Housing insecurity and health: a marginal structural model analysis of the impact of housing payment problems and forced moves on mental health, sleep and hypertension in UK adults, 2009-2019

Background: Housing insecurity is an escalating problem in the UK. Limited empirical evidence exists from which to draw reliable causal inferences about the impact of insecure housing on health. Using nationally representative panel data and causally focussed methods, we examined the effect of insecure housing on mental health, sleep disturbance and cardiovascular health, during a period of government austerity. Methods: We used longitudinal survey data (2009-2019) from the UK Household Longitudinal Study. Health outcomes included probable common mental disorder; sleep disturbance due to worry; and new diagnoses of hypertension. The primary exposure was housing payment problems in the past 12 months. Using doubly robust marginal structural models) with inverse probability of treatment weights, we estimated absolute and relative health effects of housing payment problems, and population attributable fractions. We performed stratified analyses to assess potentially heterogeneous impacts across the population, and the potential modifying effects of austerity measures in the UK. Findings: The average absolute effect of housing payment problems was a 2.5 percentage point increased risk of experiencing a common mental disorder (95% CI 1.1%, 3.8%) and 2.0% increased risk of sleep disturbance (95% CI 0.7%, 3.3%). Effects were larger among renters, younger people, less educated, and households with children. Effects were also larger among people living in areas most affected by austerity-related cuts to housing support services. Evidence for a cardiovascular health impact was weak (95% CI -0.1%, 1.2%). Interpretation: Housing payment problems were associated with worse mental health and sleep disturbance in a large UK sample. Households at risk of falling into rent or mortgage arrears need more support, especially in areas where housing services have been diminished. Rapid and substantial investment is needed to improve supply of social and affordable housing. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Funding: This work was supported by an Understanding Society Fellowship from the University of Sussex. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The individual-level data used in this study is available on request through the UK Data Service (http://doi.org/10.5255/UKDA-SN-6666-15). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes UKHLS data are available to approved researchers through application to the UK Data Service. Local authority data are available online at https://pldr.org/ and https://webarchive.nationalarchives.gov.uk/ukgwa/20150506003720/http://www.ons.gov.uk/ons/rel/pse/public-sector-employment/regional-analysis-of-public-sector-employment--2012/index.html