Providing Affordable Family Housing and ReducingResidential Segregation by IncomeA Systematic ReviewLaurie M. Anderson, PhD, Joseph St. Charles, MPA, Mindy T. Fullilove, MD, Susan C. Scrimshaw, PhD,Jonathan E. Fielding, MD, MPH, MBA, Jacques Normand, PhD, and the Task Force on Community PreventiveServices

Overview: The inadequate supply of affordable housing for low-income families and the increasingspatial segregation of some households by income, race, ethnicity, or social class intounsafe neighborhoods are among the most prevalent community health concerns relatedto family housing. When affordable housing is not available to low-income households,family resources needed for food, medical or dental care, and other necessities are divertedto housing costs. Two housing programs intended to provide affordable housing and,concurrently, reduce the residential segregation of low-income families into unsafeneighborhoods of concentrated poverty, are reviewed: the creation of mixed-incomehousing developments and the Department of Housing and Urban Development (HUD)Section 8 Rental Voucher Program. The effectiveness of mixed-income housing develop-ments could not be ascertained by this systematic review because of a lack of comparativeresearch. Scientific evidence was sufficient to conclude that rental voucher programsimprove household safety as measured by reduced exposure to crimes against person andproperty and decreased neighborhood social disorder. Effectiveness of rental voucherprograms on youth health risk behaviors, mental health status, and physical health statuscould not be determined because too few studies of adequate design and executionreported these outcomes. (Am J Prev Med 2003;24(3S):47–67)

Introduction

The social, physical, and economic characteristicsof neighborhoods are increasingly recognizedas having both short- and long-term conse-

quences for residents’ physical and psychologicalwell-being.1,2 Among the most pressing health-related, neighborhood-level issues currently facingthe nation are the inadequate supply of housingaffordable to lower-income households and the

increasing spatial (residential) segregation of house-holds by income, race, ethnicity, or social class, aswell as the related increase in poverty and impov-erished areas within many of the country’s urbancenters.3 Selected goals and objectives from theU.S. Department of Housing and Urban Devel-opment (HUD)4 and from Healthy People 2010,5

related to housing programs that reduce residentialsegregation by income, race, or ethnicity, are shownin Table 1.

The Inadequate Supply of Housing Affordable toLower-Income Households

Housing and health are related in several ways. Hous-ing is a basic necessity that provides shelter from theelements; facilitates the storage of food, water, andother essentials; and is the setting for the communallife of the household. Housing is an object of attach-ment and a source of identity and also has a significantrelationship to psychological well-being.6 The WorldHealth Organization’s Health Principles of Housing7

points to the association between housing and health asincluding protection against communicable diseases;protection against injuries, poisonings, and chronic

From the Division of Prevention Research and Analytic Methods,Epidemiology Program Office, Centers for Disease Control andPrevention (Anderson, St. Charles), Atlanta, Georgia; the Task Forceon Community Preventive Services and Columbia University (Ful-lilove), New York, New York; the Task Force on Community Preven-tive Services and University of Illinois, Chicago, School of PublicHealth (Scrimshaw), Chicago, Illinois; the Task Force on CommunityPreventive Services, Los Angeles Department of Health Services, andSchool of Public Health, University of California, Los Angeles (Field-ing), Los Angeles, California; National Institute on Drug Abuse,National Institutes of Health (Normand), Bethesda, Maryland

The names and affiliations of the Task Force members are listed atthe front of this supplement, and at www.thecommunityguide.org.

Address correspondence to: Laurie M. Anderson, PhD, MPH,Community Guide Branch, Centers for Disease Control and Preven-tion, 4770 Buford Highway, MS-K73, Atlanta GA 30341. E-mail:LAA1@cdc.gov.

Address reprint requests to: Community Guide Branch, Centers forDisease Control and Prevention, 4770 Buford Highway, MS K-73,Atlanta GA 30341. Website: communityguide@cdc.gov.

47Am J Prev Med 2003;24(3S) 0749-3797/03/$–see front matterPublished by Elsevier doi:10.1016/S0749-3797(02)00656-6

diseases; and reduction of psychological and socialstresses.8

Affordability of housing is linked to the health andwell-being of individuals and families. When a marketlacks a sufficient supply of affordable housing, lower-income families are often forced to limit expendi-tures for food, medical care, and other necessitiesin order to pay rent.9 The lack of affordable housingwithin a community can contribute to family residen-tial instability, as families are forced to move fre-quently, live with other families in overcrowdedconditions, or experience periods of homelessness.In the course of a year, at least 2.3 million people inthe United States, including nearly 1 million chil-dren, are likely to experience at least one period ofhomelessness.10 Although several factors contributeto homelessness, including mental illness, chemicaldependency, and domestic violence, the importance ofaffordable housing cannot be overlooked.11 Familyresidential instability is associated with children’s poorattendance and performance in school; not having aprimary source of medical care; lacking preventivehealth services (e.g., child immunizations); and suffer-ing from various acute and chronic medical conditions,sexual assault, and violence.12–14

In spite of the recent economic slowdown, homeownership rates steadily climbed through 2000 for all

income, racial, and ethnic groups, with white homeownership reaching 73.8% and minority ownershipreaching 48.1%.15 But housing affordability remains acritical concern. More than 14 million households—about one in eight—spent more than 50% of theirincomes on housing in 1999, and three in ten house-holds paid at least 30% or more of their incomes forhousing. Housing affordability problems affect moder-ate-income as well as low-income families (Table 2). Inthis country, no state offers a minimum wage sufficientto allow a family with one full-time worker adequateearnings (at 30% of income) to afford the federalfair-market rent for a two-bedroom apartment.15 Infact, in 24 states, even families with two full-timeminimum wage earners have insufficient income tomeet fair-market rents without exceeding the 30% ofincome threshold for affordability.15

On the supply side, between 1997 and 1999 morethan 200,000 unsubsidized rental units affordable toextremely low-income households were lost from thehousing stock. This brought the total number of un-subsidized units affordable to the poorest householdsto 1.2 million; with the number of extremely low-income households estimated at 4.5 million, the short-fall in affordable housing stands at 3.3 million units.15

Federal rental housing programs only partially meetthe country’s persistent need for affordable rental

Table 1. Selected U.S. Department of Housing and Urban Development (HUD) goals4 and objectives, and Healthy People20105 goals and objectives related to housing programs that reduce residential segregation by income

HUD FY2000–FY2006 Strategic Plan

Goal 1: Increase the availability of decent, safe, and affordable housing in American communities.Objective: By 2005, the number of families with children, elderly households, and persons with disabilities with worst-casehousing needs will decrease by 30% from 1997 levels. (“Worst-case housing needs” are defined as unassisted very-low-income renters who pay more than half of their income for housing or live in severely substandard housing.)

Goal 2: Ensure equal opportunity in housing for all Americans.Objective: Segregation of racial and ethnic minorities and low-income households will decline.

Goal 3: Promote housing stability, self-sufficiency, and asset development of families and individuals.Objective: The annual percentage growth in earnings of families in public and assisted housing increases.

Goal 4: Improve community quality of life and economic vitality.Objective: The share of households located in neighborhoods with extreme poverty decreases.Among low- and moderate-income residents, the share with a good opinion of their neighborhood increases.Residents of public housing are more satisfied with their safety. (Note: For the purposes of this measure, a “good opinion”of the neighborhood is defined as a response of 7–10 on a 10-point scale assessing “overall opinion of neighborhood.”)

Healthy People 2010 Goals and Objectives

Educational and Community-Based Programs Goal: Increase the quality, availability, and effectiveness of educational andcommunity-based programs designed to prevent disease and improve health and quality of life.Community Setting Objective: (Developmental) Increase the proportion of Tribal and local health service areas orjurisdictions that have established a community health promotion program that addresses multiple Healthy People 2010focus areas. (Objective 7–10)

Environmental Health Goal: Promote health for all through a healthy environment.Healthy Homes and Healthy Communities Objective: Reduce the proportion of occupied housing units that aresubstandard. (Objective 8–23)

Injury and Violence Prevention Goal: Reduce disabilities, injuries, and death due to unintentional injuries and violence.Violence and Abuse Prevention Objectives:Reduce homicides. (Objective 15–32)Reduce the annual rate of rape or attempted rape. (Objective 15–35)Reduce sexual assault other than rape. (Objective 15–36)Reduce physical assaults. (Objective 15–37)

48 American Journal of Preventive Medicine, Volume 24, Number 3S

housing. Although the federal government providesrental assistance to about 4.6 million extremely low andlow income renters, more than twice as many (9.7million) such households receive no federal housingassistance.15

Socioeconomic Segregation and the Growth inCentral-City Impoverishment

Over recent decades, metropolitan areas have seen ageneral trend of increased spatial segregation of poorhouseholds, as well as the associated increase in central-city poverty. Between 1970 and 1990, the percentage ofpoor metropolitan area residents living in extremepoverty neighborhoods (i.e., those with poverty rates ator above 40%) increased from 12.4% to 17.9%, whileindices of the residential segregation of the poor alsorose.16 At the same time, the population living inpoverty within the nation’s 100 largest central citiesincreased both in absolute terms and as a proportion ofall central-city residents. While the poverty populationof these cities rose, it also became increasingly concen-trated in impoverished areas: the percentage of central-city poor living in poverty neighborhoods (those withpoverty rates at or above 20%) grew from approxi-mately 55% to 69%, and the percentage living inextreme poverty neighborhoods grew from 17% to28%. Over the same period, impoverished neighbor-hoods significantly increased as a proportion of allcentral-city neighborhoods and the population in ex-treme poverty neighborhoods doubled.16

Considerable public debate has arisen about thesources of these post-1970 trends in poverty and itsspatial distribution. Among social policy researchers,attention has been given to untoward consequences of

federal housing policy, the rising numbers of low-skilled immigrants residing in large central cities, andstructural changes within the economy that have re-sulted in higher-paying blue-collar jobs moving fromcentral cities to the suburbs, overseas, or simply beingeliminated.17 Blue-collar jobs that offered adequatewages have been replaced by low-paying, service-sectoremployment or white-collar jobs with educational andskill requirements that preclude most working-class cityresidents.17 Exacerbating these changes to the urbaneconomic landscape are the restrictive land-use prac-tices of affluent suburbs, which hinder the relocation oflower-income families to suburban communities wherelow-skilled employment is often much more readilyavailable.18–21

African Americans are particularly affected by thesechanges in the metropolitan opportunity structure.Social, political, and economic forces have historicallyconcentrated large numbers of lower-income AfricanAmericans in central cities, and continued racial dis-crimination in housing markets impedes their move-ment out of these areas.19,22 Despite a reduction inracial segregation over recent decades, African Ameri-cans remain highly overrepresented within the popula-tions of impoverished neighborhoods. In 1990, 17.4%of all African-American residents of the country’s met-ropolitan areas lived in extreme poverty neighbor-hoods, compared with only 1.4% of all white resi-dents.23 At the same time, within the 100 largest centralcities, 24.2% of all African Americans, but only 3.2% ofwhites, lived in extreme poverty neighborhoods, withAfrican Americans representing more than 50% of thepopulation of these areas.16

Residential segregation of poor households may havesignificant ramifications for the public’s health. A grow-

Table 2. Terms used in this report to describe income and housing costs

Term Definition

Household income Moderate income household Income between 80% and 120% of the area medianLow income Income less than 80% of the area medianExtremely low income Income at or below 30% of the area median

Rent as proportion ofhousehold income

Affordable (housing) units Those not requiring more than 30% of householdincome for rent

Moderately cost burdened household More than 30% of household income for rentSeverely cost burdened household More than 50% of household income for rent

Neighborhood income Poverty neighborhood 20% or more of residents are at the poverty levelExtreme poverty neighborhood 40% or more of residents are at the poverty level

Interventions reviewed Mixed-income housing development A publicly subsidized multifamily rental housingdevelopment in which the deliberate mixing of incomegroups is a fundamental part of the development’soperating and financial plans

Tenant-based rental assistance program A publicly subsidized rental assistance program, forfamilies with incomes below 50% of area medianincome, in which families contribute 30% of monthlyincome toward housing costs and the remainder issubsidized up to a locally defined standard

Am J Prev Med 2003;24(3S) 49

ing body of literature suggests that neighborhood qual-ities associated with residents’ socioeconomic charac-teristics (e.g., poverty rate, level of welfareparticipation, percentage of workers with professionalor managerial jobs) have an effect on individual social,economic, and health outcomes that is either indepen-dent of, or interacts with, individual-level factors.24–27

These “neighborhood effects” arise from ecologic con-ditions that neighborhood-level socioeconomic status(SES) tends to reflect, such as social cohesion, theavailability of employment opportunities, the availabil-ity and quality of neighborhood services, and thequality of the physical environment. For example,studies have found that, after controlling for individualSES and other individual-level health determinants,measures of neighborhood SES generally remain in-versely associated with the risk of coronary heart dis-ease, neural tube defect, and mortality.28–30 Studieshave also found neighborhood SES to influence ado-lescent sexual activity and childbearing, behavioral andemotional problems among youth, school readiness andeducational achievement, and welfare participation.31,32

The spread of impoverished urban areas can lead tothe physical and social deterioration of neighborhoods.High residential turnover and the increased concentra-tion of poverty result in housing disinvestment anddeteriorated physical conditions, a reduction in thecapacity of formal and informal institutions to maintainpublic order, and a decline in the ability of informalnetworks to circulate information (e.g., about employ-ment opportunities and health resources) and to pro-mote healthy behaviors and positive life choices.33

Given the growing number of poor families withchildren in the United States who need affordablehousing, we sought to identify whether family housingsubsidies effectively improve household health outcomes.

Interventions Reviewed

The Task Force on Community Preventive Services (theTask Force) uses evidence from systematic reviews tomake recommendations about the use of interventionsto improve health. In the social environment andhealth logic model (described elsewhere in this supple-ment34) “neighborhood living conditions” serve as anintermediate indicator along a pathway linking re-sources in the social environment to health outcomes.Based on a priority-ranking process,34 the systematicreview development team (the team) chose to addressmixed-income housing programs. The two ways tocreate mixed-income housing are to move higher-income households into lower-SES neighborhoods, ormove lower-income households to higher-SES neigh-borhoods. The two interventions selected for reviewaim to achieve those goals. They are

1. the creation of mixed-income housing develop-ments in low SES neighborhoods, which provide

both market rate and subsidized housing unitswithin multifamily rental properties, so that house-holds from different income groups are deliberatelymixed; and

2. tenant-based rental assistance programs, which pro-vide lower-income families with housing subsidiesthat are not tied to a specific housing unit butinstead allow families choice of housing in theprivate rental market and give them access to higherincome neighborhoods.

Mixed-income housing was selected because of theintervention’s potential for bringing working familiesback into neighborhoods with high levels of poverty.This approach offers two distinct benefits: (1) thepresence of working families prevents or reverses aneighborhood’s physical and social deterioration and(2) mixed-income housing can be an effective methodfor expanding the supply of affordable housing.

Tenant-based rental assistance programs were cho-sen for review because they provide housing assistanceto lower-income households while allowing assistedhouseholds to secure housing in relatively affluentneighborhoods. Unlike mixed-income housing devel-opments, which bring non-poor families back intoneighborhoods with high poverty levels, tenant-basedrental assistance programs achieve residential decon-centration of poverty by sending families out of highpoverty areas.

Conceptual Approach

A detailed description of the general methods used to con-duct the systematic reviews for the Guide to Community Preven-tive Services (the Community Guide) has been published.35 Thespecific methods for conducting reviews of interventions topromote healthy social environments are described in detailin this supplement.34 This section briefly describes the con-ceptual approach and search strategy for interventions thatprovide affordable family housing and limit the spatial con-centration of poverty.

Analytic Frameworks

The analytic frameworks—conceptual models used to evalu-ate the effectiveness of mixed-income housing developmentsand tenant-based rental assistance programs in improvingcommunity health outcomes—are shown in Figures 1 and 2,respectively. Among environmental factors that may influ-ence health-related outcomes, the most pertinent are neigh-borhood physical and social conditions; the quality andavailability of public services in a neighborhood; opportuni-ties for employment, access to goods and services, and otherbenefits provided by economic activity within the neighbor-hood; and the adequacy of the local housing supply inproviding affordable housing for lower-income households.

For each intervention, outcome measures evaluated todetermine their success included

50 American Journal of Preventive Medicine, Volume 24, Number 3S

• reduction in housing hazards: substandard housing condi-tions that pose health and safety risks;

• improvement in neighborhood safety: reduction of inten-tional injuries, victimization from crime, crime againstperson and property, and social disorder;

• reduction in youth risk behaviors: behavioral problems inschool and at home, dropping out of school, delinquency,and arrests; and

• improvement in mental or physical health status: physicalor psychological morbidity and unintentional injury.

To ascertain implementation of the program, we collecteddata on the percentage of household income spent onhousing (for both interventions) and on the socioeconomicheterogeneity of housing development residents (for mixed-income housing developments) or of neighborhoods (fortenant-based rental assistance programs).

Search Strategy

Searches for mixed-income housing developments and ten-ant-based rental assistance programs were conducted in 10computerized databases: Avery Index to Architectural Period-

icals, EBSCO Information Services’ Academic Search Elite™,HUD User Bibliographic Database, MarciveWeb Catalogue ofU.S. Government Publications, ProQuest Dissertations, Pro-Quest General Research Databases, PsychINFO, Public AffairsInformation Services, Social Sciences Citation Index, andSociological Abstracts. Internet resources were examined, aswere reference lists of reviewed articles and referrals fromspecialists in the field. To be included in the reviews ofeffectiveness, studies had to

• document an evaluation of a mixed-income housing devel-opment or a tenant-based rental assistance program forfamilies within the United States,

• be published in English between 1965 and 2000,• compare outcomes among groups of people exposed to the

intervention with outcomes among groups of people notexposed or less exposed to the intervention (whether thecomparison was concurrent between groups or before-and-after within groups), and

• measure outcomes defined by the analytic framework forthe intervention.

Figure 1. Analytic framework used to evaluate the effectiveness of mixed-income housing developments. (Circle denotesintervention, rectangles with rounded corners denote intermediate outcomes, and rectangles with square corners denotecommunity health outcomes.)

Am J Prev Med 2003;24(3S) 51

For the review of mixed-income housing developments, theteam examined 312 citations (titles and abstracts) identifiedthrough the database search, review of pertinent referencelists, and consultation with housing specialists. These titlesand abstracts were screened to determine if the report orarticle described a comparative intervention study (as op-posed to program descriptions, general statistics on mixed-income developments, case studies, and so on). Based on thisscreening, 41 articles, reports, and dissertations were ob-tained and evaluated for inclusion, but none met the inclu-sion criteria listed above.

For the review of tenant-based rental assistance programs,the literature searches yielded 509 citations, of which 56 wereobtained and evaluated for inclusion. Of these, 33 wereexcluded because they did not evaluate a relevant interven-tion or they lacked a comparative study design. Twenty-threearticles and reports were considered qualifying studies (seeEvaluating and Summarizing the Studies in the accompany-ing article34) and the findings in this review are based onthose studies.

Intervention Effectiveness and Economic Efficiency

Mixed-Income Housing Developments

For this review, a mixed-income housing development isdefined as a publicly subsidized multifamily rentalhousing development, in which the deliberate mixingof income groups is a fundamental part of the devel-opment’s operating and financial plans. A portion of adevelopment’s units must be reserved for, and madeaffordable to, households whose incomes are at leastbelow 60% of the area median, although there may bevariation among developments in the income levels ofall residents and the relative representation of eachincome group. These developments may be createdeither through new construction or conversion of ex-isting developments, but they must exist within povertyneighborhoods (where more than 20% of householdshave income below the federal poverty level).

Figure 2. Analytic framework used to evaluate the effectiveness of tenant-based rental assistance programs. (Circle denotesintervention, rectangles with rounded corners denote intermediate outcomes, and rectangles with square corners denotecommunity health outcomes.)

52 American Journal of Preventive Medicine, Volume 24, Number 3S

Reviews of evidence. The effectiveness of mixed-in-come housing developments in providing affordablehousing in safe neighborhood environments could notbe ascertained by this systematic review. We found nostudies comparing outcomes among groups of peopleexposed to the intervention with outcomes amonggroups of people not exposed to the intervention.

Applicability and economic effectiveness were notassessed, because effectiveness of the interventioncould not be established.

Case studies and qualitative research reviewed were,however, useful for several purposes, including gener-ating hypotheses, describing programs, recognizing un-anticipated outcomes or potential harms, assessing thefidelity with which programs were implemented, andmany others. This literature was less reliable, however,for attributing effects to programmatic efforts.

Tenant-Based Rental Assistance Programs

Tenant-based rental assistance programs subsidize thecost of housing secured by low-income householdswithin the private rental market through the use ofvouchers or direct cash subsidies. HUD’s Section 8program is administered by local and state housingagencies under contract to the federal government.The Section 8 program subsidizes rental costs forfamilies with incomes below 50% of area median in-come. Families contribute 30% of their monthly in-come toward housing costs, and the Section 8 subsidyprovides the remainder for rental costs up to a locallydefined standard.

Unlike traditional, supply-side housing assistanceprograms for the poor, which subsidize the construc-tion and operation of housing for low-income house-holds, tenant-based rental assistance programs subsi-dize the cost of rentals for low-income households inthe private rental market. Low-income families can usevouchers to rent privately owned housing in neighbor-hoods of their choice, without spending more than30% of their income on housing. Historically, propo-nents of tenant-based rental assistance have arguedthat, when compared with supply-side programs such aspublic housing, tenant-based (or demand-side) pro-grams offer several advantages. They are more cost-effective, offer assisted households increased choice inhousing type and location, and provide for greaterequity by allowing limited government funds to bespread more evenly among those in need. (Supply-sideprograms, bound by the high cost of housing construc-tion, grant deep subsidies to only a lucky few.36) Fortheir part, supporters of supply-side housing have coun-tered that, given housing market dynamics, tenant-based assistance may result in higher rental costs and bedetrimental to all lower-income tenants, and the infu-sion of subsidies may spur only minor improvements inthe supply and quality of available rental housing.

Although federal housing policy has traditionallyplaced an almost exclusive dependence on supply-sideprograms in attempting to meet the housing needs oflow-income renters, recent decades have seen a dra-matic shift toward a reliance on tenant-based assistance.The increasingly apparent problems of physical andsocial deterioration in several highly publicized publichousing developments motivated this change in focus.In addition, insufficient financial resources to meethigh rent burdens are now the primary housing prob-lem faced by poor households, rather than the physi-cally substandard living conditions that supply-side pro-grams sought to alleviate.36

Tenant-based assistance now accounts for 1.4 millionof the 4.6 million rental units that are directly subsi-dized by the federal government in its effort to reducethe number of renter households forced to pay morethan 30% of their incomes on housing.15 HUD’s Sec-tion 8 tenant-based rental assistance program has al-ways sought to give subsidized households expandedchoice in where they live, instead of limiting them tothe racially and economically segregated neighbor-hoods in which public housing developments are toooften located.

The success of Section 8 vouchers and certificates inmoving assisted families to less impoverished or lessracially segregated areas is dependent on several fac-tors, including housing market discrimination, the in-experience of program participants as housing “con-sumers,” the desire of many to remain near establishedsocial ties and the conveniences of the urban core, thetime and transportation constraints that hinder suchhouseholds in conducting housing searches in subur-ban locations, and administrative and programmaticshortcomings of local housing authorities.37,38 In lightof this, some rental voucher programs are augmentedwith housing search counseling, employment and trans-portation assistance, community networking, landlordoutreach, or post-placement services.39

Effectiveness. Our search identified 12 studies40–62 (in23 papers) on the effectiveness of tenant-based rentalassistance programs in improving community healthoutcomes. These 12 studies represent four broadgroups of federal housing evaluation efforts: (1) theHousing Allowance Experiment41,45,62; (2) HUD’s Sec-tion 8 Rental Certificate and Voucher program40,46,47;(3) the Gautreaux program in which rental voucherswere provided to African-American families in raciallysegregated public housing in Chicago44,51,52,54,57–61;and (4) Moving to Opportunity for Fair Housing re-search, implemented in five large cities, which com-bines rental vouchers with household counseling tohelp low-income families move from public housing tononpoverty neighborhoods.42,43,48–50,53,55,56 Summaryeffect measures for each prespecified outcome of inter-

Am J Prev Med 2003;24(3S) 53

est are shown in Table 3. Details of the qualifyingstudies are provided in Appendix A.

Five studies41,42,48,51,53 (two of greatest design suit-ability and fair quality of execution, one of greatestdesign suitability and good execution, and two ofmoderate design suitability and fair execution) re-ported measures of neighborhood safety. For house-hold victimization, the median decrease was 6%, mea-sured, on average, 6 months after the intervention tookplace. Four studies43,48,52,55 (one of greatest designsuitability and good quality of execution, one of great-est design suitability and fair execution, one of moder-ate design suitability and fair execution, and one ofleast suitable design and fair execution) examinedchanges in neighborhood social disorder; the mediandifference was a 15.5% decrease. One study53 (ofgreatest design suitability and fair quality of execution)compared murder rates in the neighborhood to whichhouseholds relocated with rates in their neighborhoodof origin and reported a decrease.

One study55 (of least suitable design and fair qualityof execution) reported decreases in health and safetyrisks, including peeling paint, inadequate plumbing,rodent infestation, and a broken or missing lock on thedoor to the housing unit.

Three studies43,48,50 (all of greatest suitability ofdesign, one of good quality of execution and two of fairexecution) reported on youth risk behaviors, measured

between 1 and 5 years (mean, 2.9 years) after theintervention took place. The median difference was adecrease in behavioral problems of 7.8%.

Two studies43,48 (both of greatest suitability of de-sign, one of good quality of execution and one of fairexecution) reported on self-reported symptoms of de-pression and anxiety by head of household. The me-dian difference was a decrease of 8%. The same twostudies43,48 reported self-rated health status. In thesestudies, the median difference in people rating theirhealth as “good” or “excellent” compared with “fair” or“poor” increased by 11.5%.

One study43 (of greatest suitability of design andgood quality of execution) reported on diverse childhealth outcomes. A median decrease of 4.5% wasobserved in the need for acute medical care for injuriesor asthma episodes. A median decrease of 5.5% wasobserved for use of preventive services for children(e.g., well-child check-ups and vaccinations). This de-crease in use of child preventive services is an undesiredoutcome, which could reflect barriers to care in fami-lies’ new, more affluent neighborhoods (e.g., fewerproviders accepting Medicaid, fewer clinics oriented tolow-income families). The decrease in emergency roomtreatment for acute asthma episodes and injuries couldalso be an undesired outcome—reflecting decreasedaccess to care—or it could be a desired outcome,reflecting reduced need for acute care among the

Table 3. Effectiveness of tenant-based rental assistance programs on various outcomes: summary effects from the body ofevidence

OutcomeNo. of outcomemeasures

Medianchange

Range ormeasure

Neighborhood safetyExperience of victimization: crimes against person or

property, exposure to violence (mugged, threatenedwith gun or knife, beaten, assaulted, stabbed or shot)

1241,42,48,51,53 �6% �22% to � 6%

Neighborhood murder rate 153 NA �52%Social disorder: public drinking, public drug use, seeing

person carrying weapon, hearing gunfire1743,48,52,55 �15.5% �89% to �3%

Housing quality(Substandard conditions that pose health and safety risks)

Peeling paint 155 NA �53%Inadequate plumbing 155 NA �28%Rodent infestation 155 NA �34%Broken or missing lock on door to unit 155 NA �42%

Youth risksBehavioral problems in school, behavioral problems at

home, delinquent acts, arrests for violent crime, arrestsfor property crime

1643,48,50 �7.8% �8.5% to �7%

Psychological and physical morbiditySelf-reported symptoms of depression and anxiety by

household head2843,48 �8% �9.5% to �6.5%

Self-rated health status as “good” or “excellent” comparedwith “fair” or “poor”

443,48 �11.5% �9% to � 11.5%

Child needing acute medical attention for injuries orasthma

443 �4.5% �6% to 0%

Child use of preventive services 243 �5.5% �7% to �4%

NA, not applicable

54 American Journal of Preventive Medicine, Volume 24, Number 3S

relocated families, a plausible result in view of the factthat both childhood asthma and injuries are associatedwith substandard housing.43

Applicability. The rental assistance programs reviewedwere implemented in urban areas. The populationsstudied included families with children. We did notexamine housing programs that targeted the elderly orpeople with special health needs. Only low-incomesocioeconomic groups were represented, includingwhite, Latino, and African-American populations; ef-fects were similar for all of these groups.

Other positive or negative effects. Rental assistanceprograms encourage families to move to neighbor-hoods of greater prosperity; this may disrupt the socialties and supports in the old neighborhood, resulting inits increased social deterioration. Overrepresentationof Section 8 families in receiving neighborhoods, par-ticularly weaker or declining neighborhoods wheremore moderately priced housing may exist, could pos-sibly destabilize those neighborhoods and create newareas of poverty. The team conducted additional liter-ature searches to determine if the intervention hadnegative consequences for the neighborhoods of pov-erty from which families moved (i.e., disruption ofsocial ties and networks, depleting neighborhoods ofhuman capital, and furthering neighborhood decline)and none were identified. The potential for destabili-zation of receiving neighborhoods was raised in theliterature, but no data were found documenting thisoutcome.

Economic efficiency. No economic studies were foundthat met the requirements for inclusion in a CommunityGuide review.63

Barriers to intervention implementation. Barriers toimplementing tenant-based rental assistance programsare described in the literature. Relocating householdsto better neighborhoods may be hindered if familiescannot search for housing in these areas because theylack transportation or funds for apartment applicationfees, or they fear discrimination or encountering land-lords who refuse to accept Section 8 tenants. Localhousing market conditions may also inflate rents abovethe means of Section 8 rental voucher recipients.

Conclusion. Tenant-based rental assistance programsare recommended to improve household safety, on thebasis of sufficient evidence of reductions in exposure tocrimes against person and property and decreases inneighborhood social disorder. We were, however, un-able to determine the effectiveness of such programson housing hazards, youth risk behaviors, and psycho-logical and physical morbidity, because too few studiesof adequate design and execution (according to Com-munity Guide rules of evidence35) reported these out-comes.

Research Issues

Systematic reviews are useful both for developing rec-ommendations and for identifying important unan-swered questions. The research questions posed belowcan be used to guide future research, both by govern-ment agencies and foundations in their allocation ofresearch funding and by academic and other researchorganizations in their selection of research priorities.

Mixed-Income Housing Developments

Effectiveness. The degree to which creating mixed-income housing developments in neighborhoods withconcentrated poverty increases neighborhood socio-economic heterogeneity could not be determined inthis systematic review. Therefore, basic research ques-tions remain.

• Are such housing developments effective in begin-ning a process of neighborhood revitalization thatmakes an area more attractive to higher-incomehouseholds as well, or are changes to a neighbor-hood’s demographic makeup limited to the housingdevelopment itself?

• How does variability among housing developmentsaffect important outcomes, such as differences in theincome groups represented, the degree of represen-tation by each income group, and whether or not theunits occupied by the various income groups areintermixed? The types and quality of social servicesprovided at a housing development may influencethe degree of social integration among tenants ofvarious income groups, which is considered an im-portant intermediate outcome of income mixing.Similarly, the employability of disadvantaged house-hold heads may be increased in developments wherejob training, child care, or other pertinent servicesare provided.

• To what degree does bringing higher-income house-holds into neighborhoods of concentrated povertyaffect these neighborhoods in terms of crime, thequality and availability of public services, residents’access to market goods and services, and neighbor-hood physical conditions?

Other positive or negative effects. If mixed-incomehousing developments are effective in beginning aprocess of revitalization that attracts higher-incomehouseholds to a neighborhood, to what extent does thisrevitalization and the related increases in housing costsultimately push poor families out of the area?

Tenant-Based Rental Assistance Programs

Effectiveness. The causes of residential segregationand isolation of families by income, race, ethnicity, orsocial class into neighborhoods of concentrated povertyare complex. Tenant-based rental assistance programs

Am J Prev Med 2003;24(3S) 55

allow families to find affordable housing in safer neigh-borhoods, but the potential to fully realize housing andneighborhood choice could be advanced by a greaterunderstanding of factors that affect choice.

• What resources are critical in allowing families tofully realize the potential for housing mobility (e.g.,counseling on housing search strategies, transporta-tion resources)?

• How can the Section 8 program be made moreattractive to landlords, particularly when rental unitsare scarce in a tight rental market?

Applicability. Our review focused on urban areas andlow SES families with children. Applicability of thisintervention to the elderly and to those with specialhealth needs should be assessed.

Other positive or negative effects. Encouraging resi-dential mobility away from poor central-city areas maydisrupt existing neighborhood social networks andsupports, giving way to greater neighborhood socialdeterioration.

• To what extent should housing mobility strategies becoupled with revitalization efforts to make central-city neighborhoods more attractive to families at allincome levels?

• What factors contribute to residential clustering ofSection 8 families in particular neighborhoods,which could eventually lead to neighborhood declineand the reconcentration of poverty?

Economic efficiency. Tenant-based rental assistanceprograms do not add to the stock of housing but rely onavailable housing in the private rental market. In tightrental markets, when few units are available, is avoucher approach feasible? How does the programcompare in cost with housing built and maintained bypublic funds? Are rental voucher programs cost effec-tive?

Ecologic perspective. Finally, the complex interactionsof biology, individual and family characteristics, andthe social and physical environments65 posited by theCommunity Guide’s social environment and health logicmodel34 underscore the need for additional research,consistent with an ecologic perspective.

Discussion

The importance of housing policy that attempts todeconcentrate neighborhood poverty while providingaffordable housing to low-income families can be seenin the strong emphasis placed on income mixing withinthe HOPE VI Urban Revitalization Demonstration Pro-gram,64 the federal government’s program for thephysical and social revitalization of distressed publichousing. Such an emphasis is in sharp contrast to thepublic housing program’s record of concentrating pov-

erty by routinely constructing developments in impov-erished areas and reserving units for the poorest ofhouseholds, practices which are believed to be largelyresponsible for many of public housing’s most recog-nized failures: environments of violence, substanceabuse, welfare dependency, teen pregnancy, unemploy-ment, and lowered educational achievement amongyouth.

In the public health arena, increased interest inmultilevel determinants of health—biologic, individ-ual, and environmental—has spawned research linkingphysical and social conditions of neighborhoods andfamily housing to specific changes in health status. Aclearer understanding of the relationship betweenneighborhood, housing conditions, and communityhealth outcomes will allow us to invest in interventionsthat produce the most beneficial results and reducepersistent health disparities associated with income,race, ethnicity, and social class.

Use of the Recommendation

The Task Force recommendation for tenant-basedrental assistance programs can be used by public healthagencies in conjunction with local housing authoritiesto inform policy makers of the effectiveness of suchprograms for increasing family safety in the neighbor-hood environment.

Summary: Findings of the Task Force

Evidence was insufficient to determine the effectivenessof mixed-income housing developments in improvingfamily health and safety while providing affordablehousing, because no studies compared groups of peo-ple exposed to the intervention with groups not ex-posed.

The use of tenant-based rental assistance programs isrecommended for improving household safety, on thebasis of sufficient evidence of reductions in exposure tocrimes against person and property and decreases inneighborhood social disorder. The effectiveness ofthese programs in reducing housing hazards, youth riskbehaviors, and psychological and physical morbiditycould not be determined, because too few studies ofadequate design and execution reported these out-comes, and results were inconsistent.

We thank the following individuals for their contributions tothis review: Robert Filley, College of Architecture and UrbanPlanning, University of Washington; Todd Richardson, De-partment of Housing and Urban Development; Judie Feins,Abt Associates; Onnalee Henneberry, Research Librarian;Kate W. Harris, Editor; and Peter Briss for technical support.

Our Consultation Team: Regina M. Benjamin, MD, MBA,Bayou La Batre Rural Health Clinic, Bayou La Batre, Ala-bama; David Chavis, PhD, Association for the Study and

56 American Journal of Preventive Medicine, Volume 24, Number 3S

Development of Community, Gaithersburg, Maryland; ShellyCooper-Ashford, Center for Multicultural Health, Seattle,Washington; Leonard J. Duhl, MD, School of Public Health,University of California, Berkeley, California; Ruth Enid-Zambrana, PhD, Department of Women’s Studies, Universityof Maryland, College Park, Maryland; Stephen B. Fawcette,PhD, Work Group on Health Promotion and CommunityDevelopment, University of Kansas, Lawrence, Kansas; Nich-olas Freudenberg, DrPH, Urban Public Health, Hunter Col-lege, City University of New York, New York, New York;Douglas Greenwell, PhD, The Atlanta Project, Atlanta, Geor-gia; Robert A. Hahn, PhD, MPH, Epidemiology ProgramOffice, CDC, Atlanta, Georgia; Camara P. Jones, MD, PhD,MPH, National Center for Chronic Disease Prevention andHealth Promotion, CDC, Atlanta, Georgia; Joan Kraft, PhD,National Center for Chronic Disease Prevention and HealthPromotion, CDC, Atlanta, Georgia; Nancy Krieger, PhD,School of Public Health, Harvard University, Cambridge,Massachusetts; Robert S. Lawrence, MD, Bloomberg Schoolof Public Health, Johns Hopkins University, Baltimore, Mary-land; David V. McQueen, National Center for Chronic Dis-ease Prevention and Health Promotion, CDC, Atlanta, Geor-gia; Jesus Ramirez-Valles, PhD, MPH, School of Public Health,University of Illinois, Chicago, Illinois; Robert Sampson, PhD,Social Sciences Division, University of Chicago, Chicago,Illinois; Leonard S. Syme, PhD, School of Public Health,University of California, Berkeley, California; David R. Wil-liams, PhD, Institute for Social Research, University of Mich-igan, Ann Arbor, Michigan.

Our Abstraction Team: Kim Danforth, MPH; Maya Tho-landi, MPH; Carolynne Shinn, MS; Garth Kruger, MA; Mich-elle Weiner, PhD; Jessie Satia, PhD; Kathy O’Connor, MD,MPH.

We would like to acknowledge financial support for thesereviews from the Robert Wood Johnson Foundation.

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Foreword