A Mixed-Methods Investigation of Housing Issues Among Oncology Patients and Survivors in New York City Open Access

Housing is a key social determinant of health, fulfilling a fundamental human need for shelter. Cancer patients and survivors may experience housing needs after the health shock of diagnosis, including difficulty paying rent, poor living conditions, and threatened housing stability. While the implications of unmet housing needs in health have received dedicated investigation among other patient populations, this area of research is a nascent one for cancer. However, there has been growing recognition of the burden of financial hardship among cancer patients, as well as the impact of social determinants on cancer outcomes. The purpose of this dissertation was to describe the types, determinants, and outcomes of housing needs in the wake of cancer diagnosis, among New York City cancer patients and survivors. A sequential mixed-methods approach was used to answer research questions. Semi-structured interviews were conducted with 21 cancer patients and survivors reporting housing needs following diagnosis and 9 key informants with expertise on cancer and housing. To identify types of housing needs, a conventional content analysis was conducted on interviews. Next, grounded theory-informed qualitative analysis identified factors that increased vulnerability to housing cost needs among a subset of interviewees describing problems paying rent, mortgage, or utilities. Quantitative hypotheses were formulated based on qualitative findings and tested using a cross-sectional oncology patient navigation survey dataset (n=1138). Four nested logistic regression models were created to explore statistical associations between housing cost needs and hypothesized predictors, such as financial destabilization, poor physical health, and income support from friends and family after diagnosis. Lastly, grounded theory-informed qualitative analysis was conducted on all interviews to identify impacts of housing needs on cancer survivor wellbeing.A taxonomy of housing need types was developed, describing six major categories of needs: 1) housing costs, 2) home loss, 3) doubled up/ unstable housing, 4) housing conditions, 5) accessibility, and 6) safety. Issues were often interrelated. While some housing needs pre-dated cancer diagnosis, others newly emerged in the wake of cancer-related disruption to health and finances. Difficulties paying for rent, mortgage, and utilities arose due to cancer-related financial destabilization in the form of lost work income and increased expenses. Disability benefits, employer responses, and family/ friend income support were time-sensitive intervening factors with the potential to help survivors. In quantitative analyses, report of housing cost needs was associated with loss of income after diagnosis and worse physical wellbeing score but not with insurance type or family/ friend income support. Housing needs created psychosocial distress for survivors, in the form of stress, anxiety, depression, and threats to self-esteem and pride. Housing needs also competed with health priorities, detracting from cancer treatment, rest and recovery, and emotional coping with cancer. Housing needs deprived survivors of a home environment conducive to wellness and recovery. Lastly, housing needs created delays in care and had social impacts in the form of isolation and spillover effects on others like caregivers and children.Altogether, findings document the range of unmet housing needs, patterns of vulnerability, and the specific significance of housing needs to cancer patients and survivors living in New York City. Responsive social work, patient navigation, and legal services should be made available to patients. Early screening and identification of risk is critical to enable timely intervention before housing cost needs escalate. Findings also highlight the importance of creative solutions addressing ecological-level factors like housing affordability.

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