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Q+A: Links Between Eviction, Post-Traumatic Stress, and Emergency Department Use

Emergency Department signage in city

September 27, 2022

New research led by members of the Dornsife School of Public Health (DSPH) titled “Eviction, post-traumatic stress, and emergency department use among low-income individuals in New Haven, CT” will be published in Preventive Medicine Reports Vol. 29 in October 2022.

Patrick Smith, BSN RN, a doctoral student in DSPH’s Community Health and Prevention (CHP) Department is lead author.

Other contributors include Ali Groves, PhD, MHS, Assistant Professor in the CHP Department, Brent Langellier, PhD, MA, Associate Professor in the Health Management and Policy Department, both at Dornsife, and researchers at Yale University School of Public Health and American University.

"Our findings can inform efforts to make healthcare more responsive to the unique disruptions posed by forced moves, while also informing ongoing efforts to advocate for policies that prevent such moves." - Lead author Patrick Smith, BSN RN

In addition to this publication, Smith presented this research at a panel on housing and population health at the Interdisciplinary Association for Population Health Science 2022 Annual Conference on September 23 in Minneapolis, MN.

While policies enacted during the COVID-19 pandemic led to significant reductions in legal eviction filings, legal and informal evictions have continued. There is an imminent need to address the country’s growing housing crisis and the many adverse health outcomes associated with it.

Smith answered some questions about the research, which found strong links between eviction, post-traumatic stress, and emergency department use among low-income individuals.

What are the associations between landlord-related forced moves with emergency department use over time?

Each year, millions of Americans are legally evicted from their homes, and millions of additional renters are forced to move through informal eviction processes, including threats and coercion.

Past research has established that legal eviction is associated with worsened physical and mental health and that the health-related impacts of eviction can last for years. However, comparatively few studies have examined how disruptions related to eviction influence healthcare use.

Using data from a longitudinal cohort study of low-income adults in New Haven, CT, we sought to examine whether landlord-related forced moves—including, but not limited to, legal eviction—were associated with a higher likelihood of subsequent emergency department (ED) use.

We found that individuals who experienced a landlord-related forced move were more than twice as likely to report ED use as those who did not experience such a move – a finding which persisted after accounting for an array of sociodemographic and other health-related factors. We further found that this association persisted over time, that the effects of legal eviction were similar to those of landlord-related forced moves more broadly, and that high degrees of post-traumatic stress among those who used the ED post-eviction helped to explain this association.

What do these findings tell us?

Our findings suggest that individuals subjected to any type of landlord-related forced move (i.e., legal or otherwise) are more likely to have poor mental health and use the ED than those without such disruptions. Demonstrating this link between landlord-related forced moves, mental health, and healthcare use is especially important in light of evidence (from studies in Milwaukee, Philadelphia, and nationally) that informal evictions are as common (or more common) than legal evictions.

Our findings suggest that there is a continued need to integrate trauma-informed care approaches, and housing and mental health support, into emergency care delivery. At the same time, clinical interventions alone are unlikely to dramatically reduce evictions or their negative health impacts among U.S. renters. Rather, further structural interventions are urgently needed to increase access to safe, stable, and affordable housing, particularly for those most vulnerable to eviction.

What kinds of structural interventions that promote housing stability are needed?

The leading cause of eviction is non-payment of rent, which is tied to a longstanding shortage of affordable housing in the United States. Across the country, nearly half of all renter households are cost-burdened, spending over 30 percent of their income on rent and utilities; for poor households, this problem is worse.

The high (and increasing) cost of rental housing has significant implications for health. Rent burdens reduce the amount of money that renters can spend on healthy food, education, transportation, medical care, and other household necessities, while also increasing the likelihood that a single unexpected event—an illness, a job loss, a transportation disruption—may result in eviction due to non-payment of rent.

Despite this, just 1 in 4 income-eligible renters receive federal housing assistance. Waitlists for housing assistance in many jurisdictions are years long, and in some cases, are closed. Expanding access to housing assistance—through the construction of new units, renovation of existing units, and increased funding for housing voucher programs, among other initiatives—may help to reduce cost burdens and therefore promote housing stability.

At the same time, there is a need for interventions that aim to keep existing renters in their homes. Whereas most landlords are represented by legal counsel in court eviction proceedings, most tenants are not. Expanding access to legal representation (e.g., through right to counsel legislation and eviction diversion programs) may offer important opportunities to prevent default eviction filings and protect tenants' other housing-related rights; ongoing research can determine the health-related impacts of such programs.

How will these interventions help to advance health equity?

Across the country, Black, Latinx, and female renters are evicted at alarmingly high rates. Poor Black women – and particularly those with children – are among those most likely to be evicted.

Differential exposures to eviction hold significant implications for health equity throughout the life course. Evictions exacerbate financial strain, impact health, and disrupt future housing stability. Compared to those who are not evicted, children born to parents who are evicted are more likely to be born prematurely or at low birthweight, to experience a higher risk of household food insecurity during early childhood, and to have lower school performance at age nine. Coupled with evictions' direct effects on physical and mental health, such stresses are likely to have significant, long-lasting effects on health equity.

Our study illustrates one more potential mechanism through which eviction affects individuals' health. Our findings can inform efforts to make healthcare more responsive to the unique disruptions posed by forced moves, while also informing ongoing efforts to advocate for policies that prevent such moves.

Why are these findings important for public health and policymakers?

Our work adds to a growing body of evidence that housing and health are inextricably linked.

As healthcare systems continue to face strain related to emerging infectious diseases, worsening population-level mental health, and high degrees of staff burnout, there is an urgent need to invest in strategies that promote health and reduce potentially preventable healthcare use. Our findings—that eviction is a potentially traumatizing event that is linked to a higher likelihood of subsequent emergency department use—can inform both clinical practice and advocacy. Specifically, findings suggest that investing in eviction prevention may help reduce strain on healthcare systems by protecting renters' mental health. 

Read the full publication