Relationship between area mortgage foreclosures, homeownership, and cardiovascular disease risk factors: The Hispanic Community Health Study/Study of Latinos

Racial residential segregation made Hispanic/Latino and black households particularly vulnerable to predatory lending practices and these populations were thus hardest hit by the U.S. housing crisis beginning in 2007 [1]. Whether the housing crisis placed an additional burden on cardiovascular health in the Hispanic/Latino population is unclear. Hypertension, high cholesterol, and smoking are referred to by the Centers for Disease Control and Prevention (CDC) as key risk factors for heart disease [2]. Nearly half of U.S. adults have at least one of these heart disease risk factors [3]. Prior studies examining the relationship between foreclosure and cardiovascular disease risk have included body mass index (BMI) [4–6], blood pressure [7–9], fasting glucose [7], mental health [10], and risk for hospitalization for heart attack and stroke [9, 11, 12]. These results, however, have been inconsistent. For example, Arcaya and colleagues [8] showed that adults living in close proximity to a foreclosed property were more likely to have elevated blood pressure, whereas Christine et al. [7] showed a small inverse relationship between foreclosures in a neighborhood and blood pressure. Studies of associations of area foreclosures and BMI are similarly inconsistent [4–6]. Inconsistent findings among these studies may reflect differences in measurement of foreclosures at the neighborhood levels or possibly differing mechanisms driving the association between foreclosures and various cardiovascular disease risk factors.

As research further uncovers the mechanisms linking foreclosures to health, examining the role of homeownership can be an important step in guiding policy. Homeowners are generally considered the most vulnerable during a foreclosure crisis but studies showing an association between neighborhood foreclosures and health suggest that both homeowners and renters can be affected by high foreclosures in the area. [4, 11, 12]. A high level of neighborhood foreclosures may influence health outcomes by reflecting conditions that contribute to environmental-related stress of residents [8, 10]; limited access to health care [11, 12]; and/or limited access to resources for a healthy diet and physical activity for residents [13]. More research is needed to confirm prior findings of the association of neighborhood foreclosures and cardiovascular disease. These studies should characterize the risk among homeowners and renters and examine a wider range of cardiovascular disease risk factors such as high cholesterol and cigarette smoking.

Despite a growing literature on the associations between neighborhood foreclosure and health [14], as well as homeownership and health [15], existing studies examining cardiovascular disease risk factors suffer from a variety of limitations. First, most studies do not examine more nuanced associations between neighborhood foreclosure, homeownership, and health. For example, among residents living in proximity to foreclosed properties, it is not clear whether residents who rent are as likely to show the poor health-related association of living in a high foreclosure risk neighborhood as residents who own their own home. Second, few studies include health behaviors associated with cardiovascular disease such as smoking. Third, many studies have not included large samples of racial and ethnic minorities, including Hispanic/Latinos – the largest ethnic minority population in the U.S. Fourth, many studies focus on single cities or limited geographical areas, which limits generalizability. The purpose of this study was to examine the relationship between neighborhood foreclosure risk, homeownership, and cardiovascular disease risk factors - i.e., hypertension, hypercholesterolemia, cigarette smoking - among Hispanic/Latino adults living in 4 major metropolitan areas in the U.S. We further examined whether the association of neighborhood foreclosure risk on cardiovascular disease risk factors differed between homeowners and renters, rarely addressed in previous research.

The HUD mortgage foreclosure risk metric identifies at-risk neighborhoods on the verge of economic instability and crisis. It is a measure that captures areas starting to decline providing a window to prevention where policy may influence cardiovascular disease. Using a sample of Hispanics/Latinos sheds light on the health consequences of a largely growing demographic in the U.S. hardest hit by the 2007 housing crisis. Our results showing a significant association of area foreclosure risk with hypertension and hypercholesterolemia among renters but not homeowners suggest that renters are particularly vulnerable in areas where the risk for foreclosures is high. The null finding among homeowners may suggest that residents owning their homes are better able to weather the economic downturn than renters. This is consistent with data showing that homeowners have stronger social ties within the communities that they live in and are better able to access the resources in their neighborhood that promote healthier lifestyle choices and overall wellbeing [23–25]. In our study, we also showed that renters were more likely to be current cigarette smokers than homeowners. This is consistent with reports showing smoking risk to be almost three times more likely among renters than homeowners [26]. Renting, in this study, may indicate a less stable housing environment; and living in less stable housing undermines prioritizing healthy behaviors [27, 28].

Saegert proposes a model where home foreclosures also contribute to racial disparities in housing and place racial and ethnic minorities in housing niches where once a household is in this niche they are exposed to cumulative hazards that affect current and future generations [29, 30]. This is an interesting approach to understanding the health consequences of area foreclosures as a contextual exposure influencing access to resources over time. More research is needed to further elucidate the pathways that might link neighborhood foreclosures and cardiometabolic disease. Considering the intersection of foreclosure, homeownership, and health can inform housing policies with the potential to broaden public health impact and reduce racial and ethnic and socio-economic status-related health disparities [31, 32].

The strength of our foreclosure metric is that it is consistent with federal guidelines used to determine the allocation of resources to communities in most need. The health consequences of the foreclosure crisis that preceded the Great Recession affected renters as well as homeowners. [9] In our study, we posit that neighborhood foreclosure risk is a useful measure of the neighborhood cost of economic decline particularly as it relates to housing insecurity, which can affect all of those living in an area, renters and homeowners alike. Foreclosure risk as measured in this study has some precedent in its use in understanding adverse health outcomes. In a sample of breast cancer survivors, Schootman et al. [20] used a HUD predicted measure of area foreclosures to show that women living in high foreclosure risk areas are more likely to report fair-poor health than women in low foreclosure risk areas. This suggests that residents can begin to feel the distress of living in an at-risk area prior to an actual increase in foreclosure rates. This measure is directly applicable to federal housing-related policies that use this metric to distribute aid to vulnerable communities.

There are substantial burdens of cardiovascular disease risk factors in the U.S. among all major Hispanic/Latino background groups [35], and greater risks in low-income individuals [3]. As the pathways that contribute to these racial/ethnic and SES disparities in cardiovascular health are uncovered, housing has been identified as an important upstream social determinant that requires interdisciplinary interventions to address [36]. The growing evidence including the results from this study show that home mortgage foreclosures can negatively affect community health. Public health practitioners are increasingly looking outside of health care to housing policy to address many social and economic determinants of health [36, 37]. Housing policies that provide pathways to stable housing for homeowners and renters may bolster cardiovascular disease prevention campaigns within neighborhoods. For example, Making Home Affordable (MHA) programs are resources available to homeowners to help keep them in their homes should they be faced with the possibility of a foreclosure. Among renters, preventing eviction and displacement by implementing legislation that provides rental relief for tenants that pay more than 30% of their gross income on rent and utilities such as that proposed under the Rental Relief Act; or providing legal representation in housing court for low-income residents as is being done in New York City can be useful strategies to stabilize housing for vulnerable residents. Providing opportunities for residents to stay securely housed has the potential to curb the adverse health outcomes that accompany unstable housing.