In a nationally representative sample of adults with diabetes, this study found individuals who reported housing insecurity had a lower likelihood of a number of self-reported diabetes processes of care and self-care behaviors, and this relationship was moderated by both employment and race/ethnciity. The American Diabetes Association (ADA) recommends as part of their standards of care that adults with type 2 diabetes who are meeting glycemic targets visit their physician and receive diabetes education at least annually, receive their annual flu vaccine, and have their A1c checked at least two times per year. The ADA also recommends annual eye exams, however, if there is no evidence of retinopathy for one or more annual eye exams and patient is meeting glycemic targets, then screening every 1–2 years may be considered [9]. Housing insecure individuals with diabetes who reported being employed were less likely to see a physician, have an A1c checked in the past 12 months, or have an eye exam, while unemployed individuals were less likely to receive a flu vaccine. Non-Hispanic White adults with diabetes who reported housing insecurity were less likely to receive an eye exam or flu vaccine or to engage in physical activity, while Non-Hispanic Black adults were less likely to have a physicians visit in the last 12 months.

This paper adds to the current literature by showing how housing insecurity influences processes of care and self-care behaviors and that this relationship differs by employment and race/ethnicity. Findings are in line with previous literature that found unstably housed, low-income families who reported difficulty paying their rent or mortgage were less likely to have a usual source of medical care and more likely to postpone needed treatment than those who have more-affordable housing [5, 23, 30]. Regarding differences by race/ethnicity, Non-Hispanic Blacks and Hispanics have historically been found to be less likely than Non-Hispanic Whites to have a primary care provider for routine preventative care needs and have lower quality of care [2, 30]. Our study found that housing insecure Non-Hispanic White adults were less likely to report receiving an eye exam or flu vaccine when compared to housing secure Non-Hispanic Whites, but that this difference did not exist for Non-Hispanic Black and Hispanic adults, which could indicate a difference in how these processes of care are prioritized based on the level of health care an individual has access to.

Additionally, this study found differences in the relationship between housing insecurity and diabetes processes of care and self-care behaviors by employment status. Specifically, those reporting housing insecurity who were employed were less likely to have a physicians visit, A1c check, and eye exam, while unemployed individuals were less likely to have a flu vaccine. While being employed allows some people to access employer-sponsored health coverage, many low-wage jobs do not come with sufficient sick leave coverage which may create a barrier to seeking health care [31]. It is possible that putting in work hours leaves less time for individuals to make their health a priority. Literature suggests that when people have competing unmet basic needs, they will prioritize needs for food and shelter above health when time and resources are scarce [5]. Interestingly, however, those who were unemployed were less likely to have received a flu shot. Potentially, those who are employed could be more likely to get a flu shot if their employer encourages or requires them to receive one.

One positive finding is that those reporting housing insecurity were more likely to report having received foot care. This could be because foot care is a pillar in clinics that provide care to more vulnerable populations. Foot checks may also be prioritized by those facing housing insecurity because it’s a relatively easy and cost-free self-care activity that can help prevent more serious diabetes complications such as limb amputation and disability. More research into how individuals with diabetes choose to prioritize some self-care activities over others when they are facing challenges meeting basic needs may be warranted.

Clinical Implications

Socio-economic, social support factors, and clinician promotion of self-care behaviors are considered positive contributors in facilitating self-care activities in patients with diabetes [12]. However, interventions focused only on self-care do not provide clinicians with the tools they need to maintain standard of care in patients who are housing insecure if not also focused on social risks and psychosocial factors [23]. Housing insecurity is known to have a destabilizing effect on all facets of a person’s life impacting their feelings of self-efficacy. As a psychosocial factor, self-efficacy has been found to have a strong association with self-care behaviors and is independently associated with improvements in glycemic status [17]. Self-efficacy interventions for diabetes provide strong evidence for improving health outcomes when deployed by health educators in a clinical setting [32, 33]. Therefore, careful consideration of how to incorporate addressing housing insecurity into interventions aimed to increase positive self-care behaviors and improve self-efficacy are warranted.

The American Diabetes Association recommends that homelessness risk and psychosocial factors (including self-efficacy) are assessed during particular patient encounters and offers tools for these assessments in their standards of care guidelines [9]. Unfortunately, in a nationally represented sample of adults with diabetes who were unstably housed only 2% of participants reported receiving help with housing in a clinical setting. Safety-net clinics that care for the most vulnerable populations often have difficulty putting standard of care guidelines into practice, especially when there is a lack of quality community resources. 6 Housing insecurity could be assessed more systematically via social needs screening tools that incorporate social determinants of health in the Electronic Medical Record (EMR) [34]. Using screening tools in EMRs could be a way to identify when referral to a social worker, patient navigator, intensive case management, wraparound services, and/or clinic-based interventions to address housing. All resources listed have shown improvements in those with chronic disease and could have impact on patients with diabetes facing housing insecurity [9, 35]..

Limitations

The data is cross-sectional so causation cannot be commented on based on these results. Second, as diabetes was self-reported, those who are living with diabetes but who have not been diagnosed or are unaware of their condition would not be included in the study sample. Third, the analysis was based on data available within BRFSS, so were unable to include details such as how indivduals are receiving diabetes care, duration of time they have been living with diabetes, or regional and local information on urbanization and population density. Future research should explore healthcare datasets that link social context information to healthcare data providing more detailed information on patient level treatment factors. In addition, data that allows for investigation of multiple levels of influence may provide clarity on areas for future intervention. Lastly, the measure of housing insecurity was only assessed using one question and may under-represent the range of experiences surrounding housing insecurity. Unfortunately, housing insecurity has no standard definition and refers to a variety of housing related issues [4, 36]. Without a universal measure and standardized framework for conceptualizing housing insecurity it’s difficult to quantify the scale and severity of the problem. Therefore, estimates may be conservative if housing insecurity was under-represented.

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