hsci 11 extra

A journal article summary/evaluation example is provided.

For Full Credit:

Summaries must be one page each, single-spaced

Each summary must be based on a current scholarly journal article that is pertinent to your behavior change.

The journal article must be at least 4 pages in length 

A PDF copy of the article must be turned in

Each summary must be typed. Times New Roman or Arial, size 12, 1-inch margins. 

A reference page for the articles must be included

Summaries must include an evaluation of how it was useful to your project.

Plagiarized summaries will receive no credit and will be reported to the Office of Student Conduct and Ethical Development

TITLE OF ARTICLE:

Centered

FIRST PARAGRAPH:

Summary of the article

Tips:

• Summarize what you read in
your own words and avoid using
quotations.

• Plagiarized summaries will
result in a zero and will be
reported to the Office of
Student Conduct

• Include information such as:
o What is the background

that led to the research?
o What is the study about?
o Who were the

participants?
o How did they collect data?
o What were the

results/findings?

CHOSEN ARTICLE:

• Must be scholarly
• At least 4 pages
• RELATED to your health behavior topic

SUMMARY/EVALUATION:

• 1 page
• Single-spaced
• 12 size font
• Times New Roman OR

Arial
• 1 inch margins (all sides)

SECOND PARAGRAPH:

Explain how this article was
useful for your project.

Tips:

• Did it help you with
your project?

• Why or why not?
• What did you learn?

Policy to tackle the social determinants of
health: using conceptual models to understand
the policy process
Mark Exworthy

Accepted 22 June 2008

Like health equity, the social determinants of health (SDH) are becoming a key

focus for policy-makers in many low and middle income countries. Yet despite

accumulating evidence on the causes and manifestations of SDH, there is

relatively little understanding about how public policy can address such complex

and intractable issues. This paper aims to raise awareness of the ways in which

the policy processes addressing SDH may be better described, understood and

explained. It does so in three main sections. First, it summarizes the typical

account of the policy-making process and then adapts this to the specific

character of SDH. Second, it examines alternative models of the policy-making

process, with a specific application of the ‘policy streams’ and ‘networks’ models

to the SDH policy process. Third, methodological considerations of the preceding

two sections are assessed with a view to informing future research strategies.

The paper concludes that conceptual models can help policy-makers understand

and intervene better, despite significant obstacles.

Keywords Policy process, social determinants of health, health inequalities, research

methodology

‘What is striking is that there has been much written often

covering similar ground . . . but rigorous implementation of

identified solutions has often been sadly lacking.’ (Wanless

2004, p.3)

This quote was written about UK policy addressing the social

determinants of health (SDH) but is applicable to most high or

low and middle income countries. Despite mounting evidence

of the causes of health inequity, even in the latter countries,

attention on the policy process is a notable omission. This may

reflect the epidemiological emphasis on SDH research and/or a

lack of engagement between public health and policy analysts.

This article seeks to remedy that by closely examining the

nature of the SDH policy process, how it might be conceptua-

lized and researched.

Re-visiting the policy-making process
The term ‘policy’ is so widely used that it often obscures

meaning. Searching for definitional clarity can be misleading.

Its various uses denote the significance attached to it by mult-

iple stakeholders (Hogwood and Gunn 1989; Buse et al. 2005)

KEY MESSAGES

� Social determinants of health (SDH) represent major challenges to health policy-makers in all countries.

� Models of the policy process are often ill-suited to local contexts and the nuances of SDH.

� A sensitive application of models such as ‘streams’ and ‘networks’ offers significant insights into the nature of SDH policy

and the opportunities/constraints facing policy-makers.

� Understanding and explaining SDH policy processes need to be undertaken sensitively, recognizing peculiar methodological

challenges.

School of Management, Royal Holloway-University of London, Egham,
Surrey, TW20 0EX, UK. E-mail: M.Exworthy@rhul.ac.uk

Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine

� The Author 2008; all rights reserved.
Health Policy and Planning 2008;23:318–327

doi:10.1093/heapol/czn022

318

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and/or the multiple levels at which it is developed. A useful way

of understanding ‘policy’ is in terms of context, content, process

and power (Walt 1994). First, context is the milieu within

which interventions are mediated; it therefore shapes and is

shaped by external stimuli like policy. Second, content refers to

the object of policy and policy analysis, and may be divided into

technical and institutional policies (Janovsky and Cassells

1996). Third, Wildavsky’s (1979) reminder that ‘policy is a

process, as well as a product’ is crucial because it draws

attention to the course of action over time. Finally, power

draws attention to the interplay of interests in negotiation and

compromise.

The ‘policy process’ is often presented as a linear, rational

process moving from formulation to implementation; for

example:

� ‘Politicians identify a priority and the broad outlines of a

solution . . .;

� Policy-makers . . . design a policy to put this into effect,

assembling the right collection of tools: legislation, funding,

incentives, new institutions, directives;

� The job of implementation is then handed over to a different

group of staff, an agency or local government;

� . . . the goal is (hopefully) achieved’ (UK Cabinet Office 2001,

p.5).

This is an over-simplistic view. The distinction between

formulation and implementation is rarely clear-cut; intentions

and action are often hard to distinguish. It may be more helpful

to view the ‘policy process’ as disjointed and ‘messy’. For

example, John (2000) argues that there is often no start or end

point, only a middle. Policies are developed within a pre-

existing context that effectively constrains new opportunities.

The legacy of former decisions creates conditions from which

policy-makers may find it difficult to diverge, a condition

known as ‘path dependency’ (Greener 2002). Most resource

decisions, for example, only consider marginal changes rather

than taking fundamental re-assessment of principles. Path

dependency limits the range or possibility of radical changes of

direction, at least in the short term—often called ‘increment-

alism’ (Lindblom 1959). This perspective also contends that the

policy process can often be static for relatively long periods,

only to be disturbed by moments of change—disjointed

incrementalism and punctuated equilibrium. As a result, the

policy process is characterized by (positive and negative)

feedback loops and rarely reaches completion. However, Clay

and Schaffer (1984), for example, demonstrate the ‘room for

manoeuvre’ that policy-makers can enjoy.

The health policy process is also characterized by other

features. First, policy decisions rarely take place at a single

point in time and can be protracted over months or even years.

It is therefore difficult to discern if/when a specific decision was

made. Policy decisions often reflect a broad direction (despite

conflict) so as to mollify stakeholders’ concerns or to denote

their power. Second, policy-making rarely occurs in public but

rather behind ‘closed doors’, despite some attempts to make it

more transparent. Third, policy-making often results in no

decisions or non-decisions. The lack of (observable) action or

outcome may actually signify a complex set of forces that have

stifled a decision or prevented proposals from being enacted

(Lukes 1974). Finally, much of the evidence on the policy process

originates from high income countries (HICs); there is thus an

empirical question as to whether typical approaches and under-

standing are valid in low and middle income countries (LMICs).

Questions about similar translations between demographic/

population and income groups may also be posed.

SDH offer an insightful case study of health policy processes

because they have in recent years assumed a more central place

in policy processes of many HICs and LMICs; previously, policy

analysis has tended to overlook the issue in favour of other

policy imperatives. It is, therefore, instructive to learn how the

specific nuances of these complex phenomena are articulated

in the content, context and process of health policy processes.

Such a case study is significant because, on the one hand,

SDH are more prominent in topical debates about MDGs and

poverty reduction, and on the other, SDH are illustrative of

increasingly complex developments in policy process (such as

governance and internationalization). However, each aspect

that public policy in each country seeks to address is, more or

less, a particular configuration of issues. Practically, these issues

need to be understood and explained by academics and by

policy-makers that they may assess the likely impact of SDH

policy.

Broadly, eight challenges to addressing SDH through public

policy can be identified. Defining clearly the features of SDH

helps to draw sharper implications for policy development and

implementation. First, SDH are multi-faceted phenomena with

multiple causes. Models of SDH are useful conceptual devices to

identify the causal pathways which have differential impacts on

health (see Figure 1).

However, SDH models rarely offer policy-makers a clear

direction for policy development (Graham 2004). First, some

policy-makers believe that the lack of a ‘simple problem’

hinders the development of ‘simple policy solutions’ or that

policy is ineffective in the face of wider social forces (such as

globalization). Others see SDH as ‘invisible’ (Dahlgren and

Whitehead 2006, p.15). As a result, there has often been no

policy response to ‘act upon SDH’ or, where there has been

some attempt, a diffuse approach. This has often been

hampered by the lack of consensus among academics and

policy-makers about the policy solutions required.

Second, the life-course perspective (Blane 1999) presents a

challenge to policy-making processes whose timescales are

rarely measured over such long periods. The life-course perspec-

tive posits that early life influences (say, upon diet or educa-

tion) have life-long impacts that will only be evident many

years hence. This perspective contrasts with the tenure of

elected and/or appointed officials (which is usually measured

in years, rather than decades), the electoral cycles in

parliamentary or presidential democracies (usually measured

from 5 to 7 years), and organizational reporting cycles (e.g. for

budgetary purposes usually measured annually). Moreover,

coalitions of interests in support of SDH policies may be

unsustainable over the time periods necessary to witness

significant change, thereby presenting a challenge to create

and sustain commitment to and involvement in the policy goals

and process. Partly as a result, attention of the public (often

supported by the media) and some practitioners has tended to

reinforce such short-term timescales. This second feature is

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thus a challenge to integrate long-term approaches with short-

term organizational/political imperatives.

Third, SDH necessitate policy action across different organiza-

tions and sectors (not least, the health care sector) (Hunter 2003;

Gilson et al. 2007). Often, policy responses are only disease-

specific rather than addressing SDH. Inter-organizational and

inter-sectoral partnerships are critical to formulating and

implementing policy towards SDH. However, evidence shows

that partnerships at all levels are hampered by cultural,

organizational and financial issues (Lee et al. 2002; Sullivan and

Skelcher 2002). Different values, different accountabilities and

performance measures/criteria, and different reasons for colla-

borating are among the challenges for partnerships. Moreover,

the ‘health’/SDH agenda may be marginal to collaborating

organizations, SDH being perceived as beyond their core purpose.

It can also be argued that action on SDH requires intervention

beyond state/government, by civil society organizations or even

private sector agencies. Such collaboration regarding SDH is likely

to be even more problematic.

Even within governments, inter-organizational collaboration

has often been poorly developed. Traditionally, government

agencies tend to be organized vertically (Ling 2002; Bogdanor

2005). For example, education ministries are largely focused on

running schools, health ministries on delivering health care

services, etc. Yet, such ‘silo’ or ‘chimney’ approaches are not

well suited to tackle cross-cutting issues. A strong coordination

role, say, across government or by an external (international)

agency might offset the ‘silo’ approach but the balance of power

usually remains with ministries.

Fourth, SDH are one of many competing priorities for policy-

makers’ attention and resources. Economic, foreign or devel-

opment policies might take precedence over SDH, inter alia.

More specifically, SDH may be over-shadowed in the policy

process by health care itself. As most states take a prominent

role in the financing and/or delivery of health care to its

population (Saltman 1997), it is perhaps inevitable that states

take a close interest in such matters. However, this health care

focus is often to the neglect of health and SDH per se (Gilson

et al. 2007). That said, other spheres of policy (such as

education or transport) can be informed by SDH.

Fifth, SDH are so complex that the cause-effect relationships

are not readily apparent. Moreover, some evidence is equivocal

about these associations. For example, statistical correlations

are common in epidemiological studies which inform policy-

making, but they rarely demonstrate causation. Knowing and

understanding causal pathways is a first step in devising

appropriate policies but many gaps in knowledge remain,

especially in LMIC contexts. Attributing policy mechanisms to

their impact upon health can often be obscured because:

‘Policy cannot be intelligently conducted without an under-

standing of mechanisms; correlations are not enough’

(Deaton 2002, p.15).

As a result, policy levers (such as legislation and resource

allocation) are seen as blunt instruments in tackling SDH,

whose consequences are not, and sometimes cannot be,

ascertained with sufficient clarity.

Attribution of policy interventions to outcomes is problematic.

Such outcomes may not be evident for many years, if at all, as

indicated by the life-course perspective. Consequently, there is

often a reliance on ‘process’ measures as indicators of progress,

assuming that they are associated with outcomes. This may be

particularly problematic the higher the level of analysis, such as

macro-economic policy (Turrell et al. 1999), or as policy is

transferred from HICs to LMICS. Attribution may also pose

dilemmas for targets given the multi-faceted nature of policy

outcomes.

Sixth, the identification, monitoring and analysis of epide-

miological changes over time, is crucial to inform the policy-

making process. Yet, routine data are not always available, are

of poor quality or have been collected over insufficient periods

Figure 1 The main determinants of health.
Source: Dahlgren and Whitehead (1991).

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to aid policy-making (Center for Global Development 2006;

Exworthy et al. 2006). Data categorization by population groups

(e.g. ethnicity, gender) or geographically is often poor.

However, whilst data are necessary, they alone are not

sufficient to secure policy implementation.

Seventh, globalization and multi-lateralism are significant

factors in delivering ‘global public goods’ such as health (Chen

et al. 1999) but such goods have been influenced by the

changing role of the nation state in policy-making (Lee et al.

2002; Labonte and Schrecker 2007). Powers have been re-

located to supra-national organizations such as the European

Union, World Trade Organization, International Monetary Fund

and World Bank. In particular, these supra-national institutions

tend to promote a neo-liberal agenda (Raphael 2003).

Governments’ ability to shape and mould the SDH with the

goal of improving their population’s health is becoming limited

as many of the ‘causes’ of poor health (Wilkinson and Marmot

2003) no longer fall within their responsibility. They, therefore,

need to rely on influence and leverage in multi-national

networks. By contrast, decentralization to regions and cities

has had a similar effect on the policy-making capacity of

governments. Decentralization in HICs and LMICs can be seen

as an attempt to make public services more responsive to local

needs (and in that sense, improve intra-area/population equity).

However, despite its popularity, decentralization in LMICs and

HICs is rarely achieved in full or within parameters defined by

central government (Bossert 1998; Atkinson et al. 2002). As

such, decentralization might be seen as less of a threat to

national policy-making than globalization, since the implemen-

tation of the former lies mainly within governments’ control

These seven challenges of the contemporary policy process as

applied to SDH are summarized in Table 1.

The challenges demonstrate that, despite the growing volume

of evidence on SDH, understanding of the particular demands

of the policy process around SDH in particular contexts has

been limited. In short, despite the growing attention on SDH,

understanding of the policy process in particular contexts has

been missing. Policy models and frameworks can help in

developing the theory and practice of policy development to

tackle SDH.

Policy models and their application to
SDH
Conceptual models can provide tools to describe, understand

and explain policy processes. Such models are important for

two reasons. First, much health policy practice has been

developed (and researched) in HICs and ‘transferred’, often

uncritically to LMICs. However, the variability of context and

nuances of individual policies make generalizability proble-

matic. Exporting policies within or between countries is often

discounted on the basis that the ‘context’ is different and hence

lessons from host countries cannot be learnt. However, a focus

on conceptual models can obviate some of these problems by

addressing key issues such as power and resistance. By applying

concepts of the policy process, it is thus possible to discern

meanings and motives, similarities and differences in patterns

and practices across context. Second, as SDH present specific

challenges to the policy process, the configuration of SDH and

policy context in each country demands that typical policy

frameworks are adapted to local contexts.

Despite the extensive literature on this topic and for sake of

brevity, this article focuses on selective models as illustrations

of the ways in which they contribute to improved under-

standings of how the SDH policy process, specifically, may be

approached by policy-makers. The three models do represent,

however, major approaches within the extensive literature,

though they do not provide, by any means, a comprehensive

assessment:

1. streams

2. networks, and

3. stages.

’Streams’ model

This model is concerned with how issues get onto the policy

agenda and how proposals are translated into policy. Kingdon

(1995) argues that ‘windows’ open (and close) by the coupling

(or de-coupling) of three ‘streams’: problems, policies and

politics. The model (and its variants) has been applied to

analysis of policy change around health inequalities and SDH

(e.g. Exworthy et al. 2002; Sihto et al. 2006). This model is

especially pertinent to SDH because, in many (HIC and LMIC)

countries, SDH have struggled to reach the policy agenda, let

alone become implemented. This is despite mounting (epide-

miological) evidence (Wilkinson and Marmot 2003) and policy

proposals.

Problem stream

Conditions or issues (such as SDH) only become defined as

‘problems’ when they are perceived as such. Often, only those

‘problems’ which are (potentially) amenable to policy remedies

Table 1 Link between features of social determinants of health (SDH) and the impact on policy-making

Features of SDH Impact on policy-making

Multi-faceted phenomena with multiple causes Coordinated strategies are difficult to achieve

Life-course perspective Long-term approach does not match policy timetables

Inter-sectoral collaboration and partnership Partnerships are problematic

Dominance of other priorities SDH often neglected

Cause-effect relationships are complex; attribution difficulties Attribution problems hamper policy; reliance on process measures

Data Routine data that is of high quality, timely and available, are often lacking

Globalization (and decentralization) Policy-making involves more stakeholders at multiple levels,
hampering governmental action

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are recognized; many will remain unaddressed. The issues

might be brought to attention by:

1. Key events (such as crises or critical incidents) and/or

2. Publication of ‘evidence’ (such as research studies or

inquiries) and/or

3. Feedback from current policies (via the media or public

opinion).

The growing volume of research evidence has highlighted SDH

but many ‘policy-makers may even be unaware of the

magnitude and trends of existing inequities in health among

their people’ (Dahlgren and Whitehead 2006, p.16). This

underlines the fact that researchers are but one stakeholder

and evidence is just one source of information in policy

processes (Trostle et al. 1999). The lack of consensus about

evidence among the research community may hamper their

influence in defining the ‘problem’. The role of key events and

feedback (e.g. funding crises or negative public opinion) should

not be overlooked in accounting for the policy experience of

specific countries. Also, stakeholders or interest groups (e.g.

medical profession or community groups) might play a

prominent role in highlighting specific issues and bringing

them to the attention of policy-makers (often via the media).

The publication of a key research report [such as the UK

Acheson Inquiry (1998) on health inequalities or the World

Health Organization Commission on SDH] may be such a

prompt (Exworthy et al. 2003).

Policy stream

The multiple strategies and policies may be advanced not just

by civil servants or professionals but also by interest groups.

Some may be ‘kite-flying exercises’ (testing support for

particular strategies) or concrete proposals. However, for any

strategy to be enacted, it must meet a minimum threshold of:

1. Technical feasibility,

2. Congruence with dominant (socio-political) values, and

3. Anticipation of future constraints of the strategy being

proposed.

Many SDH policy proposals may fail to reach these thresholds

and so fail to offer coherent solutions. For example, policies

may not be technically feasible. Though desirable, policies may

not be (proven) effective. Moreover, addressing SDH or health

inequalities may run counter to dominant values and shifting

political values would also threaten further this criterion. The

paucity of evidence about cost-effectiveness of policy solutions

(e.g. Wanless 2002) illustrates this aspect as it might militate

against the relatively newly dominant paradigm of proving

impacts in this way (Davies et al. 2000). Future constraints may

include, for example, the (unintended) consequences of

tackling a particular condition (e.g. obesity).

Politics stream

This refers to the lobbying, negotiation, coalition building and

compromise of local, national and international interest groups

and power bases. In terms of SDH, such political debates can

be vociferous, as they often challenge the power of existing

social, economic and political systems or practices. For example,

in the UK during the 1980s and early 1990s, (right-wing)

governments rejected the notion of health inequalities (Berridge

and Blume 2002); this effectively stifled any policy development

towards SDH.

Coupling the streams

These three streams may be coupled by chance factors, political

(e.g. elections) or organizational cycles (e.g. staff turnover), or

by the actions of a policy entrepreneur. The ‘policy entrepre-

neur’ (such as a government minister, leading doctor, civil

servant or academic) facilitates the coupling process by

investing their own personal resources (namely, reputation,

status, time):

‘Policy entrepreneurs are people willing to invest their

resources in return for future policies they favour’ (Kingdon

1995, p. 204).

De-coupling may also occur if/when conditions in each stream

are not met. For example, the policy entrepreneur may move

position. Equally, there may be a change of government or

other issues assume greater importance. The ‘policy window’

will, therefore, close. The ability of policy-makers to ‘fix the

window open’ (by integrating SDH policy into ‘mainstream’

policy processes) will largely determine the long-term viability

of the policy.

Coupling the streams is not guaranteed; failure may be more

likely (Wolman 1981). Failure to join these streams can

result in disillusionment and claims that policies are purely

symbolic (Edelman 1971). For example, the inability to couple

‘streams’ (in terms of SDH) may be indicative of wider

constraints:

‘Many declarations to tackle inequities . . . appear to be

merely rhetorical, as they have not been followed by any

comprehensive policies and actions to address the problem’

(Dahlgren and Whitehead 2006, p.16).

Other policy models adopt a similar ‘streams’ approach,

involving the conjunction of separate dimensions. Webb and

Wistow (1986) and Challis et al. (1988) argue that three

streams (policy, process and resource) need to be conjoined to

complete the policy process.

1. The policy stream is concerned with policy aims and

objectives;

2. The process stream is concerned with policy means (the

instruments or mechanisms to achieve the policy ends);

3. The resource stream is concerned with the human, financial

and material resources needed to facilitate the process

stream.

A ‘successful’ policy will comprise clear objectives, mechanisms

that achieve those objectives and the resources to facilitate the

process (Powell and Exworthy 2001). However, aspects of

technical and political feasibility make the process stream

highly problematic for SDH policy. Moreover, SDH must

compete for resources (including staff time and finances)

among other priorities.

Another related model by Richmond and Kotelchuck (1991)

concerns the development of ‘health policy priorities’ by

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integrating the evidence base, social strategies and political will

which equates with a ‘public mandate for policy action’

(Nutbeam1998, p.31). Similarly, Nutbeam (2004) claims that

policy implementation is most likely when there is a synthesis

of plausible evidence, political vision and practical strategies

(see also Petticrew et al. 2006).

’Networks’ models

The policy process rarely operates in isolation but rather

through networks of stakeholders, each with their own

interests and motivation. These networks involve interactions

between communities of stakeholders (inside and beyond the

policy process):

‘Although decision-making bodies have some room for

manoeuvre, they usually depend on each other, and thus

form close relationships within a policy sector’ (John 2000,

p.83).

Kickert et al. (1997) argue that policy-making takes place in

‘networks consisting of various actors (individuals, coalitions,

bureaux, organizations), none of which possesses the power to

determine the strategies of other actors’ (p.9).

Whilst networks might develop high degrees of trust and

dependence, they can equally exclude others from the policy

process. Close network relations can also foster learning and

development as they are grounded in practical experience. As

such, networks can foster bottom-up policy developments.

These broad principles are illustrated by two main ‘network’

models: (1) policy and issue networks, and (2) the advocacy

coalition framework (Hudson and Lowe 2004).

(1) Policy and issue networks

The distinction between policy networks and issue networks

revolves around the degree to which stakeholders are involved

directly in the policy process. Four features characterize

networks:

� Membership (number and type of members),

� Integration (frequency, continuity and consensus),

� Resources (their distribution), and

� Power (balance between members) (Marsh and Rhodes

1992).

Policy networks comprise civil servants, politicians and co-opted

members (for example, academic experts). These networks

involve stable relationships among a limited group of stake-

holders with shared responsibility and high degree of integra-

tion. By contrast, issue networks are oriented around specific

‘issues’ and tend to comprise loose, open connections amongst

a shifting group of stakeholders. Heclo (1978) proposed that

issues are not defined by members’ interests but rather the

issues themselves become their interests (Nutley et al. 2007,

p.108).

Applied broadly to SDH, issue networks (relating, say, to

public health or community groups), which seek to raise

attention to the ‘problem’, promoting solutions and lobbying

policy-makers, have become commonplace. An ‘SDH policy

network’, by contrast, has traditionally been absent or poorly

developed, as it implies cross-departmental working (which has

typically not been the modus operandi of governments). There are

signs that such networks are becoming more established as

(some) governments begin to take action on SDH (e g. Judge

et al. 2005; Stahl et al. 2006), partly due to the influence of issue

networks and supra-national institutions (e.g. World Health

Organization and European Union). A schematic summary

indicates that ‘SDH policy networks’ tend to be small, weak and

poorly integrated (though the assessment is dynamic and

peculiar to each country) (Table 2).

Across any government, there are potentially several policy

networks relating to SDH. These networks will inevitably

involve trade-offs, say, between public health and health-care,

between ministries, between SDH policies and routine service

delivery, and between equity and other principles (such as

efficiency). In short, there are (greater or lesser) signs of an

uneasy integration of issue networks into policy networks, as

SDH become established as a legitimate sphere of government

competence in many countries. However, as this happens, new

patterns within policy networks are emerging, although the

SDH discourse has yet to fully permeate all corners of any

government (Exworthy et al. 2003).

(2) Advocacy Coalition Framework (ACF)

Sabatier (1991) (among others) has argued that the policy

process involves the formation and maintenance of complex

coalitions (networks) of interest as well as the top-down

prescription (for example, in terms of achieving ‘perfect

implementation’) (Hudson and Lowe 2004, p.212).

Sabatier’s ACF model views the policy process as a series of

networks which are composed of all the organizations and

Table 2 Assessment of policy networks and issue networks in relation to social determinants of health (SDH)

Network
characteristic

Assessment criteria in
relation to SDH Policy networks Issue networks

Membership 1) Number of participants
2) Types of interest

1) Low
2) Focused

1) High
2) Highly varied

Integration 1) Frequency
2) Continuity
3) Consensus

1) Low but growing
2) Low
3) Weak especially regarding interventions

1) High
2) High/medium
3) Weak

Resources Distribution Mainly hierarchical Loose affiliation

Power Balance of power Strong. Balance of power tilted towards government
ministries and towards health-care

Weak but varied.

Source: Adapted from Marsh and Rhodes (1992).

POLICY TO TACKLE SOCIAL DETERMINANTS OF HEALTH 323

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stakeholders (inside and beyond the policy process) with a

particular interest in that policy sphere.

‘Whatever the motivation for action, it is essential to find

potential allies and partners sharing common or converging

values and objectives, or to find acceptable trade-offs when

conflicting interests are unavoidable’ (Ritsatakis et al. 2006,

p.146).

These networks comprise a ‘coalition of advocates’ and are

termed ‘sub-systems’. They are defined by a set of core values

and beliefs which are resistant to changing ideas and new

policies. Although sub-systems are constantly involved in

examining and learning about their policy environment,

change is only likely to occur when a significant amount of

those values are challenged successfully.

It has become apparent that, over the last decade or so,

coalitions of advocates have been forming in many countries

around a set of core beliefs (relating to SDH) which are

challenging existing dominant values. Such beliefs have been

heavily shaped by the challenge of the SDH research paradigm,

as in the case of the UK’s Acheson report (1998). According to

Sabatier, the impact of such shifts in core beliefs upon policy

might only be apparent after a decade or more. Thus, for SDH

policy programmes which have only recently been established,

it is too early to judge their success. New coalitions may not

always be effective as resistance to new paradigms and

approaches might be expected from (coalitions of) interests

within and beyond the policy process.

’Stages’ models

Some commentators have sought to clarify and explain the

complexity of the policy process by developing models which

identify a linear progression through stages of policy develop-

ment. They offer a heuristic value in understanding the

evolution of policy and may help identify, for example,

potential points at which policy may falter through the use of

(negative) feedback loops (such as implementation failure,

leading to a re-formulation of the ‘problem’).

The most commonly applied example of ‘stages’ in relation to

SDH is by Dahlgren and Whitehead (2006) who identify seven

stages towards action (Figure 2).

Ritsatakis and Jarvisalo (2006) offer a variation of the

Dahlgren and Whitehead ‘stages’ model:

1. Reaching policy-makers and the public (raising awareness);

2. Securing the information (such as international databases,

presentation and discussion, parliament);

3. Policy formulation and implementation (inter-sectoral com-

mittees, leadership, consensus conferences, formal consulta-

tions in drafting legislation, public referenda, informal

contacts);

4. Seeking partnerships and alliances; and

5. Provisions for implementation.

No single policy model offers a fully comprehensive description

or understanding of the policy process as each answers

somewhat different questions. The selection and appropriate

application of these models to health policy analysis is crucial

in understanding and explaining the ways in which SDH are

addressed in specific national contexts.

Conducting research on the SDH
policy process
Understanding better the policy process is a crucial step in

applying it to the SDH context. However, it is also important to

understand how such processes affect the conduct of research

about the policy process. Five considerations are noteworthy

(Table 3).

First, the long-term nature of policy development (arising

from the life-course perspective and engrained nature of SDH in

society) presents a challenge for research which is often funded

on a short-term basis in the hope of seeking quick answers and

remedial solutions. Tracing policy developments over the long-

term involves different methodologies too. For example, as

outcomes may not be observable for some time, intermediate

measures of progress are often sought.

Second, tracing causes and effects of policies presents attrib-

ution difficulties. Tracking the pathways from epidemiological

data to policy responses and their impact is complicated by the

‘open systems’ within which SDH operate. Counter-veiling

forces (such as the economic climate or globalization) might

Measurement

Recognition

Awareness raising

Concern Denial/indifference

Mental block
Will to take action

Isolated initiatives

More structured developments

Comprehensive coordinated policy

Figure 2 Action spectrum on health.
Source: Dahlgren and Whitehead (2006, p.95).

Table 3 Researching the social determinants of health (SDH) policy
process

Features of SDH
policy-making Impact upon researching the policy process

Long-term perspective

� Long-term research

� Search for process measures

Attribution � Programmes of research,
examining range of issues

� Development of monitoring techniques

Non-decisions � Participant-observation
� Policy ethnography

Multiple agencies
and stakeholders

� Research into cultural, organizational
and political practices

Multiple policy
programmes

� Programmes of research, examining
range of issues

� Long-term research

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undermine or counteract policy effects in unintended or

unobservable ways. Methodological responses to such dilemmas

might include research projects examining discrete interven-

tions but this loses the inter-connectedness of SDH (Milward

et al. 2003). Research programmes (with several projects) might

mitigate this, but doing so on an international scale is often

prohibitive.

Third, the opaqueness of policy-making (and especially non-

decisions) is problematic for researchers. Gaining access to

organizations is a perennial issue for researchers but it is

perhaps even more difficult to observe policy-making processes

in action. Moreover, the ways in which decisions ‘emerge’

(rather than taking place at a single moment and often

unobservable to the researcher) are particularly problematic.

Participant-observation is a strategy that is seemingly easy to

adopt but difficult in practice. There is perhaps understandably

a reliance on semi-structured interviews and documentary

analysis.

Policy ethnography is a developing methodology which

involves long-term immersion in a policy domain (Flynn et al.

1996; Exworthy et al. 2002). Nonetheless, it is difficult to

construct an authentic account of the policy-making process

that captures its nuances and complexity over the long-term.

Becoming too closely associated with policies can create a bias

as researchers can become apologists for the policy that they are

investigating. Decisions and non-decisions taken elsewhere may

thus become less apparent. Case studies and witness seminars

(involving stimulated recall of the key actors; Berridge and

Blume 2002) can also be useful techniques.

Fourth, capturing the views of multiple stakeholders and

tracing the influence of each organization’s practices and cul-

ture upon the policy process are complex tasks and time-

consuming. Studies of inter-organizational relationships have

a long lineage and researchers should draw on this extant

knowledge (Ferlie and McGivern 2003). However, the scale of

the task in terms of SDH should not be under-estimated given

the multiple agencies that could (potentially) be involved in

SDH policy (Nutbeam 1998).

Fifth, by its very nature, tackling SDH implies a multi-faceted

approach. Whilst much public policy tends to focus on single

strategies for particular population groups in specific circum-

stances, there is a need to examine the inter-connectedness of

components of SDH. The breadth of such research is daunting

and therefore requires large-scale, longitudinal research pro-

grammes (including policy research). This observation implies a

multi-disciplinary approach which is often antithetical to the

organization of universities, their criteria for appointments and

tenure, and the publication of research. Large-scale research

programmes may offer insights into the ways in which

international institutions are shaping the cross-national

causes of SDH; whether political action will be forthcoming

to address SDH globally is arguable.

Conclusion
Partly as a result of methodological difficulties, there is often

a search for conceptual development and theoretical elabo-

ration in health policy research. The policy process has been

described as an exercise in ‘collective puzzlement’ (Heclo and

Wildavsky 1974, p.305). In puzzling about possible policy

options available to policy-makers, there is an implicit

imperative for making choices and for understanding the

ways in which policy-makers learn from themselves (e.g.

Freeman 2006; Marmor et al. forthcoming). Conceptual

models are useful techniques in such learning.

This paper has sought to raise awareness of the ways in

which policy towards SDH may be better described, understood

and explained. By identifying the components of the policy

process and the ways in which features of SDH require the

adaptation of traditional approaches, it is possible to apply

conceptual models which offer new insights about SDH policy-

making. Researchers must therefore adapt and apply exist-

ing methodologies to the specific nuances of SDH policy.

Together, conceptual models and appropriate methodologies

may contribute to improved policy-making which may, in

turn, ameliorate conditions for many of the poorest across the

world.

Acknowledgements
Research for this article was conducted by the author as a part

of the Measurement and Evidence Knowledge Network of the

WHO Commission on the Social Determinants of Health, of

which he is a member (http://www.who.int/social_determi-

nants/knowledge_networks/en/index.html). He is grateful to

members of the Knowledge Network, WHO representatives

and participants at the Health Policy Methodology Workshop

(sponsored by ODI in London in May 2007) for their

constructive comments. The views of this article do not neces-

sarily represent the M&E Knowledge Network, the Commission

or the WHO.

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Social Determinants of Health

Housing and Health
in Los Angeles County

February 2015

2 Los Angeles County Department of Public Health

INTRODUCTION
Health and health problems result from a complex interplay of a number of forces. The most important
forces that impact population health — the health outcomes of a group of individuals — are the social
and economic environments in which we live, learn, work, and play. We refer to these factors collectively
as the “social determinants of health.” This report, the second in a Department of Public Health series on
the social determinants, follows our introductory release, “How Social and Economic Factors Affect
Health.” Here, we explore the intersection of health and housing in Los Angeles County.

Characteristics of healthy and safe home environments include access to clean air and water; efficient
transportation, including safe, walkable neighborhoods; affordable, healthy foods; violence-free places to be
physically active; and affordable, secure, quality housing. Unfortunately, while tradition holds that home is
a haven, where people are protected and nurtured, for many home is a health hazard where factors such as
poverty, environmental contamination, and poor design combine to cause or exacerbate disease.1 A lack of
affordable, stable, and quality housing affects health in multiple ways. For example:

1. Unaffordable housing reduces the income that a household has available for other subsistence needs,
such as nutritious food, necessary health care expenses, and transportation. Unaffordable housing also
negatively impacts mental health, due to continuous stress. In addition, families that cannot afford
their housing may have to move more frequently, which can lead to more psychological stress, and
depression, particularly in children.2 Low-income families, in particular, tend to move more often in
their search for an affordable home.

2. The experiences of eviction, foreclosure, and living in others’ homes can all negatively impact mental
health. Lacking a stable place to live increases levels of depression, anxiety, and hopelessness. Housing
instability is associated with behavioral issues in children as well as increases in teen pregnancy, drug
use, and depression in adolescents.3,4 When people become homeless, they experience physical and
mental deprivation that can cause acute and chronic health problems.

3. Housing quality, assessed in terms of environmental exposure, also impacts health. Exposure to
toxins such as lead, radon, molds, and extreme temperatures (due to lack of adequate heating and
cooling systems) affects physical health, as do housing conditions that increase risk for falls or fires.
Some environmental conditions, such as loud or continuous noise and inadequate lighting, affect sleep
quality and mental health.5 Overcrowded housing has been recognized as a health risk since the 19th
century, and is associated with increased risk for infectious disease, such as influenza and tuberculosis,
along with chronic diseases like asthma, cardiovascular disease, and depression.6,7

Housing affordability, stability, and quality are essential for health and well-being. Indeed, because housing
is fundamental to maintaining an adequate standard of living, the United Nations Declaration of Human
Rights codifies housing as a human right.8 In the absence of affordable, secure, quality housing, social
inequities and health disparities are exacerbated. As part of the Los Angeles County Department of Public
Health’s commitment to achieving health equity among County residents, we present this report as an
introduction to the issue of housing in Los Angeles County from the public health perspective, providing a
framework from which to advance our collective efforts to address this critical public health issue.

http://publichealth.lacounty.gov/epi/docs/SocialD_Final_Web

http://publichealth.lacounty.gov/epi/docs/SocialD_Final_Web

3Social Determinants of Health: Housing and Health in Los Angeles County

Housing Issues in Context:
The Impact of the Great Recession
California was one of the states most severely impacted by the economic recession of 2007-2009, which
affected millions of Los Angeles County residents. Between 2007 and 2011, incomes declined for all but
the highest paid earners in the County. Low income households suffered the most, with earnings for the
poorest fifth of County residents declining 12% between 2007 and 2011.9 Those most harmed
by job loss were largely communities of color; historically disadvantaged groups experienced a
disproportionate deterioration in economic conditions during the recession.10 To make matters worse,
Southern California has recovered from the recession more slowly than other parts of the state.11

The recession itself was triggered by a crisis in the housing market. Aggressive and sometimes predatory
mortgage lending practices allowed and even encouraged borrowers to take on high-risk loans, and banks
approved mortgages for customers who were unlikely to be able to make their payments. Growing
evidence shows that financial institutions specifically targeted African American and Latino families for
predatory and deceptive lending practices and subprime loans.12,13

Many banks backed their financial securities on these problematic mortgages. When borrowers defaulted
on their loans, foreclosures skyrocketed: in Los Angeles County in 2007, they increased by nearly 800%
from the previous year, with African Americans and Latinos hit particularly hard.14 The nation’s financial
institutions fell into crisis, initiating a chain reaction, with banks putting a halt on lending, freezing credit
critical to the functioning of entrepreneurs, businesses, and community agencies. The stock market
plunged, home sales plummeted, construction stalled, fewer jobs were created, and with reduced consumer
activity, businesses laid off employees. These losses continue to reverberate today.

The U.S. Government Promotes Healthy Housing

In June 2010, President Obama signed an Executive Order creating the National
Prevention, Health Promotion, and Public Health Council, bringing together 17 federal
agencies and offices, including the Department of Housing and Urban Development
(HUD). The Council formally recognizes that where we live, learn, work and play all have
an impact on our health. In June 2011, the Council issued a National Prevention Strategy
that identified “Healthy and Safe Community Environments” as one of its four strategic
directions. Specifically, the document calls for the design and promotion of affordable,
accessible, safe and healthy housing. By providing families with greater
residential stability, affordable housing can reduce stress and related adverse
health outcomes. Well-constructed and well-managed affordable housing
developments can reduce health problems associated with poor quality
housing by limiting exposure to allergens, neurotoxins, and other dangers.

National Prevention Council, National Prevention Strategy, Washington, DC:
U.S. Department of Health and Human Services, Office of the Surgeon General, 2011.

http://www.surgeongeneral.gov/initiatives/prevention/2011-annual-status-report-nphpphc

http://www.surgeongeneral.gov/initiatives/prevention/2011-annual-status-report-nphpphc

4 Los Angeles County Department of Public Health

METHODS
Data contained in this report come from two sources:

1) The Los Angeles County Health Survey (LACHS) is a periodic, population-based random-digit-dial
telephone survey that measures the health of County residents. The survey provides updates on key health
indicators and identifies emerging public health issues among adults and children residing in the County’s
eight Service Planning Areas (SPAs) and 26 Health Districts. The survey also allows the Department of
Public Health to track health issues over time. To properly address the root causes of poor health, the
survey looks beyond risk factors for individual diseases to factors in the physical and social environment
that influence health, such as safety, poverty, and educational attainment. The 2011 survey collected
information on a random sample of 8,036 adults and 6,013 children.

The 2011 LACHS included the following questions to assess housing affordability, housing stability, and
housing quality among adults (age 18+ years):

♦ During the past 2 years, was there any month when you/your family delayed paying or were not able
to pay your mortgage or rent? (This is a measure of affordable housing.)

♦ Thinking back over the past 5 years, was there ever a time when you were homeless or did not have
your own place to live or sleep? (This is a measure of stable housing.)

♦ Which of the following describes your current home or apartment? (This is a measure of quality
housing.)

• It has mold or growth that concerns you.

• It has pests such as cockroaches or mice.

• It was built before 1978 and has peeling or chipping paint.

• It has heat or hot water when you need it.

For more information about LACHS methodology, please see:
www.publichealth.lacounty.gov/ha/hasurveyintro.htm.

2) The American Community Survey (ACS) is an ongoing version of the U.S. Census. Five-year
estimates from the ACS provide more reliable data for smaller geographic regions, by combining 60 months
of data into one estimate.

Five-year estimates (2008-2012) of the ACS provided the following data:

♦ Percent of people who spend 30% or more of their income on monthly housing costs, gross rent or
mortgage. (This is a measure of affordable housing.)

For more information about the ACS methodology, please see: www.census.gov/acs/www/.

5Social Determinants of Health: Housing and Health in Los Angeles County

HOUSING AFFORDABILITY
What makes housing affordable? According to the United States Department of Housing and Urban
Development, housing is considered affordable if the people living there pay less than 30% of their income
on rent or mortgage payments. Households who pay over this amount are considered to have a high
housing burden, as it is more likely they will not have enough money to meet other needs such as food and
medical care. Housing burdens across the U.S. have increased during the previous decade, particularly for
low-income people.15

Data from the 5-year estimates (2008-2012) of the ACS reveal that 52.1% of households in Los Angeles
County had high housing burden.16 For home owners, 45.3% reported high housing burden, compared to
58.5% of renters. In Los Angeles County, a median income household can afford only about 24% of homes
available for purchase.17 Based on this measure, Los Angeles County is the nation’s third most expensive
housing market. The County has the highest percentage of renters of the twenty largest metropolitan areas
in the nation, with 52% of households renting.18

Affordable rental housing is out of reach for many families in the County. According to the National Low
Income Housing Coalition, a worker in Los Angeles County needs to earn $26.88 per hour to afford rent
on a 2 bedroom apartment. Meanwhile, the average renter earns only $18.53 per hour, while minimum
wage workers make a mere $9.00 per hour.19

The Los Angeles County Health Survey estimated housing affordability by asking adults, “During the past
two years, was there any month when you or your family delayed paying or were not able to pay your
mortgage or rent?”

• Overall, 17.2% (or an estimated 1.2 million people) reported they were unable to pay or delayed
paying their mortgage or rent in the past 2 years (Table 1).

• Significantly more African Americans (26.2%) and Latinos (21.3%) reported this issue than Asians/
Pacific Islanders (13.5%) or whites (10.9%).

• Households with lower incomes were significantly more impacted: 26.8% of those living below
the federal poverty level (FPL) and 23.2% of those with household incomes of 100-199% FPL
reported problems affording housing. Higher income households were also affected: 15.7% of those
with incomes 200-299% FPL and 8.5% of those at or above 300% FPL also reported that housing
affordability was an issue.

• Having at least a college degree appeared to provide some protection against housing unaffordability,
with significantly fewer college graduates reporting problems than those with less formal education
(9.4% compared to 20.1%).

• Nearly one-quarter (23.0%) of adults with a disability reported housing affordability was an issue,
significantly more than the 15.8% of adults without a disability.

• A significantly higher percentage of unemployed respondents (24.9%) reported housing affordability
was an issue compared to those who were employed (17.0%) or not in the labor force (those who
were retired, students, homemakers, unemployed and not looking for work, or not working due to a
disability) (13.8%).

• Housing unaffordability varied greatly across the County, with only 7.5% of residents in the West SPA
reporting difficulty paying mortgage or rent, compared to 28.0% in the Antelope Valley SPA.

6 Los Angeles County Department of Public Health

Table 1: Percent of Adults (18+ years old) Who Were Unable to
Afford or Delayed Paying Their Mortgage or Rent in the Past Two
Years, LACHS 2011.
Percent (%) 95% CI Estimated

#

Los Angeles County 17.2 16.0 – 18.4 1,222,000

Gender
Male 16.6 14.7 – 18.5 572,000
Female 17.7 16.2 – 19.3 650,00

0

Age Group
18-24 13.9 10.5 – 17.3 134,000
25-29 17.0 12.7 – 21.3 125,000
30-39 23.1 19.9 – 26.4 323,000
40-49 19.9 17.2 – 22.6 274,000
50-59 20.1 17.2 – 23.0 239,000
60-64 13.0 9.6 – 16.4 57,000
65 or over 6.9 4.8 – 9.0 70,000

Race/Ethnicity
Latino 21.3 19.2 – 23.3 659,000
White 10.9 9.2 – 12.5 245,000
African American 26.2 21.6 – 30.7 159,000
Asian/Pacific Islander 13.5 10.2 – 16.8 148,000

Education
Less than high school 22.7 19.7 – 25.6 373,000
High school 18.4 15.6 – 21.3 290,000
Some college or trade school 19.2 16.8 – 21.6 380,000
College or post graduate degree 9.4 7.9 – 10.8 176,000

Household Income $

0-99% FPL 26.8 23.7 – 29.9 454,000
100-199% FPL 23.2 20.3 – 26.1 381,000
200-299% FPL 15.7 12.5 – 18.8 147,000
300% FPL or above 8.5 7.2 – 9.8 241,000

Disability
Yes 23.0 20.0 – 25.9 318,000
No 15.8 14.4 – 17.1 900,000

Service Planning Area
Antelope Valley 28.0 21.8 – 34.3 71,000
San Fernando 16.3 13.7 – 18.8 255,000
San Gabriel 15.2 12.4 – 17.9 191,000
Metro 18.2 14.7 – 21.7 154,000
West 7.5 4.5 – 10.4 38,000
South 22.5 18.4 – 26.7 151,000
East 19.2 15.5 – 22.9 174,000
South Bay 17.1 13.8 – 20.5 189,000

$ Based on U.S. Census Bureau, Housing and Household Economic Statistics Division, 2009 Federal Poverty Level (FPL) thresholds which for a family of four (2 adults, 2 dependents) correspond to annual incomes
of $20,444 (100% FPL), $40,888 (200% FPL), and $61,332 (300% FPL).

7Social Determinants of Health: Housing and Health in Los Angeles County

Competing Expenses
High housing costs may reduce an individual’s or a family’s capacity to meet other essential needs in their
lives, including their ability to pay for health care expenses or purchase nutritious, quality food. Research
demonstrates that these tradeoffs threaten the health of adults and children, resulting in poorer overall
health status.20

The LACHS examined the ability of Los Angeles County adults to meet their subsistence needs by inquiring
about their ability to access health services including medical care, prescription drugs, mental health care,
and dental care. The survey also measured the ability to access food through a series of questions that
assess food security, which is defined by the U.S. government as the ability of people to access, at all times,
enough food to live an active, healthy life.21,22

♦ Health Care Affordability
• Compared to those who did not report difficulty paying mortgage or rent on time, adults who had

difficulty paying for housing faced significantly increased difficulty affording health services.

• Compared to those who did not experience problems with housing unaffordability, approximately
three times as many adults who reported a problem with housing affordability also were unable to
afford to see a doctor for a health problem, purchase their prescription medication, or obtain mental
health care. Over twice as many reported not being able to afford dental care, including check-ups
(Figure 1).

0

2

5%

50%

75%

Unaffordable Housing Affordable Housing Unable to Afford
Unable to Afford Unable to ObtainUnable to Afford

12.1

35.4

11.2

35.1

4.6

13.4

25.4

54.5

Health Services Needed During the Past Year

Unable to
Afford

Dental Care

Unable to
Afford Mental
Health Care

Unable to
Obtain

Prescription
Medication

Unable to
Afford to See

MD for
Health Problem

Unaffordable Housing

Affordable Housing

Figure 1: Percent of Adults Who Were Unable to Afford Access
to Various Health Services by Affordable Housing, LACHS 2011

8 Los Angeles County Department of Public Health

0

25%

50%
75%

Low Food SecurityVery Low Food Security

NoYes

6.6

26.7

30.2

14.1

Affordable Housing

20.8

56.9

#

Figure 2: Percent of Adults <300% FPL with Food Insecurity (Low and Very Low) by Affordable Housing, LACHS 2011

♦ Food Insecurity
Food Insecurity refers to the inability to purchase enough food for adequate nutrition, and is reported

here only for adults with household incomes <300% FPL. Food insecurity consists of low food security, defined as reduced quality, variety, or desirability of diet, and very low food security, which involves disrupted eating patterns and reduced food intake.21,22

• Compared to those who did not experience housing unaffordability, adults with incomes <300% FPL who reported trouble paying their mortgage or rent during the last two years were over two and a half times more likely to be food insecure (56.9% vs. 20.8%) (Figure 2).

• Furthermore, adults with incomes <300% FPL who reported difficulty affording housing were over twice as likely to have low food security (30.2% vs. 14.1%) and over four times as likely to have very low food insecurity (26.7% vs. 6.6%) compared to those who did not report difficulties paying their mortgage or rent.

# Total prevalence is not additive due to rounding.

9Social Determinants of Health: Housing and Health in Los Angeles County

Figure 2: Percent of Adults <300% FPL with Food Insecurity (Low and Very Low) by Affordable Housing, LACHS 2011

HOUSING INSTABILITY AND HOMELESSNESS
Poor health is a major cause of homelessness, and homelessness itself leads to poor health. Acute and
chronic mental health problems, other chronic illnesses, and disability can lead to homelessness when
stable housing becomes too difficult to maintain without assistance.23 Homelessness can exacerbate
chronic physical and mental health conditions or contribute to debilitating substance abuse problems.24
Environmental exposures, communicable disease exposures, lack of access to preventive care and medical
treatment, and lack of access to proper nutrition and sleep all contribute to high rates of poor health among
homeless persons. Strikingly, the average life expectancy of homeless people is estimated to be almost 30
years shorter than the general population.25

In 2013, the Los Angeles County Homeless Services Authority (LAHSA) biannual count of homeless
people estimated that 57,737 people were homeless in the County.26 While the Los Angeles County Health
Survey cannot directly count homeless people as LAHSA does, we assessed the burden of homelessness
Countywide by asking respondents if there was ever a time during the previous 5 years when they were
homeless or did not have their own place to live or sleep. This method allows for the inclusion of the
“hidden homeless,” those who reside not on the street or in shelters during periods of housing instability,
but with family, friends, or in hotels/motels.

Best Practice: Tenant-Based Rental Assistance

The Community Preventive Services Task Force recommends tenant-based rental
assistance programs as an intervention that expands affordable housing options to low-
income families. These programs are supported by public housing funds and subsidize the
cost of housing by allotting rental vouchers to low-income households. Such subsidies allow
participants a greater range of rental options, reducing the likelihood of living in high-poverty
neighborhoods. Tenant-based rental assistance programs have demonstrated reductions in
violent victimization of household members and improved neighborhood safety.

Single Adult Model

The Single Adult Model (SAM) is the basis for a multi-departmental collaborative among the
Los Angeles County Departments of Public Health (DPH), Health Services (DHS), Mental
Health (DMH), and Public Social Services (DPSS), and the Los Angeles County Community
Development Commission to create a County infrastructure to reduce homelessness among
single adults in the County. The goal is to permanently house and provide supportive services
to homeless single adults who have physical and/or mental health conditions, and who may
also have a co-occurring substance use disorder. SAM participants will be identified through
DPSS General Relief participation or by multidisciplinary integrated teams that conduct street
and shelter-based outreach and engagement.

http://www.thecommunityguide.org

http://www.thecommunityguide.org/healthequity/housing/tenantrental.html

http://www.thecommunityguide.org/healthequity/housing/tenantrental.html

http://ph.lacounty.gov/

http://dhs.lacounty.gov/wps/portal/dhs

http://dmh.lacounty.gov/wps/portal/dmh

http://dmh.lacounty.gov/wps/portal/dmh

http://dpss.co.la.ca.us/

http://www3.lacdc.org/CDCWebsite/Default.aspx

http://www3.lacdc.org/CDCWebsite/Default.aspx

10 Los Angeles County Department of Public Health

Table 2: Percent of Adults (18+ years old) Who Reported Being
Homeless or Not Having Their Own Place to Live or Sleep in the
Past 5 Years, LACHS 2011
Percent (%) 95% CI Estimated #

Los Angeles County 5.2 4.4 – 5.9 373,000

Gender
Male 5.3 4.1 – 6.5 186,000
Female 5.0 4.1 – 6.0 187,000

Age Group
18-24 6.4 3.9 – 8.8 63,000
25-29 8.4 5.0 – 11.7 62,000
30-39 7.5 5.4 – 9.6 106,000
40-49 4.7 3.2 – 6.2 66,000
50-59 5.1 3.5 – 6.7 61,000
60-64 1.8* 0.6 – 3.0 8,000
65 or over 0.7* 0.2 – 1.2 7,000

Race/Ethnicity
Latino 5.2 4.1 – 6.4 164,000
White 4.1 2.9 – 5.3 94,000
African American 14.8 10.8 – 18.9 91,000
Asian/Pacific Islander 1.8* 0.4 – 3.2 20,000

Education
Less than high school 5.8 4.2 – 7.5 97,000
High school 5.5 3.7 – 7.2 88,000
Some college or trade school 7.4 5.6 – 9.1 147,000
College or post graduate degree 2.1 1.3 – 2.8 39,000

Household Income $

0-99% FPL 9.5 7.4 – 11.6 163,000
100-199% FPL 7.2 5.4 – 9.0 120,000
200-299% FPL 4.4* 2.4 – 6.4 42,000
300% FPL or above 1.7 1.0 – 2.4 48,000

Disability
Yes 10.5 8.3 – 12.8 147,000
No 3.9 3.1 – 4.7 225,000

Service Planning Area
Antelope Valley 4.5* 2.0 – 7.0 12,000
San Fernando 5.9 4.0 – 7.8 94,000
San Gabriel 3.8 2.4 – 5.3 49,000
Metro 6.0 3.6 – 8.5 52,000
West 1.5* 0.2 – 2.8 7,000
South 7.6 4.9 – 10.4 51,000
East 4.4 2.7 – 6.1 40,000
South Bay 6.1 3.8 – 8.3 68,000
* The estimate is statistically unstable (relative standard error ≥23%) and therefore may not be appropriate to use for planning or

policy purposes.

$ Based on U.S. Census Bureau, Housing and Household Economic Statistics Division, 2009 Federal Poverty Level (FPL) thresholds which for a family of four (2 adults, 2 dependents) correspond to annual incomes
of $20,444 (100% FPL), $40,888 (200% FPL), and $61,332 (300% FPL).

11Social Determinants of Health: Housing and Health in Los Angeles County

• In LA County, 5.2% of adults (approximately 373,000 people) reported being homeless or not having
their own place to live or sleep at some time in the past 5 years (Table 2).

• One in seven African Americans (14.8%) reported housing instability, compared to 5.2% of Latinos,
4.1% of whites, and 1.8%* of Asians/Pacific Islanders (Figure 3).

• As household income increased, reported housing instability decreased, from 9.5% among those with
household incomes <100% FPL, to 1.7% among those with household incomes 300% FPL or above. Further, approximately 75% of those reporting housing instability reported household incomes <200% FPL.

• Adults who reported having a disability were over twice as likely to report housing instability (10.5%)
compared to adults who did not report having a disability (3.9%).

• Adults who were unemployed reported more housing instability (11.0%) than those employed (3.8%)
or not in the labor force (4.9%).

• Renters were more likely to report housing instability (8.3%) compared to those who owned their
homes (1.0%*).

Figure 3: Percent of Adults Who Have Been Homeless
or Not Had Their Own Place to Live in the Past 5 Years
by Race/Ethnicity, LACHS 2011

0
5%

10%

15%

20%

25%

Asian/Pacific
Islander

African
American

WhiteLatinoLA County

5.25.2 4.1

14.8

1.8*

*The estimate is statistically unstable (relative standard error ≥23%) and
therefore may not be appropriate to use for planning or policy purposes.

12 Los Angeles County Department of Public Health

HOUSING PROBLEMS AND ADVERSE HEALTH OUTCOMES
Data from the LACHS demonstrate the deleterious associations between unaffordable housing, unstable
housing, and health. Compared to people with relatively affordable and stable housing, those with
challenges to securing housing fared significantly worse on multiple measures of health.

♦ Health Status
• Significantly more Los Angeles County adults who reported delaying or not paying their mortgage

or rent during the last 2 years reported fair or poor health status compared to those who did not
report problems paying for their housing (30.9% vs. 18.7%).

• Survey respondents who had trouble paying their mortgage or rent during the last 2 years also
reported significantly more unhealthy days during the past month (days when their physical
or mental health was not good) compared to those who did not report problems with housing
affordability (8.6 vs. 4.8 unhealthy days).

• LA County residents who experienced housing unaffordability also reported significantly more days
that their normal activities were limited due to problems with physical or mental health, compared
to residents who did not have trouble paying for housing. Those who reported difficulty paying for
housing on average faced 3.5 activity limitation days per month, compared to 1.8 days for those
without difficulty.

• Nearly one third (31.5%) of Los Angeles County adults with a history of homelessness during
the last 5 years reported fair or poor health status, compared to 20.2% of those who had not
experienced housing instability.

• Adults with a history of housing instability also reported significantly more unhealthy days in the
last month (days when their physical or mental health was not good) compared to people without a
history of homelessness (11.2 unhealthy days vs. 5.1).

• Similarly, LA County adults with housing instability reported an average of 5.2 activity limitation
days per month, versus 1.9 days for those with stable housing.

13Social Determinants of Health: Housing and Health in Los Angeles County

♦ Mental Health
• Significantly more adults who reported unaffordable housing were at risk for major depression^

than those who were able to pay their mortgage or rent (18.1% vs. 8.9%) (Figure 4).

• Los Angeles County adults who reported they or their family delayed or did not pay their mortgage
or rent sometime during the last 2 years had significantly higher rates of current anxiety or stress
disorder (10.8% vs 5.6%) and significantly higher rates of current depressive disorder (14.3% vs.
7.1%).^^

• Adults who experienced housing instability were over three times more likely to be at risk for major
depression (30.8%) than those in stable housing (9.3%) (Figure 4).

• Additionally, adults who experienced homelessness during the previous 5 years were significantly
more likely to be suffering from current anxiety or stress disorder (17.6%) or current depressive
disorder (19.4%) compared to those in stable housing (5.8%, and 7.7%, respectively).

0
10%
20%

30%

40%

8.9

18.1

9.3

30.8

Unaffordable Housing Affordable Housing

At Risk for Major DepressionAt Risk for Major Depression

Stable HousingAffordable Housing

Unstable HousingUnaffordable Housing

Figure 4: Percent of Adults At Risk for Major Depression by
Affordable and Stable Housing, LACHS 2011

^At risk for major depression was assessed through the Patient Health Questionnaire 2 (PHQ-2), a two item screening tool.
^^ To be considered to have current anxiety or current depression, the survey respondent reported that s/he had been previously
diagnosed with an anxiety/phobia/stress disorder or depressive disorder and reported that s/he currently had symptoms of this
disorder or was receiving treatment for it at the time of survey interviewing.

14 Los Angeles County Department of Public Health

QUALITY HOUSING
Environmental Factors
Quality housing is associated with positive physical and mental well-being. How homes are designed,
constructed, and maintained, their physical characteristics, and the presence or absence of safety devices
can impact injury, illness, and mental health. Indoor air quality, water quality, chemicals in the dwelling
and the neighborhood, resident behavior, and the home’s immediate surroundings all impact health.
According to the Surgeon General of the United States, the link between these housing features and illness
and injury is clear and compelling.27

Environmental hazards in the home that are harmful to occupants include mold and pests. Exposure to
mold and pests increases the risk for allergy symptoms, asthma, and other respiratory problems. Use of
pesticides to eliminate insects or rodents can cause poisonings and may cause chronic health problems
including cancer, low birth weight, and prematurity.28

Many hazards, like exposure to lead paint and tobacco smoke, are particularly dangerous for children. Lead
exposure can result in lasting impairment of a child’s development and behavior, such as decreased IQ
and attention span, and increased risk for delinquent behavior.29 Lack of heat or hot water in the home is
considered a threat to the health and safety of its occupants, and in some circumstances a dwelling lacking
these is considered uninhabitable.30

Poor housing quality also affects mental health, and these effects are especially profound in children.
Research by the MacArthur Foundation has found that poor quality housing was the most consistent
and strongest predictor of emotional and behavioral problems in low-income children and youth among
housing characteristics studied, including affordability, stability, and ownership.31

We assessed housing quality in the LACHS by asking specific questions about the physical conditions
of the house or apartment. The survey inquired about tobacco use within the home. We also queried a
subsample of about 1,000 respondents about the presence of mold, pests, and available heat or hot water
in their homes, as well as exposure to lead paint. To establish whether lead paint was present, we based our
question on the California Code of Regulations, which states that “presumed lead-based paint” is paint or
surface coating affixed to a component in or on a structure constructed prior to January 1, 1978.32

According to the 2011 LACHS,

• In LA County, 6.9%, equivalent to about 220,000 households, had mold that concerned
respondents.

• Over one in ten households (11.5%), or about 368,000 homes, reported that their homes had pests
such as cockroaches or mice. The percentage was nearly double among respondents with household
incomes under 200% FPL (15.8%), compared with those whose household incomes were 200%
FPL or higher (8.3%).

• Approximately 116,000 homes, or 3.6%* of households, did not have heat or hot water when
needed.

*The estimate is statistically unstable (relative standard error ≥23%) and therefore may not be appropriate to use for planning or

policy purposes.

15Social Determinants of Health: Housing and Health in Los Angeles County

• In LA County, 23.0% of adults reported that their home or apartment was built before 1978 and
had peeling or chipping paint, meaning that 671,000 households are at risk for exposure to toxic
lead paint.

• Among County households with children, 14.7%, or approximately 154,000 homes, were built
before 1978 and had peeling or chipping paint, increasing the risk for lead poisoning among these
children.

• Among households with children, 16.7%, or about 199,000 households, were exposed to tobacco
smoke in the home, placing children at risk for more frequent and severe ear and lung infections,
wheezing, and asthma.

Asthma Coalition of Los Angeles County (ACLAC)

Coordinated by the LA County Department of Public Health, the Asthma Coalition of Los
Angeles County (ACLAC) is a broad-based coalition of community partners that advocates
policy and systems change to prevent, minimize, and manage the burden of asthma.
The coalition supports activities including training medical professionals to better
manage uncontrolled asthma, providing health assessments and education focused
on reducing asthma irritants and triggers in patients’ homes, and promoting
policies to improve multi-unit housing home inspections and mandates to reduce
pests and other asthma triggers.

Hardware Store Partnership

The LA County Department of Public Health’s Childhood Lead Poisoning Prevention
Program partners with local paint and hardware stores to promote lead safety
awareness by training sales associates to educate consumers about the dangers
of disturbing lead-based paint in older homes and to offer information on how to
safely repaint or remodel their home. Participating stores include the Home Depot,
Lowes, Ace Hardware, True Value, Sherwin Williams, Dunn Edwards, and Walmart.

Public Housing Units Go Smoke-Free

In March 2011, the LA County Department of Public Health (DPH) contacted the directors
of LA County’s public housing units and strongly encouraged them to implement the smoke-
free public housing recommendations released by the U.S. Department of Housing and Urban
Development (HUD). DPH emphasized the well documented dangers of secondhand smoke
in the home, especially for children and adults with asthma or other chronic
illnesses, pregnant women, and the elderly. Following the initial outreach,
DPH’s Tobacco Control & Prevention Program partnered with the Housing
Authority of the County of Los Angeles to develop a smoke-free multi-unit
housing policy, which was adopted on July 1, 2013 for its 63 public housing
developments and protects 6,539 residents from the dangers of secondhand
smoke in the home.

http://www.asthmacoalitionla.org

http://www.asthmacoalitionla.org

http://publichealth.lacounty.gov/lead/

http://publichealth.lacounty.gov/lead/

http://publichealth.lacounty.gov/tob/

16 Los Angeles County Department of Public Health

The Los Angeles County Department of Health Services (DHS) created the Housing for
Health division in 2012. Housing for Health strives to end homelessness in Los Angeles
County, reduce inappropriate use of expensive health care resources, and improve health
outcomes for vulnerable populations. The program achieves these goals by providing
permanent supportive housing, recuperative care, and specialized primary care to homeless
people with complex physical and behavioral health conditions. Access to community-
based housing options is an important element of the evolving County health care system,
particularly in response to the unique opportunities presented by the Affordable Care Act.
Since its inception, Housing for Health has provided housing for over 500 patients.

Working in collaboration with case managers, health care providers, housing finance
agencies, housing developers, and philanthropy, Housing for Health aims to create 10,000
units of housing linked to the health care system. In addition to the central goal of creating
permanent supportive housing, Housing for Health
develops other residential settings to improve the
flow of patients within the health system, including
a significant expansion of recuperative care/
stabilization beds available to DHS hospitals.

The Los Angeles County Department of Public Social Services (DPSS) Housing Program
offers a number of benefits and services designed to assist CalWORKs families who are
homeless or at risk of homelessness to move out of the current housing crisis into affordable
permanent housing. The DPSS Housing Program includes financial assistance as well as
case management services. In addition, DPSS collaborates with other County, City and
community agencies on the Homeless Family Solutions System (HFSS). The HFSS is a
regional, coordinated, Housing First approach to address family homelessness by diverting
and rapidly re-housing families while connecting families to supportive services within their
own communities.

The Housing Authority of the County of Los Angeles is partnering with the Central
Neighborhood Health Foundation (CNHF) to open a satellite community clinic at
Carmelitos Public Housing Development. Located in the City of Long Beach, Carmelitos
encompasses 64 acres and has a total of 713 units. The demographic make-up of the
resident population consists of 88% female-headed households, with an average annual
income of $14,055. The Development includes a children’s play area,
tennis and basketball courts, senior and family community centers, family
resource and computer learning centers, recreation center, Head Start
program, and a 7-acre award winning Urban Farm, named The Growing
Experience. The CNHF, a Federally Qualified Health Center, serves
individuals and families with or without health insurance, and will provide
services in primary care, family planning, pediatric care, and senior care.

Home

dhs.lacounty.gov/wps/portal/dhs/housingforhealth

dhs.lacounty.gov/wps/portal/dhs/housingforhealth

http://dpss.lacounty.gov/dpss/hcm

http://file.lacounty.gov/dmh/cms1_216129

http://www.endhomelessness.org/pages/housing_first

http://www.hacola.org/

http://www.cnhfclinics.org/

http://www.cnhfclinics.org/

17Social Determinants of Health: Housing and Health in Los Angeles County

DISCUSSION
Affordable, stable, and quality housing contribute to health in many ways. This report assesses the social
determinants and relationships that exist between these aspects of housing and health in Los Angeles
County residents.

As the nation continues to recover from the most severe economic downturn since the Great Depression,
the costs associated with housing continue to rise, even though unemployment, wages, and other social and
economic indicators lag behind. As a result, in order to remain housed, people are forced to make difficult
financial sacrifices that can adversely impact their health. The MacArthur Foundation recently reported
that more than half of all U.S. adults have made at least one financial sacrifice in order to cover their rent or
mortgage during the past three years, including getting another job, cutting back on health care or healthy
foods, or saving money by moving to a less safe neighborhood or one with worse schools.35

People in Los Angeles County generally experience a very high housing burden. The ACS 5-year
estimates reveal that over half of County households paid 30% or more of their income on housing.
One consequence of this high housing burden is that people have difficulty making their mortgage or
rent payments. In assessing housing affordability through the 2011 LACHS, we found that an estimated
1.2 million adults (17.2%) reported that they or their family were unable to pay or delayed paying their
mortgage or rent during the past two years.

We identified significant racial/ethnic, social, economic, and geographic disparities among adults who
experienced difficulty paying for their housing. The County’s African American and Latino populations
faced a significantly higher burden compared to Asians/Pacific Islanders and whites. Similarly, lower
income households, less educated individuals, and those with disabilities were significantly more impacted
by housing unaffordability compared to their respective counterparts. Adults in the Antelope Valley SPA
experienced the highest housing burden of all the County SPAs.

The LACHS found that 5.2%, an estimated 373,000 adults, experienced housing instability during the last
5 years, meaning that they did not have their own place to live or sleep at some time during that period.
This estimate includes adults who may have needed to sleep on the street and in homeless shelters, as
well as those who stayed with friends, relatives, and in hotels/motels. Adults who were unemployed, those
who rent, those who reported having a disability, and African Americans faced significantly higher housing
instability burdens.

Our assessment of LACHS data revealed relationships between housing affordability, housing stability, and
multiple measures of physical and mental well-being. Adults who reported difficulty paying for housing
had significant difficulty meeting other subsistence needs, such as access to vital health services and
nutritious, high quality food. Similar results were found for adults who experienced housing instability.
Those who reported housing unaffordability or instability fared more poorly in measures of health status,
well-being, and mental health.

For the past century, social reformers and researchers have recognized the link between housing quality
and human health. It is universally established that humans living in households with mold, or pests such
as cockroaches or mice, are at increased risk of infectious disease and poor health outcomes. There is also
clear and established evidence linking lead exposure in older houses to neurodevelopmental problems.36
Lack of adequate heat and hot water creates substandard and illegal housing.

18 Los Angeles County Department of Public Health

In our assessment of housing quality through the LACHS, we found that hundreds of thousands of
households in the County experience these potentially unhealthy or dangerous housing conditions.
Because we administered housing quality questions to only a subsample of LACHS adult respondents,
and these issues do not evenly impact all residents at the same rates, we were unable to further explore
disparities in housing quality. Nonetheless, the data demonstrate that poor housing characteristics
likely affect the lives of millions of people in the County.

It is important to note that the LACHS data we present in this report are self-reported and based on a
cross-sectional study, which provides a snapshot of the social determinants and relationships between
housing and health outcomes at one point in time. Though we found that strong relationships exist
between housing unaffordability, housing instability, poor quality housing and poor health outcomes,
the cross-sectional study design limits our ability to determine causality. However, these results are
consistent with research conducted around the U.S. and the world during the last 15 years.15,37,38

Overall, results from the LACHS do further establish that these three dimensions of housing—
affordability, stability, and quality— affect health in inter-related ways, particularly for those of low
social and economic status. Lack of affordable housing, housing instability, and poor quality housing
can lead to serious health consequences, and create or contribute to profound health inequities.
The findings shared here are supported by studies that show that many low-income families who
lack affordable housing cannot afford competing expenses for basic needs, and are more likely to
experience food insecurity and homelessness. Also, lack of affordable housing can drive families to live
in overcrowded conditions or to seek cheaper accommodations, which may be less well maintained,
and more likely to host pests, as well as mold or environmental toxins like lead paint.

The links between housing affordability, housing stability, housing quality, and health are key to
understanding adverse health outcomes among the Los Angeles County population. Housing issues
underlie many health disparities observed in the County, and must inform our efforts to advance
the public’s health. Programs and policies that improve housing options and conditions for County
residents represent key points of intervention through which we can modify the social determinants of
health, ultimately achieving equity for all.

19Social Determinants of Health: Housing and Health in Los Angeles County

RECOMMENDATIONS
Public health has played a historic role in developing and enforcing housing standards, and must play
a key role moving forward in advocating for increasing access to adequate, affordable and safe
housing.

Housing experts, health practitioners, policymakers, and advocates need to continue to work together
to craft interdisciplinary solutions. Public health’s role in this effort includes advancing our “health in
all policies” approach. We must educate ourselves and the community about the link between housing
and health and the importance of increasing access to safe, stable, affordable, quality housing through
collaboration between governmental and non-governmental organizations. A coordinated and integrated
approach among housing, transportation, environmental and public health agencies, which includes public
and private entities, is necessary to achieve better housing and health outcomes.

General:
• Increase collaboration across government agencies at all levels and between stakeholders from

community groups, public health agencies, and private groups (e.g., employers) to ensure a
coordinated approach to housing as a determinant of health and health disparities.39,40,41

• Support policies that increase economic security for individuals and families by expanding
opportunities for employment and increasing workers’ incomes, such as a higher minimum wage and
earned income tax credit.

• Advocate for sufficient funding to meet annual public housing operating and capital costs, as well as
increased funding to address the backlog of public housing capital needs.42,43

• Support policies that provide for development without displacement, preserving or replacing
affordable housing for low-income residents in all neighborhoods and areas undergoing development.44

Housing affordability:
• Expand the supply of affordable housing units for low-income individuals and families. Protect

existing affordable housing that is at risk of conversion to unaffordable market-rate housing.42,43,44

• Preserve or redevelop federal, state, and County resources for affordable housing or access to housing
by extremely low-income people.39,45

• Continue federal involvement in lending and fairness standards for banking and loan institutions.
Improve banking and lending procedures of the private-sector to create equal opportunities for
credit.39

• Include housing cost considerations in the federal poverty level.42

20 Los Angeles County Department of Public Health

Housing stability:
• Identify locations in LA County where low-income tenants are at increased risk for displacement

due to surrounding development and rising rent costs, and put policies in place to stabilize people
in their current homes.

• Keep families in their homes and prevent them from becoming homeless with services such
as landlord mediation, help with overdue rent and utility bills, and emergency food, clothing,
childcare, and transportation assistance.43

• Expand efforts to increase access to permanent housing with supportive services for homeless
individuals and families. Support services should be tailored to each individual’s and family’s
specific needs to help them rebuild and maintain stability and self-sufficiency.45

• Reduce the time individuals and families stay in emergency shelters with quick placements into
permanent housing, often with rent subsidies tailored to each individual’s and family’s specific
situation.43

Housing quality:
• Improve and enforce current federal, state and local housing codes and guidelines to reflect

current knowledge regarding hazards within the home environment.39,41

• Use national, state and local public campaigns and programs to educate and empower private-
and public-sector housing providers, owners and tenants about the dangers of unsafe and
unhealthy housing and about their rights and responsibilities.39,41

• Increase resources and expand the role of public health agencies in housing education, inspections
and enforcements at the local, state and national level.39,40

Healthy Homes

The LA County Department of Public Health’s Environmental Health Division (EH) has
a Healthy Homes Program that focuses on multiple family dwellings with histories of
substandard conditions, including, but not limited to, general dilapidation, vermin, mold,
defective plumbing, and lack of heat or hot water. These properties receive inspections to
detect code violations, and their tenants and landlords are educated on key healthy housing
conditions. In an effort to reduce inspection costs and increase the effectiveness of this
Program, EH began to collaborate with community-based organizations (CBOs) to pilot a
Healthy Homes Program in the Trinity Park neighborhood of the City of Los Angeles. Seven
properties were selected based on their inspection and documented histories of substandard
conditions. The Program seeks to utilize community partners to increase inspection access
to multiple family dwelling units, improve education outreach to residents, encourage the
use of integrated pest management applications to reduce pesticide exposure, and identify
measurable correlations of resident health and sustained code compliance.

http://publichealth.lacounty.gov/eh/

21Social Determinants of Health: Housing and Health in Los Angeles County

on the web
U.S. Department of Housing and Urban Development’s (HUD) mission is to create strong,
sustainable, inclusive communities and quality affordable homes for all. www.hud.gov

National Center for Healthy Housing develops and promotes practical methods to protect children from
environmental health hazards in their homes while preserving affordable housing.
www.healthyhousing.org

National Health Care for the Homeless Council is a network of more than 10,000 doctors, nurses,
social workers, patients and advocates who share the mission to eliminate homelessness by ensuring
comprehensive health care and secure housing for everyone. www.nhchc.org

National Low Income Housing Coalition works to achieve socially just public policy that assures people
with the lowest incomes in the United States have affordable and decent homes. http://nlihc.org

Southern California Association of Non Profit Housing (SCANPH) faciliates affordable housing
development across Southern California by advancing effective public policies, sustainable financial
resources, strong member organizations, and beneficial partnerships. http://scanph.org

Inner City Law Center is the only provider of legal services on Skid Row in downtown Los Angeles,
combatting slum housing while developing strategies to end homelessness. www.innercitylaw.org

The LA Human Right to Housing Collective is a coalition of community based organizations working
in various communities across Los Angeles County to support low-income tenants in private and public
housing in defending and expanding their right to affordable, safe housing as a human right.
www.lahumanrighttohousing.org

Neighborhood Legal Services of Los Angeles County (NLSLA) works to combat poverty through the
judicial system to improve the lives of individuals and families and in our community. They offer free legal
representation, advice and education. www.nlsla.org

St. John’s Well Child and Family Center (SJWCFC) serves patients of all ages through its health centers
and school-based clinics in Central and South Los Angeles and Compton. SJWCFC’s Environmental Health
Projects provide a combination of holistic medical care, health education and home-based interventions to
reduce patients’ exposures to health hazards present in their homes. www.wellchild.org

Strategic Actions for a Just Economy (SAJE) is a community organizer and advocate working on behalf
of the residents of South LA, particularly in the Figueroa Corridor. SAJE takes slumlords to court, helps
establish land trusts, and works to find positive solutions to conflicts between institutions and low-income
city residents. www.saje.net

Esperanza Community Housing Corporation works to achieve comprehensive and long-term
community development in the Figueroa Corridor neighborhood of South-Central Los Angeles.
www.esperanzacommunityhousing.org

UNIDAD—United Neighbors In Defense Against Displacement is a campaign committed to future
development of South LA that includes and benefits all members of the community. The coalition works
to address the displacement of thousands of local residents and workers from the community due to
skyrocketing rents, slum conditions, tenant harassment, job loss, and housing discrimination.
www.facebook.com/UNIDADLA

www.hud.gov

www.healthyhousing.org

http://www.nhchc.org/

http://nlihc.org/

www.innercitylaw.org

www.esperanzacommunityhousing.org/

22 Los Angeles County Department of Public Health

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Los Angeles County Department of Public Health
Cynthia A. Harding, MPH
Interim Director

Jeffrey Gunzenhauser, MD, MPH
Interim Health Officer

Office of Health Assessment and Epidemiology
Margaret Shih, MD, PhD, Director
Susie Baldwin, MD, MPH, Chief, Health Assessment Unit

Health Assessment Unit:
Amy S. Lightstone, MPH, MA
Gigi Mathew, DrPH
Yan Cui, MD, PhD
Yajun Du, MS
Jerome Blake, MPH
Douglas Morier, PhD

Acknowledgments:
We thank Stephanie Caldwell, MPH, Gayle Haberman, MPH
Elizabeth Norris-Walczak, PhD, Heather Jue Northover, MPH
and John Walton Senterfitt PhD, RN, MPH for their assistance.

Los Angeles County
Department of Public Health
313 N Figueroa Street, Room 127
Los Angeles, CA 90012
213.240.7785

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Office of Health Assessment & Epidemiology

LA County Board of Supervisors
Hilda L. Solis, First District
Mark Ridley-Thomas, Second District
Sheila Kuehl, Third District
Don Knabe, Fourth District
Michael D. Antonovich, Fifth District

LA Health

Suggested Citation: Housing and Health in Los Angeles County. Social Determinants of Health, Issue no.2. Los Angeles:
Los Angeles County Department of Public Health; February 2015.

2012 Model Practice Award
Los Angeles County Health Survey