMed  PubMed Central  Google Scholar 

  27. Blankenship KM, Rosenberg A, Schlesinger P, Groves AK, Keene DE. Structural Racism, the Social determination of health, and health inequities: The intersecting impacts of housing and mass incarceration. Am J Public Health. Jan 2023;113(S1):S58-S64. doi:https://doi.org/10.2105/AJPH.2022.307116

    Article  PubMed  PubMed Central  Google Scholar 

  28. Gaskin DJ, Thorpe RJ, Jr., McGinty EE, et al. Disparities in diabetes: the nexus of race, poverty, and place. Am J Public Health. Nov 2014;104(11):2147-55. doi:https://doi.org/10.2105/AJPH.2013.301420

    Article  PubMed  PubMed Central  Google Scholar 

  29. Willner S, Whittemore R, Keene D. "Life or death": Experiences of insulin insecurity among adults with type 1 diabetes in the United States. SSM Popul Health. Aug 2020;11:100624. doi:https://doi.org/10.1016/j.ssmph.2020.100624

    Article  PubMed  PubMed Central  Google Scholar 

  30. Mosley-Johnson E, Walker RJ, Nagavally S, et al. Relationship between food insecurity and housing instability on quality of care and quality of life in adults with diabetes. PLoS One. 2022;17(12):e0278650. doi:https://doi.org/10.1371/journal.pone.0278650

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Denary W, Fenelon A, Whittaker S, Esserman D, Lipska KJ, Keene DE. Rental assistance improves food security and nutrition: An analysis of National Survey Data. Prev Med. Apr 2023;169:107453. doi:https://doi.org/10.1016/j.ypmed.2023.107453

    Article  PubMed  Google Scholar 

  32. Borrell LN, Dallo FJ, White K. Education and diabetes in a racially and ethnically diverse population. Am J Public Health. Sep 2006;96(9):1637-42. doi:https://doi.org/10.2105/AJPH.2005.072884

    Article  PubMed  PubMed Central  Google Scholar 

  33. Schneider AL, Pankow JS, Heiss G, Selvin E. Validity and reliability of self-reported diabetes in the Atherosclerosis Risk in Communities Study. Am J Epidemiol. Oct 15 2012;176(8):738-43. doi:https://doi.org/10.1093/aje/kws156

    Article  PubMed  PubMed Central  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA

    Carolina Gonzalez-Lopez MD & Kasia J. Lipska MD

  2. Section of Endocrinology, Yale University, 333 Cedar Street, P.O. Box 208020, New Haven, CT, 06520, USA

    Carolina Gonzalez-Lopez MD

  3. School of Public Health, University of Minnesota-Twin Cities, Minneapolis, MN, USA

    Andrew Fenelon PhD

  4. Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA

    Whitney Denary MPH, Penelope Schlesinger BA & Danya Keene PhD

  5. Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA

    Denise Esserman PhD

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  1. Carolina Gonzalez-Lopez MD
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Corresponding author

Correspondence to Carolina Gonzalez-Lopez MD.

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Conflict of Interest

Funding for this project was provided by grants R01 DK124500 from the NIDDK, NIH (Dr Keene); UL1 TR001863 from the National Center for Advancing Translational Sciences (Dr Esserman); and P2C HD041025 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (Dr Fenelon). This paper’s authors would like to clarify that no conflicts of interest or disclaimers will be reported. The research presented herein is solely based on the author’s independent work. It does not involve any financial or personal relationships that could have influenced this paper’s content, methodology, or conclusions. Dr. Lipska has stated that she is in receipt of grant support from NIH, other support from CMS, and royalties from UpToDate.

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Gonzalez-Lopez, C., Fenelon, A., Lipska, K.J. et al. Association Between Rental Assistance Programs and Undiagnosed Diabetes Among U.S. J GEN INTERN MED (2024). https://doi.org/10.1007/s11606-024-08673-2

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