Investigating the Relationship Between Food,Housing,and Transportation Insecurity and Chronic Disease Among US Women Using Nationally Representative Data

Settings & Design

Data for this cross-sectional study were derived from the Health Information National Trends Survey (HINTS) fielded by the National Cancer Institute between March and November 2022. HINTS is a nationally representative sample of noninstitutionalized US adults 18 years and older. Data on health communication, digital health use, and sociodemographic characteristics are collected.

Sample

The sampling strategy for HINTS 6 comprised a two-stage design. In the first stage, a stratified sample of addresses was selected from a file of residential addresses. In the second stage, one adult was selected within each sampled household. The total number of respondents surveyed was 6252, with a 28.1% response rate. However, this study was restricted to only 3535 female respondents included in the data. Detailed information about the HINTS survey and methodology is reported elsewhere. ¹⁸

Measures

Analysis

All analyses used the recommended analytical strategy by the HINTS analyst and applied 50 replicate jackknife survey weights to account for variance estimation and generalizability.

Initial weighted descriptive statistics were analyzed for all respondents. Chi-square tests were used to compare the key independent variables, food, housing, transportation, and overall insecurities to chronic conditions, and reported in graphs. Next, we performed separate weighted logistic regression models to test the unadjusted association of the study variables and each chronic condition. Third, multivariate logistic regression models were created to explore the adjusted association between the outcome and control variables.

We conducted separate adjusted prediction models based on statistical significance to understand the interactions between age and insecurity (No/Yes) and chronic conditions (No/Yes) and interaction between race and insecurity (No/Yes) and chronic conditions (No/Yes), and reported them in graphs.

Multicollinearity was also examined using the variance inflation factor, and no collinearity was found among the independent variables. Hosmer-Lemeshow goodness-of-fit test was conducted; models with an insignificant chi-square test output demonstrate a good fit. We reported the unadjusted odds ratio (OR), adjusted odds ratio (aOR), and corresponding 95% confidence interval (CI). A 2-sided significance level of α < .05 for statistical significance was applied. Missing or unknown observations were dropped for all analyses. Analyses were performed with Stata statistical software (version 17 SE; StataCorp).

Summary

This study examined the association between food, housing, and transportation insecurity and self-reported chronic disease, including diabetes, hypertension, high blood pressure, and depression or anxiety, using a nationally representative sample. Our study found that almost half (45.2%) of the US adult women have at least one chronic condition. Additionally, women who experienced food, housing, and transportation insecurities were statistically more likely to report chronic conditions than those without. These findings support the growing literature showing a strong link between social factors and chronic disease.^5,21,22 This calls for a comprehensive approach linking community services and medical care to addressing adverse social determinants of health influencing women’s health and wellbeing.

Access to food, affordable housing, and reliable transportation is crucial to sustaining women’s health. While our analysis did not find a statistically significant relationship between food insecurity and diabetes, we found that food insecurity increased the odds of having high blood pressure, heart condition, depression, or anxiety, or having any insecurity. These results align with the literature, reinforcing the need for strategies to combat food insecurity as an approach to address chronic conditions.^23,24 Considering that nutrition and dietary habits play a significant role across the life course, connecting women, particularly those at risk of food insecurity, to social support services across the continuum of care, including within the community level, may help combat the growing rate of chronic conditions. For example, when incorporated into prenatal counselling programs, women who were food insecure at the beginning of pregnancy became food secure by late pregnancy, ²⁵ suggesting that incorporating nutritional counselling and connecting women with social services in the clinical and community settings may reduce food insecurity. ²⁶

This study demonstrated that housing insecurity was correlated with all the chronic conditions analyzed. Safe and reliable housing remains a significant public health problem in the US. About 771,480 people experienced homelessness in 2024, with women representing roughly 39.2% or 302,660 of the homeless population. Women experiencing homelessness are exposed to adverse living conditions, including poverty, mental health problems, or gender-based violence, ¹⁷ that exacerbate their vulnerability to chronic conditions and affect their quality of life. They also do not have access to quality health care services, so they likely have limited or lack healthcare coverage, do not have a regular physician, or seek preventive care. While this study did not specifically include homeless populations, although the definition of homelessness is nuanced, our study spotlights the issues that women facing housing insecurity encounter, which expose them to adverse outcomes, including chronic conditions. Moreover, housing insecurity is associated with pregnancy complications and adverse birth and infant outcomes.^13,17,27

Furthermore, similar to the literature, transportation insecurity independently predicted heart condition and depression or anxiety. Lack of safe and reliable transportation can lead to non-adherence and general preventive health or health care utilization. Using a national dataset, transportation insecurity was associated with 41% reduced odds of adherence to breast cancer screening. ²⁸ Additionally, the chances of adhering to preventive health screening increase as the distance between the home and the healthcare facility increases. ²⁹ Women make up the largest group of Americans with transportation insecurity (6.1% vs5.3%) which is linked to other adverse social determinants of health, such as poverty, which is prevalent among women than men (8.9% vs11. 8%).^14,30 Our study findings highlight the importance of strategies to improve the mechanisms perpetuating these inequities, leading to chronic conditions and poor quality of life.

Results show a positive association between insecurities and the predicted probability of having any chronic conditions across all racial and age groups. Older adults (65 and older) and those in the other racial category with insecurities had significantly higher predicted probabilities of chronic conditions than their counterparts. While it is likely that older adults are at increased risk of chronic conditions than other age groups, our findings deviate slightly from previous studies suggesting that housing insecurity is more prevalent during midlife (<65 vs >65 years). ³¹ Concerning the result on race and insecurities on chronic conditions, showing that ethnic minorities (non-Hispanic Black, Hispanics, and Asians) with insecurities have a lower predicted probability of chronic conditions, the literature is mixed. ³² While surprising, our study highlights the deeper structural and systemic issues around healthcare access among minority populations. For instance, the literature widely documents significant disparities in the timely screening, diagnosis, management, and treatment of chronic conditions among ethnic minorities, particularly Black and Hispanic populations. ³³ These disparities may lead to underestimating the true rates and prevalence of chronic conditions within these groups. Thus, it is likely that our results reflect this reality. We therefore caution against drawing strong conclusions from this observation, particularly in light of our sample distribution, as seen in Table 1. The findings demonstrate a need for future research on insecurities and chronic conditions among women to understand the upstream determinants of health across population subgroups.

Chronic conditions continue to be a significant public health crisis for American women; our study reinforces the need for system-level approaches to addressing the nonbiological factors that impact women’s health and well-being. ⁵ Women in the US are more likely than men to be socioeconomically disadvantaged, including having higher poverty rates, income inequality, unemployment or lower-paying jobs, and childcare responsibilities, which destabilize their earning power and potential, leading to huge economic and health disparities. ¹⁴ Additionally, women who live in under-resourced neighborhoods and built environments, and rural areas may be exposed to environmental toxins and pollutants or limited opportunities for physical activities, which have detrimental effects on their health, particularly during pregnancy and childhood, all leading to increased risk of chronic conditions. ¹³ Social and gender norms across cultures perpetuate bias and discrimination, leading to gender-based violence and harmful ideologies meant to subjugate women’s right to life, access to care, and freedom. ⁵ More so, policies and programs are often designed through a male-gendered lens with harmful unintended consequences on women’s health and well-being. ³⁴ These adverse nonbiological factors are linked to women’s health, including chronic conditions, as evident in this study.

Policy and Public Health Implications

Our study has several policies and public health implications. While the riskof chronic diseases is complex, efforts to address structural or environmental factors must be a priority. For example, while Medicaid offers chronic disease management services, issues such as lack of care coordination, the complexity of the Medicaid system, provider reimbursement rates, and differences in the scope of the services provided across states limit beneficiaries from benefiting from these services. Similarly, the 20% cost-sharing or low provider reimbursement rates among Medicare Part B beneficiaries hinder adequate chronic disease management. As a result, policymakers must enact policies to enhance patient engagement and access to care. For example, in 2023, the American Hospital Association endorsed the removal of patient cost-sharing obligations to increase access to chronic disease management. ³⁵ Beyond managing chronic conditions, policymakers must invest in primary chronic disease prevention policies by developing evidence-based direct health policies targeted at the social determinants of health. ³⁶ For example, policies on school nutrition, food assistance and access, food labelling, and the built environment can help prevent chronic disease before it occurs.

Care coordination beyond clinical referrals for chronic conditions must be harnessed to integrate community-based social services into care models. In a time when women’s health is precarious - leading to mistrust in healthcare providers or complete healthcare avoidance behaviors - integrating social services in healthcare delivery has great potential for improving health and achieving health equity.

Additionally, our study highlights the need for more research and tailored public health interventions to understand the link between social factors and chronic conditions across sociodemographic characteristics. Equitable and culturally relevant data surveillance systems, research design, public health programming, and clinical interventions must be considered to ensure representativeness. Additionally, efforts to mitigate social insecurities should account for women’s unique differences and needs across age groups.

Strengths and Limitations

Even though this study significantly contributes to the literature, our results must be interpreted in light of some limitations. We used a cross-sectional survey of a nationally representative cohort of individuals; therefore, we cannot infer causality, and the directions of the associations in the study cannot be indicated. Since the data was self-administered, it is prone to recall bias, and misrepresentation by respondents is likely. Our results only provide a snapshot of how social factors influence chronic conditions based on the confounders included in this study. For example, we would have wanted to see whether having a regular provider moderates our results, since the literature suggests that having a regular provider increases chronic disease management among reproductive-age women However, this question was not included in the 2022 HINTS data. Using clinical vs self-reported data may also alter the results. Future researchers may consider conducting primary quantitative and qualitative research to understand this relationship better.

Despite these limitations, our study updates current knowledge about the association between social factors and chronic conditions among US women.