Abstract

Objective:

To analyze by gender the relationship of forced displacements due to neglected housing insecurity with the physical and mental health of renters in Barcelona in 2019, distinguishing between economic (EHI) and legal (LHI) housing insecurity.

Method:

We conducted a cross-sectional study based on the Survey of the Living Conditions of Renters in the Barcelona Metropolitan Area 2019 (1021 women; 584 men). Self-reported health and mental well-being were the dependents variables; the main explanatory variable was neglected housing insecurity. We used adjusted robust Poisson regression models to compare health outcomes among people affected by neglected housing insecurity and those who were not affected.

Results:

We observed that the probability of worse health outcomes are greater in those affected by EHI, followed by those affected by LHI, both compared to those who have not been affected by housing insecurity. This association are mainly observed in mental health of renters affected by EHI, even after adjusting for socioeconomic and other housing variables (in women PR: 1,17, CI95%: 1,03-1,33; in men PR: 1,21, CI95%: 1,01-1,43).

Conclusions:

Neglected housing insecurity is associated with worse mental health. Enhancing the visibility of neglected housing insecurity and raising awareness of its effects on health is urgently needed to tackle this massive but hidden problem.

Keywords:
Housing insecurity; Housing; Public health; Mental health; Physical health

Resumen

Objetivo:

Analizar la relación de la inseguridad residencial desatendida sobre la salud física y mental de personas inquilinas residentes en Barcelona en 2019, distinguiendo entre inseguridad residencial económica (IRE) y legal (IRL).

Método:

Estudio transversal basado en la Encuesta de Condiciones de Vida de Personas Inquilinas en el Área Metropolitana de Barcelona 2019 (1021 mujeres y 584 hombres). Las variables dependientes fueron salud autopercibida y bienestar mental, y la principal variable explicativa fue inseguridad residencial desatendida. Se utilizaron modelos ajustados de Poisson robusta para comparar los resultados de salud entre personas afectadas y no afectadas.

Resultados:

La probabilidad de peor salud fue mayor en las personas afectadas por IRE, seguidas por las afectadas por IRL, ambas comparadas con quienes no habían sido afectadas. Esta asociación fue principalmente observada en la salud mental de las personas inquilinas afectadas por IRE, incluso tras ajustar por variables sociodemográficas y otras de vivienda (en mujeres, PR: 1,17, IC95%: 1,03-1,33; en hombres, PR: 1,21, IC95%: 1,01-1,43).

Conclusiones:

La inseguridad residencial desatendida se asocia con peor salud mental. Se necesita urgentemente visibilizar la inseguridad residencial desatendida y tomar conciencia de sus efectos en la salud para así afrontar este masivo, pero oculto, problema.

Palabras clave:
Inseguridad residencial; Vivienda; Salud pública; Salud mental; Salud física

Introduction

Currently, there is a widespread housing crisis, affecting millions of lives worldwide, and Europe is no exception.¹1. Pittini A, Laino E. Housing Europe Review. The Nuts and Bolts of European Social Housing Systems. 2012. Available at: https://www.housingeurope.eu/resource-105/the-housing-europe-review-2012.
https://www.housingeurope.eu/resource-10... This problem has become more evident after the housing market bubble burst in 2007, forcing various European states to take measures to alleviate the consequences of the collapse of the mortgage market.²2. Enoch C, Everaert L, Tressel T, et al. From fragmentation to financial integration in Europe. 2013. Available at: https://www.elibrary.imf.org/view/books/071/20740-9781484387665-en/20740-9781484387665-en-book.xml.
https://www.elibrary.imf.org/view/books/... These actions led to a shift in the housing bubble from property tenure to renting, as exemplified in Spain,³3. Bolsas y Mercados Españoles (BME), Jones Lang LaSalle (JLL). SOCIMIs. Estabilidad e inversión en el sector inmobiliario. Informe de Mercado. 2019. Available at: https://www.bolsasymercados.es/docs/BME/docsSubidos/SOCIMIs BMEJLL2019.pdf.
https://www.bolsasymercados.es/docs/BME/... ^,44. García-López MA, Jofre-Monseny J, Martínez Mazza R, et al. Do short-term rental plataforms affect housing markets? Evidence from Airbnb in Barcelona. J Urban Econ. 2020;119:103278. Available at: https://www.sciencedirect.com/science/article/pii/S0094119020300498.
https://www.sciencedirect.com/science/ar... Greece and Croatia.⁵5. Eurostat. Living Conditions in Europe - 2014 Edition. 2014. Available at: https://ec.europa.eu/eurostat/web/products-statistical-books/-/KS-DZ-14-001.
https://ec.europa.eu/eurostat/web/produc... ^,66. Eurostat. Living Conditions in Europe - 2018 Edition. 2018. Available at: https://ec.europa.eu/eurostat/web/products-statistical-books/-/KS-DZ-18-001.
https://ec.europa.eu/eurostat/web/produc... In the countries of the European Union, the rate of households allocating more than 40% of their income to rent has increased (rates from 26.2% to 28%, in 2012 and 2016, respectively), while this rate has decreased in households with mortgages (from 8.3% to 5.4%).⁵5. Eurostat. Living Conditions in Europe - 2014 Edition. 2014. Available at: https://ec.europa.eu/eurostat/web/products-statistical-books/-/KS-DZ-14-001.
https://ec.europa.eu/eurostat/web/produc... ^,66. Eurostat. Living Conditions in Europe - 2018 Edition. 2018. Available at: https://ec.europa.eu/eurostat/web/products-statistical-books/-/KS-DZ-18-001.
https://ec.europa.eu/eurostat/web/produc...

Housing insecurity is a complex phenomenon that may affect people's lives related to the housing dimensions of accessibility/affordability and stability.⁷7. Cortés Alcalá L. Indagaciones sobre la exclusión residencial. Arx Sociol. 2004;10:39-55. These dimensions, in turn, are mainly linked to economic and legal issues,⁸8. Vásquez-Vera H, Fernández A, Novoa AM, et al. Our lives in boxes: perceived community mediators between housing insecurity and health using a PHOTOVOICE approach. Int J Equity Health. 2019;18:1-14.^,99. Brändle G, García-Luque O. Measuring housing exclusion using the ETHOS typology. Housing, Care Support. 2015;18:113-24. such as living without the security of legal tenure (sub-renting, squatting or doubling-up), or being under a legal eviction process.⁹9. Brändle G, García-Luque O. Measuring housing exclusion using the ETHOS typology. Housing, Care Support. 2015;18:113-24.

However, there are other cases of housing insecurity that are less visible, usually naturalized due to their ordinary nature and lack of formal records.¹⁰10. Palomera J. Els sindicats de llogaters i la lluita per l'habitatge en el nou cicle de financiarització. Pap Regió Metrop Barcelona Territ Estratègies, Planejament. 2018;0:156-63.^,1111. Rodríguez-Dod EC. But My Lease Isn't Up Yet!": Finding Fault with "No- Fault" Evictions. UALRL Rev. 2012;35:839. This is the case of situations qualitatively different from the formal eviction process and which, therefore, do not involve a judicial or police process.¹⁰10. Palomera J. Els sindicats de llogaters i la lluita per l'habitatge en el nou cicle de financiarització. Pap Regió Metrop Barcelona Territ Estratègies, Planejament. 2018;0:156-63.^,1111. Rodríguez-Dod EC. But My Lease Isn't Up Yet!": Finding Fault with "No- Fault" Evictions. UALRL Rev. 2012;35:839. These situations are neglected types of housing insecurity, which we have classified into economic housing insecurity (being forced to leave a dwelling due to abusive rent increases or loss of household income) and legal housing insecurity (being forced to leave a dwelling in the absence of a legal lease agreement or unilateral termination of a valid lease agreement).

In Spain, the movement of the housing market bubble toward rental tenure can be observed in several indicators. For example, in the 2013-2019 period, housing prices decreased, while rents increased by 50%. This trend occurred in all the provincial capitals of the country, such as Barcelona.¹²12. Banco de España. Evolución reciente del mercado del alquiler de vivienda en España. Boletín Económico. 2019. Available at: https://www.bde.es/bde/es/secciones/informes/analisis-economico-einvestigacion/boletin-economico/index2019.html.
https://www.bde.es/bde/es/secciones/info... ^,1313. Observatori Metropolità de l'Habitatge de Barcelona. L'habitatge a la metrópoli de Barcelona 2018. Published online 2019:55. Available at: https://www.ohb.cat/wp-content/uploads/2019/07/Habitatgemetropolis 2018.pdf.
https://www.ohb.cat/wp-content/uploads/2... This trend is inconsistent with the household income growth in the country, which increased by only 1.3% in the same period.¹⁴14. Trilla C, Bosch J, Donat C, et al. Vivienda y derechos sociales en el área metropolitana de Barcelona. Barcelona: AMB; 2019. Available at: https://www.researchgate.net/publication/336058211 Vivienda y derechossociales en el area metropolitana de Barcelona.
https://www.researchgate.net/publication... Thus, in 2016, 43% of renters allocated 40% or more of their oncome to housing costs.⁶6. Eurostat. Living Conditions in Europe - 2018 Edition. 2018. Available at: https://ec.europa.eu/eurostat/web/products-statistical-books/-/KS-DZ-18-001.
https://ec.europa.eu/eurostat/web/produc...

Similarly, in this period, 440,107 evictions were registered in the country, 58% of them due non-payment of rent.¹⁵15. Consejo General del Poder Judicial. Datos sobre el efecto de la crisis en los órganos judiciales TSJ hasta 2019. Published online 2020. Available at: https://bityli.com/KUvvvG.
https://bityli.com/KUvvvG... The autonomous community with the most evictions during this period was Catalonia, with 100,935 evictions (23% of the national total), of which 64.8% were due to rental reasons.¹⁵15. Consejo General del Poder Judicial. Datos sobre el efecto de la crisis en los órganos judiciales TSJ hasta 2019. Published online 2020. Available at: https://bityli.com/KUvvvG.
https://bityli.com/KUvvvG... This situation is clearer in Barcelona city, where 84% of evictions are due to rent arrears.¹⁴14. Trilla C, Bosch J, Donat C, et al. Vivienda y derechos sociales en el área metropolitana de Barcelona. Barcelona: AMB; 2019. Available at: https://www.researchgate.net/publication/336058211 Vivienda y derechossociales en el area metropolitana de Barcelona.
https://www.researchgate.net/publication... Even though homeowners are affected by housing-related problems, the housing crisis has increased among renters, reflecting the shift in the housing bubble from the property market to the rental market.⁶6. Eurostat. Living Conditions in Europe - 2018 Edition. 2018. Available at: https://ec.europa.eu/eurostat/web/products-statistical-books/-/KS-DZ-18-001.
https://ec.europa.eu/eurostat/web/produc... ^,1414. Trilla C, Bosch J, Donat C, et al. Vivienda y derechos sociales en el área metropolitana de Barcelona. Barcelona: AMB; 2019. Available at: https://www.researchgate.net/publication/336058211 Vivienda y derechossociales en el area metropolitana de Barcelona.
https://www.researchgate.net/publication... ^,1515. Consejo General del Poder Judicial. Datos sobre el efecto de la crisis en los órganos judiciales TSJ hasta 2019. Published online 2020. Available at: https://bityli.com/KUvvvG.
https://bityli.com/KUvvvG...

Faced with this emergency housing context, various social movements emerged to tackle and safeguard people's right to housing.¹⁶16. Anzano Bergua X. Sindicat de Llogaters i Llogateres. El inquilinato insumiso. 2018 (Accessed September 22, 2019.) Available at: http://hdl.handle.net/10609/91293.
http://hdl.handle.net/10609/91293... Thus, in 2017 the “Sindicat de Llogateres” (Renters’ Union) was formed in Barcelona, whose main objective is to foster the collective vindication of renters’ rights and to influence administrative and government-related policies.¹¹11. Rodríguez-Dod EC. But My Lease Isn't Up Yet!": Finding Fault with "No- Fault" Evictions. UALRL Rev. 2012;35:839.

As far as we know, most of the studies on the topic have either addressed the problem of housing insecurity among owners or have not distinguished among types of tenure. Moreover, few studies have specifically addressed the relationship between housing insecurity and poor in renters.¹⁷17. Hulse K, Saugeres L. Housing insecurity and precarious living: an Australian exploration. AHURI Final Rep. 2008:1-51.

18. Clair A, Reeves A, Loopstra R, et al. The impact of the housing crisis on selfreported health in Europe: multilevel longitudinal modelling of 27 EU countries. Eur J Public Health. 2016;26:788-93.

19. Desmond M. Unaffordable America: poverty, housing, and eviction. Fast Focus Inst Res Poverty. 2015;22:1-6.

20. Desmond M, Kimbro RT. Eviction's fallout: housing, hardship, and health. Soc Forces. 2015;94:295-324.^-2121. Novoa AM, Ward J, Malmusi D, et al. How substandard dwellings and housing affordability problems are associated with poor health in a vulnerable population during the economic recession of the late 2000s. Int J Equity Health. 2015;14:1-11. For example, regarding general health, a study of 27 countries of European Union concluded that persons with housing insecurity reported worse self-rated health than unaffected individuals. Moreover, the negative health effects on renters were greater than those experienced by people with other types of tenure, even after adjustment by other sociodemographic variables.¹⁸18. Clair A, Reeves A, Loopstra R, et al. The impact of the housing crisis on selfreported health in Europe: multilevel longitudinal modelling of 27 EU countries. Eur J Public Health. 2016;26:788-93. The mental health effects of housing insecurity have been reported to be depression, anxiety and stress,¹⁷17. Hulse K, Saugeres L. Housing insecurity and precarious living: an Australian exploration. AHURI Final Rep. 2008:1-51.^,1919. Desmond M. Unaffordable America: poverty, housing, and eviction. Fast Focus Inst Res Poverty. 2015;22:1-6.

20. Desmond M, Kimbro RT. Eviction's fallout: housing, hardship, and health. Soc Forces. 2015;94:295-324.^-2121. Novoa AM, Ward J, Malmusi D, et al. How substandard dwellings and housing affordability problems are associated with poor health in a vulnerable population during the economic recession of the late 2000s. Int J Equity Health. 2015;14:1-11. mostly affecting women,²⁰20. Desmond M, Kimbro RT. Eviction's fallout: housing, hardship, and health. Soc Forces. 2015;94:295-324. single-parent households¹⁹19. Desmond M. Unaffordable America: poverty, housing, and eviction. Fast Focus Inst Res Poverty. 2015;22:1-6. and those with lower incomes.¹⁷17. Hulse K, Saugeres L. Housing insecurity and precarious living: an Australian exploration. AHURI Final Rep. 2008:1-51.^,1818. Clair A, Reeves A, Loopstra R, et al. The impact of the housing crisis on selfreported health in Europe: multilevel longitudinal modelling of 27 EU countries. Eur J Public Health. 2016;26:788-93.^,2121. Novoa AM, Ward J, Malmusi D, et al. How substandard dwellings and housing affordability problems are associated with poor health in a vulnerable population during the economic recession of the late 2000s. Int J Equity Health. 2015;14:1-11.It has also been observed that these effects are maintained over years, related to insecurities in other areas of people's lives (food, work, family life, and others), and have greater negative effects on the mental health of renters than that of owners.¹⁷17. Hulse K, Saugeres L. Housing insecurity and precarious living: an Australian exploration. AHURI Final Rep. 2008:1-51.^,1919. Desmond M. Unaffordable America: poverty, housing, and eviction. Fast Focus Inst Res Poverty. 2015;22:1-6.^,2020. Desmond M, Kimbro RT. Eviction's fallout: housing, hardship, and health. Soc Forces. 2015;94:295-324.

Despite the severity of this housing emergency, so far there is insufficient evidence on the relationship between health and neglected housing insecurity in renters, hindering policy design to tackle this issue. This study aimed to analyze the association of housing insecurity, both in its legal and economic dimensions, with self-rated health and mental health by gender among renters in Barcelona city in 2019.

Method

We performed a cross-sectional study. The study population consisted of people over 18 years old who were renters living in Barcelona city and who voluntarily completed the self-administered web survey “Renters’ Living Conditions of the Barcelona Metropolitan Area 2019”. The survey was designed by the Sindicat de Llogateres, La Hidra Cooperativa and the Barcelona Public Health Agency and was disseminated by social networks. The secondary data were provided by the Sindicat de Llogateres and La Hidra Cooperativa. The survey collected sociodemographic, residential and health information from the rental upswing period between the years 2014-2019.²²22. Banco de España. El mercado de la vivienda en España entre 2014 y 2019. Documentos Ocasionales. 2020. Available at: https://www.bde.es/f/webbde/SES/Secciones/Publicaciones/PublicacionesSeriadas/DocumentosOcasionales/20/Fich/do2013.pdf.
https://www.bde.es/f/webbde/SES/Seccione... Data were collected between March and May 2019 and, to ensure the independence of the observations, only one person was selected from each household. The survey was completed by 2051 individuals; subsequently, we excluded those not residing in Barcelona city. In addition, people who reported having been affected by formal evictions (n=8) were excluded as they were not part of the phenomenon to be studied. Thus, the study sample included 1637 participants (1021 women, 584 men, and 32 people not identifying with binary gender).

We used two measures of health status: mental health and self-rated health. Mental health was evaluated using the short version of the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS), which has been found to be a good proxy for mental health.²³23. Castellví P, Forero CG, Codony M, et al. The Spanish version of the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS) is valid for use in the general population. Qual Life Res. 2014;23:857-68. The variable was categorized in two groups: mental well-being (>26 points) and mental discomfort (≤26 points).²³23. Castellví P, Forero CG, Codony M, et al. The Spanish version of the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS) is valid for use in the general population. Qual Life Res. 2014;23:857-68.^,2424. Alayo I, Forero G, Vilagut G, et al. Reducción y validación de la escala WEMWBS (Warwick-Edimburgh Mental Well-Being Scale). 2019. In: XXX VII Reunión Científica de La Sociedad Española de Epidemiología y XIV Congresso Da Associação Portuguesa de Epidemiologia, Oviedo, Spain. 2019. Available at: https://www.gacetasanitaria.org/es-vol-33-num-sc-sumario-X0213911119X00C10.
https://www.gacetasanitaria.org/es-vol-3... Self-rated health was evaluated using the 5-category question “How would you say your health is in general?” We created a dichotomous outcome variable: good health (excellent, very good, good) and poor health (fair, poor).²⁵25. Quesnel-Vallée A. Self-rated health: caught in the crossfire of the quest for "true" health? Int J Epidemiol. 2007;36:1161-4.

The main explanatory variable, neglected housing insecurity, was constructed from two questions: “Have you changed your address in the last 5 years?” and “What was the main reason for this move?” We used this variable as categorical, including any of the following responses in the category “Legal Housing Insecurity” (LHI): “because the owner decided to end or not to renew the rental contract”, or “because the owner decided to evict me in the absence of a rental contract”. In contrast, the category “Economic Housing Insecurity” (EHI) was composed of persons who responded “due to financial difficulties because of the increase in housing prices” or “due to financial difficulties because of a decrease in household income”. Finally, the category “Without Housing Insecurity” was composed of both persons who did not move home and those who responded “it was a voluntary move, it was better adapted to my needs” or “it was a voluntary move, the dwelling was in poor physical condition”.

The following adjustment variables were included: employment status, occupational social class,²⁶26. Domingo-Salvany A, Bacigalupe A, Carrasco JM, et al. Propuestas de clase social neoweberiana y neomarxista a partir de la Clasificación Nacional de Ocupaciones 2011. Gac Sanit. 2013;27:263-72. age, nationality, rental situation, and risk of involuntary mobility in the next 6 months. Gender was treated as a stratification variable, based on the question “with which gender do you identify yourself?” (women, men, non-binary).

We carried out a descriptive analysis of the study variables to determine their distribution. Then, to carry out the next steps of the analysis, all persons not identifying with binary gender were excluded because there were very few cases (n=32), leaving a sample of 1605 individuals. Subsequently, a bivariate analysis was performed between the explanatory variable of the study and the sociodemographic and dependent variables, obtaining the prevalence between affected and unaffected people, and their magnitude of association using the chi-square or Fisher exact tests. Then, age-adjusted robust Poisson regression models (PRa) were fitted to compare health outcomes among people affected by neglected housing insecurity and those who were not affected. Finally, we calculated an adjusted model that included housing variables and the most relevant sociodemographic variables according to Wald's test (PRb). All the analyses were carried out stratifying by gender, using the statistical software STATA15.

Results

Analysis of the sociodemographic characteristics of the study sample showed that 50% of women were aged 35-50 years, while men and people with non-binary gender were mostly aged 18-34 years (45% and 46.9%) and 35-50 years (44.9% and 43.8%, respectively). Most participants were from Spain (∼90%). Regarding socioeconomic status, most reported being employed (women, 84.4%; men, 86.8%; non-binary gender, 84.8%) and belonging to managerial and senior professionals’ social classes (women, 63.9%; men, 58.6%; non-binary gender, 56.3%) (Table 1).

For housing conditions, most renters reported that they individually paid all the rent and housing costs (40.6%, women; 41.6%, men; 37.5%, non-binary gender), followed by those who rented with more people sharing the housing costs (38.3%, women; 38%, men; 28.1%, non-binary gender). In addition, most participants reported they were not at risk of involuntary displacement in the next 6 months.

Analysis of neglected housing insecurity showed that, among women, 12.4% reported they were under LHI and 12.3% were under EHI. Among men, 14.9% reported they were under LHI and 9.3% under EHI. Among persons not identifying with binary gender, the percentages were 12.5% and 25%, respectively (Table 2).

The group most affected by neglected housing insecurity, both legal and economic, were those renting a room (women, 19.1% and 31%, and men, 32% and 20%, respectively). The profile of people affected by LHI was mainly men from non-European Union countries (20%) and people who rented with other people without shared economy (women, 17.7%; men, 20.4%). EHI mainly affected people from the manual class (women, 13.6%; men, 12%) (Table 3).

The prevalence of mental discomfort showed a gradient, in which people affected by EHI reported a higher prevalence of mental discomfort (74.8%, women; 74%, men) than people affected by LHI (64.6%, women; 61.2%, men) and these, in turn, had a higher prevalence than those not reporting housing insecurity (60.3%, women; 60.2%, men), with this association being significant in women. Likewise, the PRa (95% confidence interval [95%CI]) of people affected by EHI was 1.2 (1.1-1.4) among women and 1.2 (1.0-1.5) among men compared with non-affected renters; the PRa (95%CI) of people affected by LHI was 1.1 (0.9-1.3) and 1.0 (0.8-1.2), respectively. The same gradient was observed for self-rated health: people affected by EHI reported a higher prevalence of poor self-rated health (15.1%, women; 14.1%, men) than people affected by LHI (12.5%, women; 11.5%, men), who, in turn, reported a higher prevalence than non-affected renters (11.1% women; 9.3%, men). In addition, the PRa (95%CI) of people affected by EHI was 1.6 (1.0-2.5) among women and 1.8 (0.9-3.7) among men compared to individuals without housing insecurity; in those who reported LHI, the PRa (95%CI) was 1.3 (0.8-2.1) and 1.4 (0.7-2.6), respectively.

When adjusting for sociodemographic variables, we found that women with EHI had a mental discomfort PRb of 1.2 (95%CI: 1.0-1.3) and that men with EHI had a PRb of 1.2 (95%CI: 1.0-1.4) compared to those without housing insecurity. The results for persons affected by LHI were not significant, although women affected by LHI showed a possible tendency to being so, with a mental discomfort PRb of 1.1 (95%CI: 1.0-1.3). Regarding self-rated health, women and men under EHI had a higher likelihood of poor health than those without housing insecurity, with a PRb of 1.5 (95%CI: 0.9-2.4) and 1.90 (95%CI: 0.9-3.9), respectively. The same result was observed in women and men under LHI, with a PRb of 1.3 (95%CI: 0.8-2.2) and 1.4 (95%CI: 0.7-2.8), respectively. However, none of these results were statistically significant (Table 4).

Discussion

This is the first study in Spain that shows the relationship between neglected housing insecurity and mental and physical health among renters. We found that the likelihood of worse health due to neglected housing insecurity was greater in renters affected by EHI, followed by people affected by LHI, both compared to those not affected by housing insecurity. This association were statistically significant in the mental health of renters affected by EHI, both women and men, even after adjustment for socioeconomic and other housing variables.

In this study, mental health was worse in both women and men affected by EHI than in people without housing insecurity. This finding is consistent with previous studies reporting that people who have been forced to leave their dwellings due to economic problems have more mental health problems such an anxiety, depression, stress and lack of control.¹⁷17. Hulse K, Saugeres L. Housing insecurity and precarious living: an Australian exploration. AHURI Final Rep. 2008:1-51.^,1919. Desmond M. Unaffordable America: poverty, housing, and eviction. Fast Focus Inst Res Poverty. 2015;22:1-6.^,2020. Desmond M, Kimbro RT. Eviction's fallout: housing, hardship, and health. Soc Forces. 2015;94:295-324.^,2727. Burgard SA, Seefeldt KS, Zelner S. Housing instability and health: findings from the Michigan recession and recovery study. Soc Sci Med. 2012;75:2215-24. For instance, a previous study with people under different stages of housing insecurity showed that persons who had been forced to leave their dwellings due to financial problems in the last three years were more likely to report recent anxiety attacks.²⁷27. Burgard SA, Seefeldt KS, Zelner S. Housing instability and health: findings from the Michigan recession and recovery study. Soc Sci Med. 2012;75:2215-24. Furthermore, two studies conducted in low-income renters with housing insecurity found that they had worse mental health than those without housing insecurity and, also, reported that renters with housing insecurity problems were more likely to delay seeking healthcare due to financial reasons.¹⁷17. Hulse K, Saugeres L. Housing insecurity and precarious living: an Australian exploration. AHURI Final Rep. 2008:1-51.^,2828. Meltzer R, Schwartz A. Housing affordability and health: evidence from New York City. Hous Policy Debate. 2016;26:80-104. In addition, the authors reported that renters with housing insecurity were more likely to experience insecure conditions in other areas such as work, family, food, study, and interpersonal relationships.⁸8. Vásquez-Vera H, Fernández A, Novoa AM, et al. Our lives in boxes: perceived community mediators between housing insecurity and health using a PHOTOVOICE approach. Int J Equity Health. 2019;18:1-14.^,1717. Hulse K, Saugeres L. Housing insecurity and precarious living: an Australian exploration. AHURI Final Rep. 2008:1-51.^,2828. Meltzer R, Schwartz A. Housing affordability and health: evidence from New York City. Hous Policy Debate. 2016;26:80-104.

29. Burke T, Pinnegar S, Phibbs P, et al. Experiencing the housing affordability problem: blocked aspirations, trade-offs and financial hardships [Internet]. Melbourne, Australia; 2007. Available from: https://apo.org.au/node/3542.^-3030. Kirkpatrick SI, Tarasuk V. Housing circumstances are associated with household food access among low-income urban families. J Urban Health. 2011;88:284-96. According to Hulse and Saugeres,¹⁷17. Hulse K, Saugeres L. Housing insecurity and precarious living: an Australian exploration. AHURI Final Rep. 2008:1-51. these situations of housing insecurity could contribute to the coexistence of diverse insecurities in people's lives that would be aggravated and produce negative effects on people's health and the generational transmission of this precariousness.

Mental health was slightly worse in women affected by LHI, although this difference was not significant. However, studies from the United Kingdom have reported that being forced to leave housing due to unilateral termination of a valid lease agreement or not being able to renew the lease generates negative psychosocial effects such as lack of control and a loss of the sense of belonging, as people have to move and restart daily routines elsewhere;³¹31. McKee K, Soaita AM. The "frustrated" housing aspirations of generation rent. UK Collab Cent Hous Evid. 2018; (August.).^,3232. Bone J. Neoliberal nomads: housing insecurity and the revival of private renting in the UK. Sociol Res Online. 2014;19:2-3. these problems of neglected housing insecurity can also lead to an excess responsibility among affected persons, because there is often a lack of legal guarantees in housing policies for people experiencing these underground phenomena.¹⁰10. Palomera J. Els sindicats de llogaters i la lluita per l'habitatge en el nou cicle de financiarització. Pap Regió Metrop Barcelona Territ Estratègies, Planejament. 2018;0:156-63.^,3333. Christudason A, Kenna P. Can housing rights be applied to modern housing systems? Int J Law Built Environ. 2010;2:103-17. It has been reported that these elements operate as mechanisms that affect people's mental health.⁷7. Cortés Alcalá L. Indagaciones sobre la exclusión residencial. Arx Sociol. 2004;10:39-55.^,1717. Hulse K, Saugeres L. Housing insecurity and precarious living: an Australian exploration. AHURI Final Rep. 2008:1-51.

In this study, self-rated health was worse in persons affected by EHI and LHI than among unaffected individuals. Although these results were not statistically significant, the prevalence ratios were large enough to suggest that greater statistical power would have confirmed this trend. Moreover, other studies of formal evictions have reported an evident negative effect on people's health.²⁸28. Meltzer R, Schwartz A. Housing affordability and health: evidence from New York City. Hous Policy Debate. 2016;26:80-104.^,3434. Vásquez-Vera H, Rodríguez-Sanz M, Palència L, et al. Foreclosure and health in Southern Europe: results from the Platform for People Affected by Mortgages. J Urban Health. 2016;93:312-30. Formal eviction is more traumatic situation which affects health faster than neglected eviction; however, when this latter become repetitive, may reaches the same extent of negative health consequences than formal eviction.²⁷27. Burgard SA, Seefeldt KS, Zelner S. Housing instability and health: findings from the Michigan recession and recovery study. Soc Sci Med. 2012;75:2215-24. This association need to be further investigated.

The sample was mainly composed of people aged between 18 and 50 years and with Spanish nationality, which is consistent with observed data of the renter population in the Barcelona Health Survey.³⁵35. Bartoll X, Pérez K, Pasarín M, et al. Resultats de l'Enquesta de Salut de Barcelona 2016/17. Available at: https://www.aspb.cat/wpcontent/uploads/2018/07/Enquesta-salut-Barcelona-2016-17.pdf.
https://www.aspb.cat/wpcontent/uploads/2... The distribution of managers and senior professionals in the sample was approximately double that of the Barcelona renter population (∼31%).³⁵35. Bartoll X, Pérez K, Pasarín M, et al. Resultats de l'Enquesta de Salut de Barcelona 2016/17. Available at: https://www.aspb.cat/wpcontent/uploads/2018/07/Enquesta-salut-Barcelona-2016-17.pdf.
https://www.aspb.cat/wpcontent/uploads/2... Consequently, if the sample had been more representative of the population of Barcelona, a stronger association would probably have been observed between housing insecurity and health outcomes, because it is well-known that people from disadvantaged groups, such as the manual social class, have worse health status than people from more advantaged groups.¹⁹19. Desmond M. Unaffordable America: poverty, housing, and eviction. Fast Focus Inst Res Poverty. 2015;22:1-6.^,2121. Novoa AM, Ward J, Malmusi D, et al. How substandard dwellings and housing affordability problems are associated with poor health in a vulnerable population during the economic recession of the late 2000s. Int J Equity Health. 2015;14:1-11. People not identifying with binary gender had more EHI problems and worse health outcomes than women and men. This finding is consistent with studies indicating that transgender and non-conforming gender people experience more discrimination than cisgender people in terms of housing and employment.³⁶36. Kattari SK, Whitfield DL, Eugene Walls N, et al. Policing gender through housing and employment discrimination: comparison of discrimination experiences of transgender and cisgender LGBQ individuals. J Soc Social Work Res. 2015;7:427-47. Moreover, worse health outcomes are associated with several forms of discrimination that constrain opportunities and access to basic aspects of life.³⁷37. White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med. 2015;147:222-31. Further in-depth studies are needed to investigate the association in these and other disadvantaged groups (e.g. children and elderly).

One of the limitations of this study is that the sampling method did not allow us to obtain a representative sample of renters in Barcelona and could have introduced selection bias, because it did not include renters affected by neglected housing insecurity but who were unable to participate (e.g., individuals without access to online services, the elderly). Such individuals would likely have even poorer health, and therefore the associations would have been stronger. Second, some categories had a very low sample, and consequently the findings should be interpreted with caution. Third, the magnitude of the association between health outcomes and housing insecurity may have been lost, due to the time interval between exposure and the observation of results; however, self-rated health is a stable indicator of people's health status.²⁵25. Quesnel-Vallée A. Self-rated health: caught in the crossfire of the quest for "true" health? Int J Epidemiol. 2007;36:1161-4.

Despite these limitations, a strength of the study is that we constructed variables that allow an approach to the measurement and visibility of the phenomenon of neglected housing insecurity. This approach could contribute to future studies of invisible evictions, which are currently seriously affecting the Spanish context. In addition, this study is replicable in other contexts since we employed questionnaires that are used in European population studies. Moreover, the collaboration with the Sindicat de Llogateres allowed us to forge alliances between the academic and civil sectors to contribute to change country's housing policies. Finally, and closely related to the use of the online survey platform, another strength of the study is the cost-benefit and time-benefit ratio with which we were able to carry out recruitment.

Neglected housing insecurity is a phenomenon that currently affects many renters. These situations are associated with worse mental health. There is a need for neglected housing insecurity indicators to measure these phenomena and facilitate preventive interventions for this massive but hidden problem. In this regard, the study provides evidence that increases the visibility of this social reality and raises awareness of its implications, thereby contributing to the debate on solutions to this new housing emergency. Further studies are needed to continue investigate the relationship between neglected housing insecurity and renters health.

Acknowledgments

The authors thank the Sindicat de Llogateres (Renters Union) for its participation and for access to the study data, the Hidra Cooperative for its contribution to data collection, and the people who participated in the survey.

References

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