4 Literature Review

Authors’ Note:

There are very few articles that address the specific phenomenon of interest to us in this research study. We searched for others who may have similar interests or may be using similar lenses. This review reflects their research and recognizes that because health impacts the whole person, we had to consult many different disciplines to see how they approached the issue of housing as a social determinant of health and design. We recognize that the literature that is reflected in this review is heavily weighted on the social impacts of housing – including mental health and wellbeing. This is because the research and the literature reflect more work in this area. The contribution of design to mental health and wellbeing – in the area of affordable or supportive affordable housing is underexplored. Many of the articles that have been published on housing and the social determinants of health are US or UK based, and so we are also aware that there is a need to generate more empirical research and evidence of both the need for and the value of affordable housing, and good design on positive health outcomes within a Canadian context.

Affordable Housing, Design and Their Impact on Health and Wellbeing

Introduction

Social Determinants of Health (SDOH) are aspects of one’s life which can impact them either positively or negatively in their development. Housing is a key SDOH that is a basic human right and its provision is important to our wellbeing (CMHA, n.d.). The impact of housing on health is now widely considered by policy makers to ensure effective intervention. Housing is one of the best-researched SDOH, and selected housing interventions for low-income people have been found to improve health outcomes and decrease health care costs (Taylor, 2018). A basic human right, housing is a necessity for living a physically and mentally healthy life (Raphael et al., 2020, p.38). There are many health benefits that stem from the provision of affordable housing options (Maqbool et al., 2015; Kottke, 2017). A number of research studies concentrate on the physical impacts of inadequate housing (Pomeroy & Marquis-Bissonnette, 2016) while others address the impact on mental health and wellbeing (Gibson et al., 2011). Krieger and Higgins (2002) make the point that physical impacts are easier to measure and provide evidence of those impacts on mental health and wellbeing.

 As a highly-industrialized country, Canada, is experiencing a housing crisis and has been for several decades and the precariousness of housing is further aggravated in 2020 as a result of COVID-19 (MacKinnon & Cooper, 2020). Physical distancing and safe health practices, such as hand-washing that are essential to limiting the spread of the disease, are even more difficult to achieve without adequate housing. Furthermore, the economic hardships faced by an increasingly large segment of the population serve to further highlight the inadequacy of housing for many (Tetley, 2020). Over the past thirty years, rents have risen well beyond the cost of living, particularly in urban areas. Raphael et al. (2020) refer to the inability to afford a place to live as housing insecurity, which, they say, is a ‘precursor to homelessness’(p.38). Accordingly, inadequate housing has three criteria that makes it so:

• affordability, in which the household spends 30 % or more of their income on shelter costs;
• suitability, by which housing is inappropriate for the size and composition of a household—for example, insufficient space for household size (overcrowding); and
• adequacy, in which the housing requires major repairs, such as those related to plumbing, or has structural damage. (Raphael et al., 2020, p.39; also reflected in Braveman, Dekker, Egerter, Sadegh-Nobari, & Pollack, 2011).

The definition above does not explicitly address the quality of housing that is considered affordable. Another framework for measuring housing as an SDOH devises three intersecting constructs: adequate housing conditions, affordability, and residential stability (Hernandez & Suglia, 2016, p.27). If any of these constructs are unmet, an array of negative impacts on mental and physical health become evident. When overall need for housing is met, there is the potential for long-term positive outcomes such as better health and wellbeing, decreased need for health services and increased self-reliance (Baxter, Tweed, Katikireddi & Thomson, 2019).

Both definitions share affordability as a common attribute. If rent or mortgages cannot be paid, the need for housing cannot be met and one’s health becomes precarious. Affordability of housing can have seriously adverse health impacts on individuals and families. The importance of affordability in terms of high housing costs can lead to stress as a result of fear of eviction as well as living in overcrowded conditions (Hernandez & Suglia, 2016, p.27). Studies show that many families resort to living in overcrowded conditions in an attempt to lower hosing costs which can result in potential spread of infectious disease as a result of increased exposure as well as impacting one’s mental health due to “…lack of personal space or privacy, enforced intimate proximity to people in the home with communicable diseases, and potentially excessive social or external demands” (Leventhal, & Newman, 2010, para.11).

If, from the outset, we can provide the means to make housing more affordable, we can focus on other factors such as the experience of the space – the value of experience and the feasibility of meeting other basic needs for residents, such as suitability, condition and stability.

Housing Condition and Stability – at What Price?

 There is ample research on housing as an SDOH and how the lack of certain inherent aspects will have negative impacts on healthy development. Returning to Hernandez & Suglia’s (2016) framework, we want to further explore the notion of adequate housing conditions (p.27). Poor conditions, in terms of the physical structure of the building, can have great influence on the health of its residents from both a corporeal and mental standpoint. Examples include, but are not limited to the following: mould, pest infestation, peeling paint, drafts and energy inefficiencies, and physical crowding which directly impact physical health (Hernandez & Suglia, 2016, p.27). A specific example of a health impact is dampness. Dampness in the home has been directly tied to the development of respiratory illnesses such as asthma (Raphael et al., 2020, p.39). Dampness has also been tied to worsening pre-existing respiratory conditions in residents (Raphael et al., 2020, p.39). In addition, studies show that poor housing conditions can impact learning in terms of childhood development; “Poor housing has been linked to cognitive delays in children from exposure to neurotoxins” (Hernandez & Suglia, 2016, p.28). Poor housing conditions have also been linked to more accidents for its residents as a result of structural deficiencies (Hernandez & Suglia, 2016, p.28). In summary, if the housing itself is not physically safe, residents will be subject to harm both in the short- and long-term. As a result, a clear understanding of the mechanics of building science is imperative to anyone constructing housing that is meant to last.

Residential stability can have further adverse health impacts; “instability, defined as frequent moves or in its most extreme form, homelessness, may indirectly impact health.” (Hernandez & Suglia, 2016, p.27). Residential stability also refers to the area in which the individuals and families live, not just the frequency of moves. Typically, areas that have lower rates of affordability are low in social capital and overall are considered to be poor areas; “Another study showed that children in areas with higher rates of unaffordable housing tended to have worse health, more behavioral problems and lower school performance” (Braveman, Dekker, Egerter, Sadegh-Nobari, & Pollack, 2011). If we consider then the area in which housing is achieved, it is imperative to look around the neighbourhood and understand how a new or renovated building can have an impact beyond its property line and vice versa.

When referencing the three intersecting constructs of housing as SDOHs; adequate housing conditions, affordability, and residential stability (Hernandez & Suglia, 2016, p.27), it is evident that for all three to be considered obtained is often unachievable as a result of individual’s means for living, their location, or supply. Often for one of the constructs to be met, for example, affordability; quality, or adequate housing conditions are sacrificed (As cited in Hernandez & Suglia, 2016, p. 29). This illustrates that although one’s housing may be affordable, they are still considered to be in an inadequate housing state because of either its condition or lack of stability, which will in turn negatively impact their physical and/or mental wellbeing. It is not a surprise, therefore, that more affordable areas where inexpensive housing is found are typically not high in social capital.

As for residential stability, affordability can lead to instability as families or individuals may be forced to move frequently in search of affordability leading to impacts on physical and/or mental health. We can therefore conclude that affordability does not mean high quality; and high quality usually means unaffordability. Residential stability is elusive when either affordability or adequate housing conditions are sacrificed for one another. And when that happens, homelessness is often the result.

Housing Policy and Homelessness

Housing, specifically affordable housing, is a public policy issue; “a homelessness emergency exists in many Canadian cities” (Raphael et al., p.38). Lack of affordable housing, along with an array of physical

Figure 1: Core Housing Need in Canada (2016 Census Data)

and mental health concerns as mentioned above, can lead to homelessness which itself causes a further array of physical and mental health concerns. Studies show that “homeless people experience a much greater rate of a wide range of physical and mental health problems than the general population. Likelihood of early death among homeless people is 8-10 times greater than the general population.” (Raphael et al., p.39). The Ontario Human Rights Commission’s 2008 report “Right at Home” points to data that shows 30% to 35% of the homeless population in general, and up to 75% of homeless women in particular, suffer from a mental illness (OHRC, 2008). The Wellesley Institute (2010) reports that individuals who are homeless or vulnerably-housed are at risk of the onset of new mental health problems. Additionally, the Ontario Human Rights Commission (2008) reports that having a safe place to live is a vital part of recovery from mental illnesses and addictions.

When the requirements of adequate housing conditions and affordability are met, the next step is to move toward increased residential stability. A resident of a home which has adequate housing conditions and meets the standards of affordability, will in turn, not have to frequently move to seek adequate shelter, increasing residential stability. For housing, as an SDOH, to ultimately present a positive impact in an individual’s life, high quality of housing must meet deep affordability; specifically, when referring to publicly-available, supportive housing, in order to combat the issue of homelessness. This requires an intentionality in design, both in the process and in the physical spaces that are created, to ensure that people get to the housing and that they stay (Baxter et al., 2019).

The Impact of Housing on Health and Wellbeing

Shaw’s model of the impact of housing on health is derived from a combination of both physical and psycho-social factors. At the heart of her model is the belief that housing is a basic human right, not just basic shelter but “security of tenure; availability of services, materials, facilities, and infrastructure; affordability; habitability; accessibility; and location and cultural adequacy” (p.397).

Figure 2: Direct and indirect (hard and soft) ways in which housing can affect health

Shaw categorizes (Figure 2) the different types of impacts housing can have on health. Much of her paper is devoted to the physical impacts of housing on health, but she also devotes some time to studies that have looked at the impact of housing on mental health and wellbeing. She makes a distinct connection between the ‘hard’ which are easier to measure and the ‘soft’ impacts, which are often more difficult to measure (Halpern, 1995; Macintyre et al., 2003; Weich et al., 2002).

Within the research studies that have been conducted looking at the psycho-social impacts of design that contribute to social isolation, there are sub-populations that appear more frequently than others, such as such as older adults living in residential facilities, are explored more in the literature than the homeless population (Castenson, 2018). And although there are some studies that look at design and mental health in lower income communities, and communities, like the homeless community who face multiple barriers (López et al., 2019), the majority of studies of this type focused on older adults who had secure housing but were facing the challenge of social isolation (i.e. Kalita, 2017; Engineer et al. 2018; Kasden, 2020).

The Contribution of Housing Design to Mental Health and Community Building

In this literature review, we have focused on the importance of addressing the SDOH because of their impact on both physical and mental health and wellbeing. Lai & Rios (2017) point to both housing condition and quality as well as community design as key in how individuals experience good health. There is significant evidence that sub-par housing conditions such as poor indoor air quality, high lead levels in paint, houses that are damp, high noise levels, presence of pests, and overcrowding can contribute to health problems such as asthma, infectious and chronic diseases, and mental health issues such as stress, anxiety, and depression (Krieger & Higgins, 2002; Srinivasan, O’Fallon, & Dearry, 2003).

Affordable housing must meet the adequate housing conditions of the physical structure to maximize positive impact. However, there is always a tension between design elements and affordable housing when it comes down to bottom line and budget (CMHC, 2018). Indwell, with their use of the Passive House model within their affordable housing developments is an exception to this and seems to be, if not the sole, at least the largest affordable housing provider using this approach in Canada (Cubitt &Cubitt, 2018).  “Architects, planners, and developers play roles in ensuring that the built environment is health-promoting. Factors such as walkability, access to services, healthy food, transportation, and safety all translate to better health” (De Scisciolo, Egger, & Ayala, 2018). In addition, quality design and construction are also of high importance; “…quality design and construction, coupled with regular building maintenance, can help to prevent illness and contribute to improved physical and mental wellbeing” (De Scisciolo, Egger, & Ayala, 2018).

When looking at the specific type of building that is most beneficial to health and wellbeing, “the physical infrastructure of housing should capitalize on modern building practices that emphasize high performance metrics in energy efficiency, ventilation, lighting, thermal comfort and the use of environmentally sound materials.” (Hernandez & Suglia, 2016).

The consideration of quality design and construction, coupled with modern building practices measured by performance metrics, is an interesting way to look at the design of housing. In fact, we would argue that the two are not mutually exclusive and when deliberately integrated into the entire development and delivery process of a building, there is the potential for the creation of housing that will contribute positively to the SDOHs. The challenge is in the judgement [imagining] of what constitutes quality design. While it is an important factor that is difficult to measure, Professor Magnus Rönn emphasizes that “good solutions rely upon knowledge of the cultural setting where the project belongs” (2010). In fact, this is exactly what works for Indwell as the developer of its own buildings. It is steeped in its own culture and understands better than anyone else what its residents need to thrive and can therefore insist on design that meets their threshold of quality, as they have designed for themselves.

Designing for the Whole Person

The literature discusses multiple barriers that some individuals face when seeking housing. We discussed earlier in this review that housing instability can very quickly turn into homelessness (Raphael et al., 2020). There are also a number of groups of people who are in particularly vulnerable situations when it comes to the risk of housing instability and the possibility of homelessness. Indeed, these are what the UN calls ‘deep disparities’ in access to adequate, affordable, safe, and secure housing for Indigenous peoples, women, members of racialized communities, persons with disabilities, trans and gender-diverse people, older adults, children and young people, migrants, refugees, asylum-seekers and stateless persons (Farha, 2018).

In addition to providing physical design features, the literature also discusses the importance of designing for the needs of the whole person. This means that there need to be more affordable supportable housing options developed that take the needs of the whole person into consideration. Housing First is a part of Canada’s Homelessness Strategy and it involves moving people experiencing homelessness – particularly chronic homelessness – rapidly from the street or shelter to supportive programing (Government of Canada, 2019). The alternative to this is supporting people through temporary programs until they ‘deal’ with their other issues (i.e. substance abuse issues). However, the lack of housing and stability can often aggravate these issues, making it difficult for individuals to resolve them and they are caught in a cycle of homelessness and temporary shelters and programs (Dohler et al, 2016).

Designing supportive affordable housing for the whole person can have many benefits including increased physical and mental health (Dohler et al., 2016). In their research based on studies of supportive, affordable housing (i.e. for persons with disabilities, older adults, or people in recovery) conducted in both Canada and the US, Dohler et al (2016) found that there were a number of important design considerations when planning for successful developments:

• Permanence and affordability: Tenants pay no more than 30% of their income for rent; they cannot be evicted for reasons unrelated to being a good tenant.
• Services are housing-oriented: Services aim to help tenants remain housed
• Services are multi-disciplinary: Services are flexible; Service providers may help tenants address physical health, mental health, and substance use conditions and may involve multiple service agencies working together
• Services are voluntary but assertive: Services are voluntary; tenants will not lose their housing simply because they do not participate in services.  But providers offer supportive services assertively, which means that they will continue to show up and check on someone even if tenants do not request help
• Integration: Tenants are able to live independently but should have access to public transportation, grocery stores, parks, and other neighbourhood amenities
• Emphasis on choice: Supportive housing maximizes client choice
• Low barriers to entry: Supportive housing providers do not require clients to hit benchmarks before moving into housing or put other screening barriers in the way.

There are six principles of the Housing First program – and the sixth principle states (Government of Ontario, 2019):

Strength-based and promoting self-sufficiency: The goal is to ensure clients are ready and able to access regular supports within a reasonable timeframe, allowing for a successful exit from the Housing First program. The focus is on strengthening and building on the skills and abilities of the client, based on self-determined goals, which could include employment, education, social integration, improvements to health or other goals that will help to stabilize the client’s situation and lead to self-sufficiency.

When housing is designed with the whole person in mind, people who have been homeless, become people who are housed and part of a community because the ‘game has changed’, and there is space to grow, to learn and to succeed at their own pace.

Conclusion and Invitation

The literature demonstrates the importance of affordable and supportive housing, and the significance of ensuring its quality. Good quality, safe, and intrinsically sound housing has clear benefits for our communities and, in particular, for the vulnerable members within them. The literature also points to the need for an intentionality in the physical and purposeful design of affordable housing that will support the whole person. In the pages ahead, we invite you into a case study, where this kind of intentional approach has been taking form and supporting tenants for the past decade.