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Eviction as a Social Determinant of Sexual Health Outcomes

Jennings, Jacky M. PhD, MPH*†; Leifheit, Kathryn M. MSPH*†

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Sexually Transmitted Diseases: January 2019 - Volume 46 - Issue 1 - p 69-71
doi: 10.1097/OLQ.0000000000000936

There is an error in the order of authorship. Kathryn Leifheit is the first author and Jacky Jennings is the second author.

Sexually Transmitted Diseases. 46(9):e92, September 2019.

The United States (US) is in the midst of a housing affordability crisis and an eviction epidemic, which is particularly impacting vulnerable populations: low-income households, people of color, single mothers, and children.1–5 Two thirds of low-income US families live in rental housing,6 a proportion that has grown in the wake of the 2008 Great Recession.7 Since the Recession, low-income households have experienced rising housing costs while their incomes have remained stagnant.7,8 As a result, most poor renting households spend over half of their incomes on housing, whereas nearly 1 in 4 spends over 70%.8 As more and more families struggle to pay rent, the rate of evictions has increased. Recent estimates suggest that 2% to 3% of renters nationwide experience eviction, with rates of eviction as high as 16% (ie, 16 eviction judgments per 100 renter-occupied homes) in some parts of the country.9

Although the links between housing instability and population health more broadly are well established,10 there is a dearth of research specifically examining the connections between eviction and health, including sexual health outcomes.11 This is an important gap for 2 key reasons. First, evictions are considered by experts to be among the most deleterious sources of housing instability12 in that they often come about suddenly, create extreme financial strain and stress, and carry lasting legal consequences that can preclude families from accessing quality, affordable housing in the future. This suggests that eviction may have profound health effects and may operate both as a fundamental cause of disease,13 operating through poverty, and a pathway through which poverty becomes embodied in health outcomes.14 Second, eviction as a source of housing instability is both specific and policy-sensitive. Levers at the city and state for eviction may include reforming eviction law, changing rent court processes, or expanding existing housing voucher programs.

In this issue of Sexually Transmitted Diseases, Linda Niccolai and colleagues investigate the ecological (county-level) relationship between eviction and 2 sexually transmitted infections (STIs) (ie, chlamydia and gonorrhea),15 an interesting foray joining a long line of research demonstrating that STI incidence is highly sensitive to social processes.16–18 The authors leverage a novel data source, the Eviction Lab National Database, to answer this research question. The Eviction Lab data represents the first attempt to compile court records of eviction filings and judgments on a national scale.9 After controlling for a number of county-level demographic, social, and geographic covariates, the authors found that, on average, counties with high eviction rates (>1.9 eviction judgments per 100 renter-occupied households) had 63.8 (95% confidence interval, 45.1–82.5) more chlamydia cases and 20.4 (95% confidence interval, 13.5–27.4) more gonorrhea cases per 100,000 population 1 year later, when compared with counties with low eviction rates (<0.59 judgments per 100 renter-occupied households). These findings were statistically significant and proved robust to a number of thoughtful sensitivity analyses.

The authors present several plausible explanations for the identified associations between eviction rates and STIs 1 year later at the county-level. In general, the authors make the case that eviction may increase sexual and/or social vulnerabilities in ways that increase community levels of STIs. For example, individuals may change their behavior including engaging in sex work or increasing risky sexual behaviors in exchange for housing or other material needs (eg, food, transportation). They may also change their behavior in ways that increase risks for STIs (eg, alcohol or drug use) in an effort to cope with the stress that housing instability and the associated material hardship presents. Evictions may also cause changes to relationships (ie, disruptions in monogamous relationships, initiation of new relationships), resulting in changes to sexual network structures and increasing STI transmission potential within communities. Eviction and the resultant displacement may also disrupt health care access and decrease opportunities for STI testing and treatment, resulting in longer durations of infection. These mechanisms may impact vulnerable populations in particular who have little or no buffer to safeguard against the more deleterious outcomes related to eviction.

Although we find this a well-conceptualized study, we offer 1 comment and 2 potential limitations. The authors suggest that the study's ecological design is a limitation. Although we agree that the results cannot be interpreted as the effect of individual-level eviction on individual STI risk, it is also true that solutions to the eviction epidemic will likely be implemented and evaluated at a community level (eg, county or state). Thus, we encourage researchers to continue to focus on policy-relevant geographies to aid in the identification of policy-based solutions to eviction and its downstream health effects. One limitation that bears mentioning is the potential for selection bias. Approximately 17% of US counties had missing eviction rates and were excluded from the analyses. Although it could be the case that the excluded counties do not differ systematically from the analytic set, this is difficult to assess based on the data presented and suggests that the generalizability of the findings might be limited to those counties with eviction data. It should also be noted that even among counties with available data, Eviction Lab data quality may vary by state.19 An additional limitation in this study is that it is unclear whether highly advantaged US counties (ie, largely white, with high income, high education, and low unemployment) ever experience high rates of eviction. If not, effect estimates for this subgroup of counties might be “off-support,” relying heavily on extrapolation.20,21 Moreover, these estimates may have limited utility,20,22 begging the question: How do we interpret the effect of exposure to high eviction rates in counties that are very unlikely to experience high eviction? To judge how much this issue, referred to in the epidemiology literature as “nonpositivity,” might threaten causal inference in this study, it would be useful for the authors to present data illustrating the degree to which combinations of the various covariates included in the multivariable regression models are predictive of exposure to eviction, as is common practice in studies that use propensity score-based approaches to address confounding.21,23

Limitations aside, this publication contributes to a small but growing body of literature linking eviction to negative health outcomes.24–30 We look forward to more research focused on eviction and sexual health outcomes to confirm and strengthen these findings. Perhaps, more importantly, we look forward to research pointing to specific interventions to prevent eviction and its downstream effects on sexual health. Some interesting work evaluating the impact of housing programs on health is already charting a course. For instance, a randomized trial evaluating the Housing Opportunities for People with acquired immune deficiency syndrome program in 3 US sites (Baltimore, MD; Chicago, IL; and Los Angeles, CA) demonstrated that provision of rental assistance could effectively address the mental and physical health needs in unstably housed and homeless people living with human immunodeficiency virus/acquired immune deficiency syndrome.31 In an observational study among public housing residents in Atlanta, GA, relocation from public housing to other neighborhoods resulted in a reduced odds of testing positive for an STI (chlamydia, gonorrhea, and trichomonas).32 Given the health promoting potential of high-quality, stable housing, researchers and public health advocates should lend their expertise to the planning, implementation, and evaluation of interventions to address the root problem of affordable housing in the United States. Adopting a “Health in All Policies” approach, we can address this important social determinant of health, advance health equity, and promote population health.33,34


1. Desmond M. Evicted. Poverty and Profit in the American City. New York, NY: Broadway Books, 2016.
2. Desmond M, Shollenberger T. Forced displacement from rental housing: Prevalence and neighborhood consequences. Demography 2015; 52:1751–1772.
3. Desmond M. Eviction and the reproduction of urban poverty. Am J Sociol 2012; 118:88–133.
4. Desmond M, An W, Winkler R, et al. Evicting children. Soc Forces 2013; 92:303–327.
5. Leifheit K, Pollack C, Black M, Jennings J. Eviction in the United States: Affected populations, housing and neighborhood-level consequences, and implications for health. In: Society for Epidemiologic Research Meeting. Baltimore, MD; 2018.
6. U.S. Census Bureau. American Community Survey 1-Year Estimates; 2017 2017.
7. Joint Center for Housing Studies. The State of the Nation's Housing. Boston, MA, 2017: Accessed November 8, 2017.
8. Desmond M. Unaffordable America: Poverty, Housing, and Eviction. Madison, WI, 2015: Accessed November 8, 2017.
9. Desmond M, Gromis A, Edmonds L, et al. Eviction Lab National Database. Princeton University: Version 1.0.
10. Shaw M. Housing and public health. Annu Rev Public Health 2004; 25:397–418.
11. Vásquez-Vera H, Palència L, Magna I, et al. The threat of home eviction and its effects on health through the equity lens: A systematic review. Soc Sci Med 2017; 175:199–208.
12. Amore K, Baker M, Howden-Chapman P. The ETHOS definition and classification of homelessness: An analysis. Eur J Homelessness 2011; 5:19–37.
13. Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav 1995; 80–94.
14. Krieger N. Embodiment: A conceptual glossary for epidemiology. J Epidemiol Community Health 2005; 59:350–355.
15. Niccolai L, Blankenship K, Keene DE. Eviction from renter-occupied households and rates of sexually transmitted infections: A county-level ecological analysis. Sex Transm Dis 2018; 1:63–68.
16. Jennings JM, Curriero FC, Celentano D, et al. Geographic identification of high gonorrhea transmission areas in Baltimore, Maryland. Am J Epidemiol 2005; 161:73–80.
17. Poundstone KE, Strathdee SA, Celentano DD. The social epidemiology of human immunodeficiency virus/acquired immunodeficiency syndrome. Epidemiol Rev 2004; 26:22–35.
18. Hogben M, Leichliter JS. Social determinants and sexually transmitted disease disparities. Sex Transm Dis 2008; 35:S13–S18.
19. Minton J. Eviction data can keep cities from “designing policy in the dark.” Eviction Lab. Published 2018. Accessed October 9, 2018.
20. Westreich D, Cole SR. Invited commentary: Positivity in practice. Am J Epidemiol 2010; 171:674–677.
21. Ahern J, Cerdá M, Lippman SA, et al. Navigating non-positivity in neighbourhood studies: An analysis of collective efficacy and violence. J Epidemiol Community Health 2013; 67:159–165.
22. Messer LC, Oakes JM, Mason S. Effects of socioeconomic and racial residential segregation on preterm birth: A cautionary tale of structural confounding. Am J Epidemiol 2010.
23. Ho DE, Imai K, King G, et al. Matching as nonparametric preprocessing for reducing model dependence in parametric causal inference. Polit Anal 2007.
24. Desmond M, Kimbro RT. Eviction's fallout: Housing, hardship, and health. Soc Forces 2015; 94:295–324.
25. Damon W, McNeil R, Milloy MJ, et al. Residential eviction predicts initiation of or relapse into crystal methamphetamine use among people who inject drugs: A prospective cohort study. J Public Health (Oxf) 2018.
26. Kennedy MC, Kerr T, McNeil R, et al. Residential eviction and risk of detectable plasma HIV-1 RNA viral load among HIV-positive people who use drugs. AIDS Behav 2017; 21:678–687.
27. Kennedy MC, McNeil R, Milloy MJ, et al. Residential eviction and exposure to violence among people who inject drugs in Vancouver, Canada. Int J Drug Policy 2017; 41:59–64.
28. Pilarinos A, Kennedy MC, McNeil R, et al. The association between residential eviction and syringe sharing among a prospective cohort of street-involved youth. Harm Reduct J 2017; 14:24.
29. Rojas Y, Stenberg S-Å. Evictions and suicide: A follow-up study of almost 22,000 Swedish households in the wake of the global financial crisis. J Epidemiol Community Health 2016; 70:409–413.
30. Rojas Y. Evictions and short-term all-cause mortality: A 3-year follow-up study of a middle-aged Swedish population. Int J Public Health 2017; 62:343–351.
31. Wolitski RJ, Kidder DP, Pals SL, et al. Randomized trial of the effects of housing assistance on the health and risk behaviors of homeless and unstably housed people living with HIV. AIDS Behav 2010; 14:493–503.
32. Cooper HL, Haley DF, Linton S, et al. Impact of public housing relocations: Are changes in neighborhood conditions related to STIs among relocaters? Sex Transm Dis 2014; 41:573–579.
33. Stahl T, Wismar M, Ollila E, et al. Health in All Policies Prospects and Potentials 2006.
34. Satcher D. Include a social determinants of health approach to reduce health inequities. Public Health Rep 2010; 125(Suppl 4):6–7.
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