Vásquez-Vera et al. International Journal for Equity in Health (2019) 18:52 https://doi.org/10.1186/s12939-019-0943-0 RESEARCH Open Access Our lives in boxes: perceived community mediators between housing insecurity and health using a PHOTOVOICE approach Hugo Vásquez-Vera1,2,3,5* , Ana Fernández1,4, Ana M. Novoa1,5, Lucía Delgado6, Joaquín Barcala6, Carlos Macías6, Carme Borrell1,2,4,5 and Photovoice Working Group of Public Health Agency of Barcelona Abstract Background: While the negative effects of housing insecurity on health are well known, the mechanisms and mediators of these effects have been less well studied. The aim of this study is to identify perceived mediators involved in the relationship between housing insecurity and health. Methods: We used a participatory action research approach, the Photovoice methodology. It promotes a reflective process where participants critically discuss housing insecurity and human health and make recommendations to find solutions for the issues identified. This study was conducted with 18 members of the Platform for People Affected by Mortgages who were living in a situation of housing insecurity in Barcelona during the first half of 2017. Results: Participants took 990 photographs, of which 147 were printed for analysis in discussion sessions. 109 of these photographs were then selected for categorization by the participants. 11 major categories emerged, representing various factors related to housing insecurity and health. Most categories were acknowledged as possible mediators of the housing/health problem, including: psychological changes; housing-related material aspects; health-related behaviors; eviction; harassment by financial institutions; and family, neighbors and social network. Others were considered as modifiers that could alter the effects of housing insecurity on health. Co-existing determinants may interact with housing insecurity, thereby increasing negative effects on health. Conclusions: Through this participatory approach, the Photovoice project gives insight into the mechanisms underlying the relationship between housing insecurity and human health, and provides valuable recommendations to combat this serious public health issue. Keywords: Housing insecurity, Foreclosure, Evictions, Photovoice, Mediators, Pathways Background housing insecurity due to economic barriers, which in- Housing is a key social determinant of health that includes cludes housing-related situations that interfere with the both physical and socioeconomic dimensions [1–4]. This normal development of personal and family life, and are latter dimension is related to several aspects such as hous- linked to the level of economic and legal security of resi- ing affordability and secure tenure, which allow people to dential status. It includes the threat of eviction, unsecure have a stable home, a place that protects privacy, contrib- housing tenure (e.g. illegal occupation) and doubling-up utes to physical and mental health and supports the devel- (i.e. being forced to live with relatives or friends because opment of a life plan and social integration of its of a lack of one’s own dwelling) [6–9]. inhabitants [5]. A lack of these features can lead to Systematic reviews published in recent years agree that housing unaffordability, foreclosures and the eviction * Correspondence: hvasquez@aspb.cat 1 process can have negative consequences for both mental Agència de Salut Pública de Barcelona, Plaça Lesseps 1, ES-08023 Barcelona, Spain health (depression, anxiety, and suicides) and physical 2 Department of Experimental and Health Sciences, Universitat Pompeu health (poor self-reported health, high blood pressure, Fabra, Barcelona, Spain child maltreatment) [10–12]. There is also evidence that Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Vásquez-Vera et al. International Journal for Equity in Health (2019) 18:52 Page 2 of 14 people affected by these processes are more likely to de- housing insecurity and health among affected groups with velop unhealthy behavior, such as smoking and leading a the PAH; ii) to promote a reflective process where partici- sedentary lifestyle [12]. pants critically discuss housing insecurity and health based The Spanish housing market was strongly affected by on photographs that they have taken; iii) to make recom- the ‘subprime’ property crisis in 2007. Due to the in- mendations for tackling the pathways identified, and im- creased unemployment, thousands of families were prove the health of people affected by housing insecurity; forced to make monthly mortgage and rent payments and iv) to inform policy makers about these recommenda- that they could not afford, leading to a rise in foreclos- tions. This paper identifies perceived mediators of the re- ure, eviction and other types of housing insecurity, such lationship between housing insecurity and health and as squatting [13]. Between 2008 and 2017, 725,259 fore- summarizes the proposed recommendations. closure proceedings were initiated and 369,152 evictions were executed [14]. This situation severely affects people’s Methods health. For instance, a study conducted in 2014 in Spain Design: Photovoice, a participatory action research reported that the prevalence of poor self-reported health This study employs a Participatory Action Research was 55.6% in women and 39.4% in men suffering housing (PAR) approach, which considers community members, insecurity, and 19.2 and 16.1% in the general population. researchers and other stakeholders as equals throughout In addition, the prevalence of poor mental health among the research and action processes. A community-based people under housing insecurity was 90.6% in women and knowledge platform is created, with the ultimate aim of 84.4% in men, compared to 15.5 and 10.2% in the general improving the lives of the participants [25, 26]. One of population [15]. Feelings of personal failure, shame and the branches of PAR is Photovoice, a tool used in par- stigma are common among people affected by foreclosure ticipatory research with “which people can identify, rep- and eviction in societies - as the Spanish one - where there resent and enhance their community through a specific is a hyper-commodification of housing, and housing ten- photographic technique” [27]. It encourages participants ure security is considered as an indicator of being a “good to take photographs that represent their life experiences citizen” [16, 17]. and to tell the stories behind these photographs. In response to this crisis, several social organizations Through a critical dialogue process based on their per- have been fighting for housing rights, the most import- sonal and collective knowledge, the participants identify ant of which is the Platform for People Affected by the main issues under discussion, namely the mediators Mortgages (PAH). Its objectives are to: stop evictions, that link housing insecurity to health, and propose rec- obtain reasonable relocation alternatives, and to pro- ommendations to address them [25, 28]. mote legislative initiatives aimed to increase the social housing stock, ensure basic amenities such as electricity, Study setting and participants gas and water, and restore renting to a secure and This study was conducted with members from the PAH affordable type of housing tenure [18, 19]. Currently, living in the metropolitan area of Barcelona during the Barcelona’s PAH has around 120 members, although first half of 2017, and who are, or have been, in some of there is not an accurate register of participation. Aproxi- the aforementioned housing insecurity situations. mately 80 people attend the PAH assemblies every week. To represent all agents involved, a steering committee While the negative effects of housing insecurity on was formed at the beginning of the study and consisted health are well known, the mechanisms and mediators of four researchers from the Public Health Agency of underlying these effects have been less well studied. In Barcelona, two members from PAH, and the project’s pho- general, the published evidence focuses on psychosocial tographer. This group led and organized the entire process. pathways and how feelings of personal failure, guilt, Recruitment began two weeks prior to the first meet- fear and insecurity can lead to psychological distress ing with the participants. It took place at the PAH head- and poor mental health [7, 20–22]. Others have re- quarters in Barcelona after a brief presentation of the ported that adopting unhealthy behaviors could medi- project to the general PAH assembly. Participants were ate the link between housing insecurity and several selected using the snowball technique by PAH members diseases [16, 23, 24]. However, the evidence on this of the steering committee, either at the meetings topic remains scarce, and several gaps must be filled to themselves, or via social media. The inclusion criteria develop a proper conceptual framework on housing in- were: > 18 years old; living or having lived under the security and its effects on health (e.g. neo material threat of eviction, illegal occupation or doubling-up; able mechanisms involved, the role of other related social to operate a camera; and willing to attend a two-hour determinants, and the inequality axes). training session and five 90 min discussion sessions. The aims of this participatory action research are: i) to All participants gave informed written consent and the identify perceived mediators of the relationship between study was approved by the Ethics Committee of Parc de Vásquez-Vera et al. International Journal for Equity in Health (2019) 18:52 Page 3 of 14 Salut Mar, Barcelona, as part of the project named “Aprox- each was trying to capture and had already been dis- imación cualitativa a los mediadores entre la seguridad cussed in previous sessions. Participants then grouped residencial y sus efectos en salud” (n° 2017/7287/l). all the selected photographs to establish categories in order to represent different mediators involved in the re- Photovoice steps lationship between housing insecurity and health. Photovoice activities were conducted between April and Finally, in sessions 7 to 9, participants from the two July 2017. We set up two groups of 9 participants each: groups worked together to share and select the final Group 1 consisted of 5 women and 4 men, and Group 2 photographs and categories, and proposed recommenda- consisted of 6 women and 3 men. Both groups attended tions to tackle the identified factors. six weekly sessions of approximately two hours at the PAH headquarters in Barcelona. Meeting days and times Data analysis, and quality of data were decided by each group independently. Data analysis began with the selection, categorization and A total of 9 sessions were conducted, 6 by each group discussion of the photographs by the participants during independently and 3 joint sessions. In each session, 2 fa- the sessions. When both groups finished their meetings, cilitators from the steering committee explained the four members of the steering committee (HV, CB, AN, aims of the session, encouraged the involvement of every AF) devised an analysis of the themes and content using participant and led the discussions. In addition, 2 the transcripts of the sessions. These four members identi- non-participant observers took field notes to record fied and coded themes using the categories proposed by nonverbal language and key ideas that emerged, as well participants as a frame of reference. The participants then as the dynamics and functioning of each session. Ses- convened to compare and discuss differences in the ana- sions 2 to 6 were audio recorded and transcribed with lysis made by the four members of the steering committee the permission of the participants. and the two groups of participants. Themes were then The first session consisted of training, including: a) an re-coded and classified, identifying common patterns and overview of the study (objectives, Photovoice process, convergences and divergences in data through an iterative ethical issues, expected benefits); b) a workshop con- process of constant comparison. Finally, the proposed cat- ducted by a professional photographer to learn how to egories were refined and enhanced by the other members use the digital cameras given to the participants, as well of the steering committee and the participants of both as basic technical, esthetical and ethical aspects of pho- groups in a devolution session (session 7). tography; c) the administration of a brief anonymous In order to ensure data quality, the information was survey to gather basic socioeconomic information of the verified using the field notes, the transcripts from each participants; and d) signing of the consent form by each session, and related literature. participant. Participants were asked to photograph what they considered to be the mechanisms and pathways Results that link housing insecurity and health using the follow- The socio-demographic characteristics of the partici- ing instruction: “photograph the things that have chan- pants are shown in Table 1. A total of 990 photographs ged in your daily life due to your current residential were taken, of which 147 were printed for analysis in status, and which are affecting (or might affect) your discussion sessions. Of these photographs, 109 were se- health or well-being”. lected to be categorized by participants. Eleven major Participants brought their photographs to sessions 2 to categories emerged that represent different factors re- 5. They chose three to five pictures, which were printed lated to housing insecurity and health (Fig. 1). Most out and discussed. The main purpose of the second ses- were acknowledged as possible mediators (“psychological sion was to reinforce the ideas to be captured by the changes”; “housing-related material aspects”; “health- participants’ photographs, for the photographer to give related behaviours”; “eviction”; “harassment by financial feedback to participants concerning technical, esthetical institutions”; and “family, neighbours and social net- and ethical issues, and to start to discuss the photo- work”), while others, such as “the PAH” and “the re- graphs. During sessions 3 to 5 the participants discussed sponse of public services”, were considered as modifiers and shared their photographs with the group. The that could vary the effects of housing insecurity on SHOWED method was used to guide the discussion, in- health. Two co-existing determinants emerged (“employ- cluding five questions: What do you see here? What is ment and household economy”; and “energy poverty”) really happening? How does this relate to our lives? which, while not recognized as mediators, might interact Why does this problem or strength exist? What can we with housing insecurity by increasing its negative effects do about it? [27]. on health. Finally, participants included two categories In the sixth session the participants brought their final called “the current housing context” and “stressful life five selected photographs that best reflected the issues events”, which were described as relevant although they Vásquez-Vera et al. International Journal for Equity in Health (2019) 18:52 Page 4 of 14 Table 1 Socio-demographic characteristics of participants Female (n = 11) Male (n = 7) Total (n = 18) Age 30 or less years-old 1 – 1 31 to 45 years-old 2 3 5 46 to 60 years old 7 3 10 61 or more years-old 1 1 2 Country of origin Spain 4 4 8 Morocco 2 1 3 Peru 2 – 2 Honduras 2 – 2 Bolivia – 1 1 Ecuador – 1 1 Italy 1 – 1 Educational level Primary or less 2 3 5 Secondary 7 3 10 College 2 1 3 Employment status Employed 2 3 5 Unemployed 7 2 9 Retiree or pensioner 2 2 4 Type of housing insecurity Due to mortgage arrears 6 5 11 Due to rent arrears 3 2 5 Illegal occupation of a dwelling 2 – 2 Fig. 1 Mediatorsα, modifiers of the mediatorsβ and co-existing determinantsμ involved in the relationship between housing insecurity and health (in brackets the number of selected photographs by each category) Vásquez-Vera et al. International Journal for Equity in Health (2019) 18:52 Page 5 of 14 are not directly involved as mediators between housing someone to my house. I have a “partner”, who lives well insecurity and health. and sometimes she tells me “let’s see when I go to your house”, and I say “no, you can not come to my house”, Psychological changes and she does not come to my house, because I am really Psychological changes and negative feelings related to ashamed.” (Fig. 3). According to participants, poor hous- housing problem were one of the most photographed ing conditions resulted from a lack of economic re- topics. Participants reported that feelings such as shame, sources and, importantly, because it is not worth guilt, uncertainty, fear and powerlessness, as well as a investing time and money in a dwelling that you may lack of control of their daily lives, negatively influenced have to leave at any time. their wellbeing and health. Uncertainty and fear were the most photographed emotions, which both groups depicted in the photograph, “our lives in boxes” (Fig. 2). Health-related behaviours This illustrates the threat of being evicted at any time Participants observed that unhealthy behaviours have while also not being able to plan one’s life in the dwell- been more common since their housing problems began. ing because of housing instability. For instance, C.P., a The photographs analysed included sedentary behaviour, 50-year-old woman said: “…My apartment is already less self-care (infrequent medical visits and treatment auctioned! I have the eviction, and I’m afraid that at any adherence), sleeping problems, unhealthy diet and in- moment they will come and take me out onto the street. creased consumption of alcohol and sleeping pills. That’s why I say, look, I will pack my bags, my clothes, Regarding sedentary behavior R.N., a 34-years-old the main things. ... and this causes me anxiety, insomnia, woman, said: “I love sports. I used to bike a lot, but not nervousness, that any day they will knock on the door anymore [since the housing problem]”] (Fig. 4a). In the and the police will take me out”. case of self-care, she added: “I do not go to the doctor, whatever happens to me (...) because the thing about go- Housing-related material aspects ing to the doctor is that I know that the doctor will ask Participants captured and emphasised that their health me for lots of things, he will send me to do lots of was directly affected by dampness, lack of proper things. You have to solve this first, because the stability insulation (problems with windows and doors), faulty [of the house] is the most serious thing, you know?” electrical outlets and connections, and inability to deal with maintenance costs due to lack of savings. Physical health is jeopardized due to the risk of electrocution, al- lergies, and contracting respiratory diseases and infec- tions. Similarly, the distress and shame of seeing one’s house in bad condition can cause psychological harm. M.E., a 61-year-old man, said: “I have 6 o 7 sockets I cannot touch them because if I touch one I will get elec- trocuted and then I will be in real trouble”, while F.H., a 57-year-old man, explained: “I’m ashamed to invite Fig. 2 Our lives in boxes (R.N. a 34-year-old women) Fig. 3 Dampness on the wall (F.H. 57-year-old man) Vásquez-Vera et al. International Journal for Equity in Health (2019) 18:52 Page 6 of 14 Participants noted that their stressful lives had led but they raise my rent.” Diminishing the quantity and them to increase their consumption of alcohol and quality of daily meals due to having to choose between sleeping pills. Most participants agreed that sleeping paying housing costs and eating well is a very common problems are very common and affect their normal daily dilemma among the participants. However, those with functioning. For instance, J.A., a 41-year-old man, men- children highlight their efforts to maintain an adequate tioned: “Yes, I have reached that extreme. I take 2 or 3 nutrition for them. C.L. explained: “If the children eat, pills to get to sleep, and it does not take effect. They that’s enough. I have to choose and buy for the children. have already changed [the pills] four or five times, and And for myself, we will see. You have to give the chil- there is no way, I cannot sleep.” (Fig. 4b). dren what there is, but these children are already poorly Unhealthy diet was a widely discussed topic. Partici- nourished since they were small.” pants agreed that they had poorer eating habits since the beginning of their housing insecurity situation, thereby affecting their health. I.G. said: “I have a simple and Eviction plain dinner every day of boiled pasta to put something Eviction of people from their homes was referred to as a into the stomach, for me and my children. Then one day traumatic event that affects both mental and physical you get sick, you go to the doctor, they do tests and they health. According to the participants, an eviction triggers say “eh, madam, you have anemia, you lack iron ... Do anticipatory anxiety and exacerbates stress suffered dur- you know that with your responsabilities, you have to ing the process. Since PAH members participate in pre- have good nourishment?” But how am I going to be able venting evictions of their neighbours, wider groups can to put food on the table tomorrow and be able to con- also experience the negative effects of evictions, along tinue paying [the house]? If they don’t raise my salary with those who are directly affected. C.L., a 40-year-old man, said: “Unfortunately, this week we had an eviction that unfortunately could not be stopped. Then, of course, I identified with all this because to see this fam- ily, they really leave their things in the street, it reminded me of that for me, because I was afraid of it too, and a week previously I had brought things to a neighbour and went to a room”. (Fig. 5a). In addition, physical health might be affected due to police interven- tion. I. G., a 49-year-old women, explained: “This [photo] is from this morning, during the eviction of a neighbour. It’s the nervousness that you endure. There, the local police hurt me on the shoulder ... because it was chaotic at that moment when they were being re- moved, and they violently take you out” (Fig. 5b). Harassment by financial institutions Regarding financial institutions, participants pointed out that in cases of mortgage and foreclosure, harass- ment by banks and other non-judicial collection insti- tutions through phone calls, letters and meetings, is a constant burden affecting their mental health and wellbeing. For instance, L.B., a 70-year-old-women, re- ported anxiety and fear every time she had to meet with bank executives: “I went to the bank to see what solution they could give me and the director first told the lady at the counter that I was leaving, that she was not going to take care of me. She said, “I will not take care of you, after the problems you’ve caused”. That bank causes me anguish because of course, I’m going to fix my problems, and this Fig. 4 a “I miss doing things that I like” (R.N., a 34-year-old woman). woman is always so sharp ... and that twists my stom- b Awake at 4 AM! (J.A., 41-year-old man) ach with anguish” (Fig. 6). Vásquez-Vera et al. International Journal for Equity in Health (2019) 18:52 Page 7 of 14 network as well. This situation leads to isolation and a lack of social support, which can produce negative ef- fects on mental health, as captured by E.V., a 55 year-old woman, in her photograph (Fig. 7a). Another aspect is the importance of family. Partici- pants explained that having strong family support lessens the negative effects of the housing crisis on men- tal health. As C.P. mentioned: “My daughter likes to be there, supporting me, caring for me, because I take her and she joins in. “Mom, I will help you”, we are pasting posters on the walls of the bank (...) it’s a way of ... how can I put it? To seek complicity with me (...) and we Fig. 5 a Family stuff on the street (C.L., 40-year-old man). b Police intervention (I.G., 49-year-old woman) Family, neighbours and social network According to participants, their social network is an- other factor involved in the relationship between hous- ing insecurity and health. Being forced to leave one’s dwelling implies leaving the community and the social Fig. 7 a Loneliness (E.V., 55-year-old woman). b “Mom, can I help Fig. 6 Rage against my bank (L.B., 70-year-old woman) you?” (C.P., 50-year-old woman) Vásquez-Vera et al. International Journal for Equity in Health (2019) 18:52 Page 8 of 14 show it at home, in actions, in any way we can, we get Energy poverty rid of the discomfort, stress, nerves, powerless, every- People experiencing housing insecurity often have to thing” Fig. 7b). However, some participants explained choose between paying their rent or mortgage and pay- that indifference and rejection by their families and ing basic amenities (electricity, gas and water). Partici- neighbours to their housing problem increased the sense pants explained that they usually prefer to pay rent of isolation, shame and guilt. In addition, affected people before paying for energy, despite saving as much as pos- usually do not share the housing crisis load with their sible by cutting their energy use prior to making that de- families in order to prevent further suffering (mainly cision. Therefore a lot of daily provisions, such as their children), which increases their own stress and heating and food, cannot be afforded, which has negative sense of isolation. consequences for their health. As L.B. said: “I do not have air conditioning or heating, so I’m sick of course. Employment and household economy It’s cold, and on top of that, I’m sick with bronchitis. While unemployment and shortage of money are causes, This time I’ve been like this for three months in bed, be- more than mediators, participants agreed that these fac- cause I’ve had pneumonia, and of course, I can’t, I can’t tors strongly interact with housing insecurity and its ef- put on either the heating or the hot water.” In addition, fects on health. In all cases, losing a job led to losing the the people affected reported high levels of anxiety due to dwelling. Further, the difficulty in finding a new job in a an imminent cut in their energy supply due to payments precarious job market makes it harder to have enough re- arrears. For instance, C.G. mentioned: “I’ve been ‘stuck’ sources to overcome housing insecurity, thereby exacer- for a long time [using] the plug until I said one day “to bating the negative consequences on health. As M.L., a hell with it”. I mean, I unplug and that’s it. As I know 56-year-old woman, added: “I cannot work. I cannot work there is no electricity [standby light], because I un- anymore in my job. So they screwed up my life. Because plugged, because I do not have to turn on the TV in the with my work, I earned money. I had the apartment, I had morning to see if they have turned off the electricity or everything, more or less. But when I could not keep work- not ... so I’m calmer”. (Fig. 9). ing, what can you do?”. T.V., a 56 year-old man, added: “We cannot make ends meet” (Fig. 8). The PAH The association between unemployment and housing All participants agreed that the PAH is the most import- insecurity is often a two-way process. People under threat ant protective factor that mitigates the negative effects of eviction said that they spend a lot of their daily time in of housing insecurity on health, by modifying several of legal and administrative proceedings such as negotiating the aforementioned mediators, namely preventing evic- with financial institutions, attending social service offices, tion, creating new social networks, and empowering and meeting with lawyers. I.G. said: “You can go so far as people by tackling psychological hardships. Participants to lose your job to fight for a house, like what happened reported that people arrive at the PAH emotionally dam- to me. I lost my shop. I was not doing very well but it was aged, with feelings of shame, guilt and powerlessness. me and it showed, and I have lost my way of life because However once they start to participate, positive changes every day for three months I had go to the housing office, rapidly occur (Fig. 10a). As T.V. explained: “Here it is court, social services ... daily, in person”. clear, and it has been shown to all of us in the PAH, that people arrive broken, the vast majority, absolutely broken, and after a while, because it has quite rapid ef- fects, the truth is, you go out, you move differently. For- tunately”. As participants reported, the PAH gives them tools to become empowered, overcoming shame and guilt and figuring out that they can find solutions for their housing situation together. T.V. added: “We went from a completely depressing state initially, lack of self-esteem, not believing in anything and such, to at- tending assemblies and meetings, and finding common solutions to fix things a bit.” Another characteristic of the PAH that diminishes negative health consequences is that collaborative work gives people motivation to take positive action. As L.B. mentioned: “For me it is great therapy because seeing that I can help that person, it is something that enhances Fig. 8 Make ends meet (T.V., 56 year-old-man) me, that is, I am no longer alone, I no longer feel Vásquez-Vera et al. International Journal for Equity in Health (2019) 18:52 Page 9 of 14 Fig. 9 Trapped by the plug (C.G., a 46-year-old woman) insignificant, I know I can do something positive, some- thing great, for others as well as for me.” The PAH usually Fig. 10 a PAH meeting (C.L., 40-year-old man). b Hanging out with provides people with a new social network and a peer sup- PAH friends (F.H. 57-year-old man) port group where they can be understood and helped. This is relevant considering the impact housing insecurity has on the social fabric, as mentioned above. I.G. said: “I life”, but we and the people that I know are not like have also found friends, maybe not close lifelong friends, that.” On the other hand, E.V. stated that a warm recep- but you can have a great friendship coming to the PAH, tion and empathy by public service workers make partic- because here we do not look at race, colour or social sta- ipants feel supported and understood, which reduces the tus, here we all come to do the same” (Fig. 10b). stress and bad feelings of their situation: “When I met the social worker, it was a service that gave me life ... Public services that woman [the social worker] to me, has given me life, Both groups agreed that public services, such as primary because she has treated me so excellently right up to health care, social services and housing assistance offices today, where this case has taken me.” (Fig. 11). might modulate the negative effects on health. Although this topic was considered a point of contention, as the The current housing market response and attitude of public service personnel can Although the current situation of the housing market in lessen or increase negative health effects among people Barcelona was not recognized as a direct mediator be- with housing insecurity. For instance, public servants tween housing insecurity and health, participants agreed sometimes make recipients of their services feel guilty in underlining it as a main structural cause of their resi- about their situation, undermining their self-esteem and dential status. They reported that real-estate speculation, mental health. As F.H. explained: “And you have that massive tourism and gentrification are leading causes of person there who is dealing with you, you know that she the housing crisis, and are making them feel angry and is in a good position and she is treating you as if you do powerless. They complained about the increased num- not want to work, like you are practically a squatter, and bers of dwellings for the investment and tourism mar- then you have to explain to her. Lots and lots of these kets, instead of being allocated for people who are people who are there, they think that we are “living the suffering housing unaffordability and exclusion (Fig. 12). Vásquez-Vera et al. International Journal for Equity in Health (2019) 18:52 Page 10 of 14 These events can act either as triggers of housing inse- curity or as interacting factors that worsen that insecur- ity. For instance, L.C., a 55-year-old-woman, said: “My husband and I work thinking that we would be in this apartment all our lives, but since my husband died I have a problem. So [in this photograph] I’m imagining that I surely have to leave the apartment”. (Fig. 13). Recommendations The recommendations proposed by the participants to tackle these factors are available in the supplementary data (Additional file 1). Discussion Fig. 11 My social worker (E.V., 55-year-old woman) This photovoice project provided insights into the mediators and mechanisms that link housing insecurity and health among people associated with the PAH in As L.B. said: “This is a cause of the problem, is it not? Barcelona. Using a participatory approach, participants Because, of course, they are making luxury hotels and reported a variety of factors associated with housing in- flats when there is a lack of housing. I mean, they specu- security that, in turn, can affect mental and physical late in making hotels with which they earn a lot, when health Additionally, participants described how being ac- there are people who do not have a home.” tive in the PAH and the response of public services can modify these factors, with either increased or diminished Stressful life events health effects. Linked to this problem, energy poverty, Participants reported that stressful life events, such as employment and household economy emerged as social the death of a relative, family break down or chronic dis- determinants that are tightly related to housing insecurity ease are closely linked to negative health consequences. and could also influence health outcomes. Finally, despite not being directly involved as mediating factors, stressful life events and economic and political causes of housing insecurity emerged as important topics to be considered. All of these results show the unbalance of the participants on social life and function practice of their social role. Some of the findings on the mediators reported here have been described in previous studies. Regarding psy- chological changes, some studies have reported that housing insecurity can trigger feelings of personal Fig. 13 “I lost my husband, with him also my house” (L.C., Fig. 12 Real estate speculation (C.P., 50-year-old woman) 55-year-old woman) Vásquez-Vera et al. International Journal for Equity in Health (2019) 18:52 Page 11 of 14 failure, embarrassment, isolation, uncertainty and having institutions, which increases victims’ feeling of lack of a lack of control over key aspects of daily living which, control, fear and anxiety. Although we did not find in turn, can lead to anxiety, depression and suicidal idea- evidence of this in our study, previous evidence has as- tion [7, 16, 20–22]. Nettleton and Burrows pointed out sociated indebtedness to negative effects on health, that living with housing insecurity affects health via two highlighting that one of the mechanisms involved would pathways: 1) through psychological changes, and 2) by be the debt collection process. This process includes for- adopting unhealthy behaviours that are risk factors for mal and informal procedures that generate stress and several diseases [16]. The second pathway is also sup- anxiety among debtors, mainly in cases where creditors ported by our findings and those of other studies show- have the right to take debtors’ property [36, 37]. ing that people report more sedentary behaviour, alcohol Another noteworthy finding was the relationship be- consumption, sleeping problems and unhealthy diet after tween energy poverty and employment and housing in- becoming affected by housing insecurity [23, 24, 29–31]. security. Despite not being direct mediators, participants The social context, such as housing, influences those in- reported that both determinants are closely linked to dividual health-related behaviours in a number of ways: housing insecurity and can most likely worsen the nega- by shaping social norms, enforcing social control, enab- tive consequences on health. Regarding energy poverty, ling or not enabling people to participate in particular Cook et al. reported that young children living in house- behaviours, reducing or producing stress, and constrain- holds suffering energy poverty are more likely to suffer ing individual choice [32]. housing insecurity and fair or poor health, although they Beyond behavioural mediators, this study added other did not analyze possible interactions between both deter- peripheral factors. Regarding family and social network, minants [38]. In turn, Hernández has proposed the term we found that people with housing insecurity may suffer “trifecta of insecurity” to discuss the associations be- from lack of empathy, rejection and discrimination from tween housing insecurity, energy insecurity and food in- family and neighbours, or forced displacement to other security, and how this can affect the health of people neighbourhoods, which can lead to isolation and loss of who are forced to make tradeoffs in meeting basic needs their social network. Likewise, Hulse and Saugeres re- due to socioeconomic constraints [39]. Generally, people ported that housing insecurity generates barriers to so- living with housing insecurity not only struggle to pay cial support and participation (related to high mobility, their rent or mortgage, but also high energy bills which lack of belonging and isolation), which are widely recog- may increase the stress or lead to energy poverty [40, 41]. nized as determinants of poor health outcomes [7, 33]. We understand housing insecurity and energy poverty to Libman et al. reported that the threat of eviction can be pieces of the same phenomenon, and their effects on create enough stress to break up families, while Murphy health and their interactions should be addressed. Partici- et al. showed that the association between housing af- pants pointed out that unemployment and other employ- fordability problems or eviction and alcohol dependence ment insecurity situations are closely associated with symptoms was stronger among people with low per- housing insecurity and health. Unemployment can directly ceived family support [29, 34]. Additionally, participants cause housing insecurity and, conversely, housing insecur- discussed how housing insecurity leads to physical de- ity can lead to job loss or can make it difficult to find a terioration of the dwelling as a consequence of house- new one. For instance, Hulse and Saugeres reported that hold economic problems and uncertainty due to an attempting to find work while experiencing housing inse- imminent eviction. This finding is supported by studies curity, and not being able to find or keep a job, reinforced showing that people affected by housing insecurity are the stress, anxiety and depression that respondents experi- more likely to live in inadequate dwellings, with mould, enced [7]. Bentley et al. studied these interactions in a dampness, and pests, compared to individuals from the sample of people of working age, and reported that em- most disadvantaged social classes [7, 35]. Most of the lit- ployment security modifies the relationship between hous- erature on mediators between housing insecurity and ing affordability and mental health. The negative effects of health has focused on psychosocial pathways. However, unaffordable housing on health were more intense among our understanding is that several mechanisms are people under insecure employment conditions [42]. explained by material living conditions that should be The response of public services and participation in addressed by further research. Regarding eviction, partic- community-based organizations, such as the PAH, ipants described it as a highly stressful event that can emerged as two important modifiers of the effects of trigger psychological distress and anxiety, and that is housing insecurity on health. They help alleviate some also a potential risk factor for physical health due to po- of the described mediators and pathways of poor health. lice intervention. However, to our knowledge no other Social services can improve household income through studies have addressed this specific issue. The final dir- subsidies, promote social inclusion of affected families, ect mediator that emerged is harassment by the financial provide legal and administrative solutions to stop Vásquez-Vera et al. International Journal for Equity in Health (2019) 18:52 Page 12 of 14 evictions and integrate affected people into the social These findings are not representative of all people experi- protection system. Primary health care centres may ad- encing housing insecurity in Barcelona, as they were ob- dress health-related behaviours and psychological tained from a specific sample, namely those associated changes using a comprehensive approach. Housing of- with the PAH. For instance, probably if participants were fices can offer social housing, rent subsidies and other not PAH members (or another social movement) the im- measures to assist people under housing insecurity. In portance of collectivism (i.e. the PAH) and the political contrast, lack of empathy and inadequate responses from empowerment highlighted on some categories (e.g. the public services can worsen the feelings associated with current housing market), would not be that much relevant housing insecurity among the recipients, leading to as in this case. However, considering the difficulty in poorer mental health outcomes. In addition, participants accessing people living with housing insecurity, we con- agreed that the lack of specific training in housing inse- sider this study an appropriate initial approach to identify curity phenomenon for public services personnel and and further characterize the problem and its links to problems related to the efficiency of bureaucratic pro- health. Finally, while we present the main findings in Fig. 1, cesses (mainly in Social Services and Housing offices) the lack of a conceptual framework on housing insecurity jeopardize a timely response to urgent issues related to and health has hindered understanding of the complex as- material living conditions (e.g. food insecurity, energy sociations we have identified. We highlight the need for poverty, lack of shelter) which can be another mechan- further research and theory in this field. ism to poor health. There was unanimous agreement among participants that the PAH was the greatest pro- Conclusion tective factor. Peer-to-peer support, empowerment and Housing insecurity in Spain, and many other places, is social inclusion were described as the first steps in eas- far from being resolved and will likely continue in the ing feelings of guilt, embarrassment and personal failure. coming years. This situation clearly affects the popula- The PAH carries out several actions to tackle housing tion’s health and exacerbates social and health inequal- insecurity. Evictions can be prevented through nonvio- ities. Understanding the pathways and mechanisms lent resistance. Collective repayment negotiations are underlying this process is a crucial task of social epi- carried out with banks. Evicted tenants are re-housed, demiology. Further research in this field and public en- ideally in nearby neighbourhoods. Attempts are made to gagement are urgently needed to design and implement push for revision of local and national laws to change public policies that tackle this serious problem. the unfair conditions of the housing system. In combin- ation, all of these actions modulate most of the de- Additional file scribed mediating factors, reducing the negatives effects on health [43]. In addition, PAH promotes the political Additional file 1: Recommendations for tackling negative effects of empowerment of its members by disrupting the hege- housing insecurity on health. (DOCX 20 kb) monic neoliberal model since people realize that losing their houses is not their personal failure but is linked to Acknowledgements structural factors [17]. As seen in this and previous stud- The authors thank the Platform for People Affected by Mortgages of Barcelona (PAH) for its valuable support to this study, and the members of ies, social and political participation is crucial to improve Photovoice Working Group of Public Health Agency of Barcelona (Mar Oriol, inadequate and unfair living conditions, and to improve Anna García, Ferrán Sanchís, Esther Teixidor, and Andrés Peralta). the health of the affected population [33, 44]. This study used a Participatory Action Research ap- Funding This study was funded by Agència de Salut Pública de Barcelona. proach, in which a Photovoice methodology engaged participants and other PAH members who themselves Availability of data and materials made decisions and validated results from the beginning. Transcriptions of the group discussions are available from Hugo Vásquez- This allowed us to obtain reliable information about the Vera (hvasquez@aspb.cat). pathways to poor health of a hard-to-reach section of Authors’ contributions the general population. In addition, the study has pro- Conception and design: HV. Collection and assembly of data: HV, AF, AN, LD, duced political recommendations for interventions by CM, JB, CB. Analysis and interpretation of the data: HV, AF, AN, CB. Drafting of the PAH, such as advocacy actions with policymakers the article: HV. Critical revision of the article for important intellectual content: HV, AF, AN, LD, CM, JB, CB. Final approval of the article: HV, AF, AN, LD, CM, JB, and other stakeholders (Additional file 1). Regarding the CB. study’s limitations, the recruitment process did not allow us to create gender-stratified groups, which limited our Ethics approval and consent to participate ability to gather gender-specific views. The definition of All participants gave informed written consent and the study was approved by the Ethics Committee of Parc de Salut Mar, Barcelona, as part of the “home” is inherently gendered, and so further research project named “Aproximación cualitativa a los mediadores entre la seguridad that takes gender differences into account is necessary. residencial y sus efectos en salud” (n° 2017/7287/l). Vásquez-Vera et al. International Journal for Equity in Health (2019) 18:52 Page 13 of 14 Consent for publication mortgages. J Urban Health. 2016;93(2):312–30 Available from: http://www. All participants who appear in the photographies have given their consent ncbi.nlm.nih.gov/pubmed/26940706. [cited 2016 Mar 7]. for publication. 16. Nettleton S, Burrows R. When a Capital investment becomes an emotional loss: the health consequences of the experience of mortgage possession in Competing interests England. Hous Stud. 2000;15(3):463–78 Available from: http://www. 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