Understanding the mental health impacts of poor quality private-rented housing during the UK's first COVID-19 lockdown.

This paper examines the mental health impacts of poor quality private-rented housing in the north of England during the UK's first COVID-19 lockdown. The paper draws on data collected from semi-structured telephone interviews with 40 renters in the private-rented sector. We use the Power Threat Meaning Framework to highlight how substandard housing was a social and material vulnerability which, underpinned by powerlessness, resulted in threats that created and exacerbated the mental-ill health of precarious private renters. The paper suggests the pandemic and increased time spent in unhealthy places of residence can create stresses at a time of broader structural fragility, and calls for the greater engagement and integration of health practitioners in the future development of housing policy at all levels.

Background

Since the deinstitutionalisation of mental health in the 1960s, studies about how people with mental ill-health cope in community settings have established understanding about the interconnections between mental health and place of residence (Wolch and Philo, 2000; Jones, 2001; Fields, 2011; Bromley et al., 2013; Piat et al., 2017). This includes how the social and material qualities of places of residence impact an individual's dissatisfaction and perceived quality of life (Evans, 2003; Jordan, 2011; Marquez et al., 2019). Place provides an analytical focus for studying the dynamics between people and environments (Agnew, 1987; Massey et al., 1995; Creswell, 2014), and at a housing scale, housing environments are known to function as mediators of wellbeing and mental health (Kearns et al., 1992; Evans, 2000). Numerous studies have linked poor housing quality (including overcrowding, damp and insufficient housing facilities) to increased anxiety, depression, stress, insomnia and panic attacks (Pevalin et al., 2017; Rautio et al., 2018; Singh et al., 2019), whilst precarious housing situations (such as unaffordability, evictions and displacement) are known to be associated with and, often, lead to emotional distress (Rojas and Stenberg, 2016; Holding et al., 2020; Gillespie et al., 2021; Wang et al., 2021) (see Table 1 ).

Table 1

Participant demographics.

Demographic	Frequency (valid %) (n = 40)
Gender
Male	16 (40%)
Female	24 (60%)
Age groups
18–29	10 (25%)
30–39	14 (35%)
40–59	15 (38%)
60–70	1 (2%)
Employment status
Employed (full time and part time)	23 (58%)
Unemployed	11 (28%)
Furlough	6 (14%)
Household type
Single	10 (25%)
Family	23 (58%)
Cohabiting	5 (11%)
House share	3 (6%)

In the UK, the impact of poor housing is estimated to cost the National Health Service (NHS) £1.4 billion annually (Garrett et al., 2021). Whilst poor housing is a feature across all tenures, the situation is particularly adverse for people who rent privately from a landlord or letting agent (Diggle et al., 2017; Rugg and Rhodes, 2018). In the UK, the number of people living in the private-rented sector increased from 2.8 million in 2007 to 4.4 million in 2021 (Department for Levelling Up, Housing & Communities, 2021). The expansion of private renting can be attributed to numerous drivers of change in the UK's housing system. This includes the loss of social housing, increased housing financialisation and the impacts of government led austerity that have created barriers to accessing socially-rented and owner-occupied tenures (Minton, 2017; Byrne, 2020). In 2020, in the most recent data available, private renters accounted for 19% of all households in England compared with 65% for owner occupiers and 17% for social housing occupants (Department for Levelling Up, Housing & Communities, 2022). However, in the same year, 21% of dwellings in the private-rented sector in England fell below the Decent Homes Standard1 (Rugg and Rhodes, 2018). The drivers of poor conditions in the private-rented sector can be attributed to the relative lack of regulation compared with the socially-rented sector, short and insecure tenancies that discourage residents from reporting problems in fear of eviction, and the growth of landlords with smaller portfolios who circumvent standards and regulations (Rugg and Rhodes, 2018).

Since the start of the COVID-19 pandemic, interventions colloquially known as ‘lockdowns’ have been implemented in multiple countries to mitigate the spread of SARS-CoV-2, the virus that causes COVID-19. These have included legally-enforced curfews, quarantines, social distancing measures, restrictions on social gatherings and ‘stay at home’ measures. In March 2020, as part of a quarantine strategy to control the initial outbreak of COVID-19, the UK Government issued a strict ‘stay at home’ policy that limited the population to their place of residence except for essential tasks or for work in key organisations. In what became known as the UK's first national ‘lockdown’, leisure, work and educational facilities were closed with interaction between households limited. The initial phasing out of these measures began in June 2020, before re-introduction in subsequent autumn and winter in response to a surge in COVID-19 cases.

Studies have reported increases in fear, anxiety and depressive symptoms amongst populations since the start of the COVID-19 pandemic (Fitzpatrick et al., 2020; Xiong et al., 2020; Wu et al., 2021), There is emerging evidence that housing quality has exacerbated incidence of mental ill-health in housing in poor quality or on the margins of poor quality (Author 5 et al., 2020; McAuley, 2020). Research in the UK estimated nearly a third (31%) of adults experienced mental or physical ill-health because of the condition of their housing during the UK's first national lockdown (NHF, 2020). Following declaration of an emergency protocol that confined people to their accommodation, a nationwide survey in Italy found high rates of post-traumatic stress, depression, anxiety, insomnia, perceived stress and adjustment disorder symptoms, all of which were attributable to poor quality housing and limited indoor space (Amerio et al., 2020). Whilst the mental health impacts of quarantine are well-understood (Henssler et al., 2021), Guessoum et al. (2020) speculated that housing confinement for unknown duration during enforced curfews was likely to produce significant long-term mental health impacts. It is increasingly clear the social implications of the COVID-19 pandemic have not been evenly spread, with many existing inequalities amplified (Blundell et al., 2020; Quantin and Tubert-Bitter, 2022). However, despite emerging research on the relationship between housing quality and lived experience during the COVID-19 pandemic, (Horne et al., 2021; Waldron, 2022), there is very little in-depth understanding about how the mental health impacts of lockdown measures might be mediated by the material and social qualities of poor and precarious housing itself.

The study upon which this paper is based aimed to elucidate the day-to-day experiences of households who were living in poor quality housing. The objective of this paper is to focus more specific on how housing inequality, namely that which relates to the quality and decency of accommodation, the impact this has had on renters during COVID-19 lockdown, and how people in poor and precarious housing managed these changes in relation to their mental health and wellbeing. In this paper, we use the Power Threat Meaning Framework (PTMF) (Johnstone et al., 2018) to examine how private renters in poor quality housing in the north of England experienced the UK's first stay at home lockdown, and why it challenged their mental health and wellbeing. The PTMF argues that worsening mental health can be seen as an understandable and meaningful survival response to threats that are experienced with the negative operation of power. The focus is then on what has happened to the person and the situation they find themselves in, in terms of threats and powerlessness, rather than focusing on what is ‘wrong’ with them. It offers an alternative to the medical model of mental illness, by seeing emotional and behavioural responses to threat and disempowerment as understandable survival responses rather than symptoms of disorders. Models such as the Stress Vulnerability Model (Zubin and Spring 1977) see threats to mental health in terms of vulnerabilities which are exacerbated by stress, but the vulnerability is still described in biological terms. Contextualised within the emerging literature on housing quality and lived experience during COVID-19, we argue that ongoing challenges associated with precarious and poor quality housing can be seen as ‘social and material vulnerabilities’ (Bartram, 2016), because they involve the environment and social world. Our analysis is therefore informed by drawing on the PTMF to help us understand how social vulnerabilities and material vulnerabilities, powerlessness and threats associated with poor quality housing were exacerbated by the pandemic, leading to emotional distress. The private-rented sector provides an important context for this study due to the limited power and control tenants have coupled with the long-standing nature of poor and precarious conditions within the private-rented sector which can adversely affect mental health. Crucially, our use of the PTMF allows us to understand mental health distress caused by the social conditions and material qualities of housing more generally.

Methods

Design

This paper presents data from a study that investigated lived experience of low-quality housing during the UK's first stay at home lockdown between March and July 2020. The study had three objectives: (1) document day-to-day lived experiences of lockdown for people living in poor quality accommodation in the private-rented and owner-occupied sectors; (2) identify coping strategies and associated issues and concerns of people living in those situations; (3) identify how poor quality accommodation had shaped people's experiences of lockdown.

Location

Whilst poor housing is a national problem in the UK, the situation is particularly acute in the north of England where around 354,000 private-rented properties fall below the Decent Homes Standard (The Smith institute, 2018). This is due to a concentration of pre-1914 properties characterised as older, colder and more damp than housing elsewhere. In this context, the study was carried out principally, but not exclusively, in the metropolitan counties of Greater Manchester and West Yorkshire. These locations were selected as we felt they broadly reflected housing across the north. Whilst our study focussed on these locations, the findings are relevant to other areas in the UK and across Europe known to also contain substandard housing.

Participants and data collection

We conducted semi-structured telephone interviews with 40 renters in the private-rented sector and 10 owner-occupiers, as well as 8 professionals in the charity and public sector who were responding to housing issues related to the pandemic. Although we interviewed owner-occupiers (initially recruited to provide a more holistic understanding) this paper draws exclusively on interviews with private renters due to the particularly severe issues that were discussed in the interviews. The interview schedule explored: background information, life under lockdown, housing quality issues, experiences of changing (and often worsening) housing quality during lockdown, relationships with landlords/specific issues for owner-occupiers, household income and support, and a summary of the main issues that had affected renters. Interview length varied between 16 and 65 min (average 32 min) and the interview was the main way in which we collected the qualitative data across the sample. Upon concluding the interview, renters were invited to take and submit photographs of the issues they had discussed. This provided an opportunity to communicate and document their experiences visually.

Recruitment and procedures

Participants were recruited through Home Improvement Agencies, local authorities, mutual aid groups and community and voluntary groups, as well as advertisements via social media. We also commissioned support of two external social research agencies to identify potential respondents and invite participation. It should also be noted ‘poor quality’ housing was self-defined by participants. However, the research team undertook screening checks to ensure issues fell within the domains of the Decent Homes Standard.

Analysis

Interviews were transcribed and coded thematically using NVivo in accordance with Braun and Clarke (2006). We designed a coding frame to increase the efficiency and effectiveness of thematic analysis; the coding frame contained pre-determined codes deduced from an initial reading of the transcripts, which then guided a discussion across the research team regarding the fit of these codes to the objectives and available literature. The coding frame was amended accordingly and then divided between each member who was responsible for coding each transcript relating to their allocated codes. A coding frame was developed in NVivo to enable the systematic coding and sorting of data. This allowed each team member to become familiar with each transcript and able to reflect across the transcripts to inform themes and patterns. Following this we amended the codes in respect of the PTMF. As a result the following themes were then generated from the data: (1) social and material stressors and threats associated with COVID-19 lockdown, (2) limited power to deal with stresses and threats; (3) anxiety and depression as a survival response to current stresses and threats; (4) coping strategies.

Ethical considerations

The study received full ethical approval by the University of Huddersfield. Participants were briefed on the research and gave informed consent in verbal form prior to each interview.

Findings

Most renters discussed the impact of their housing situation on their mental health, with few having experienced some mental ill-health prior to lockdown. Many renters felt mental ill-health had been created or exacerbated by the conditions and quality of their housing during lockdown, whilst several articulated these feelings as being new or something they had not previously experienced. This clear link between experiences of poor and/or precarious housing during lockdown and common mental health problems (predominately depression, low-mood, anxiety and worry) is consistent with the PTMF, which highlights the importance of social context, such as housing and poverty, and the importance of power (or in this case, powerlessness) in explaining emotional distress. This also fits with our characterisation of ongoing stresses associated with poor quality housing as ‘social and material vulnerabilities’, shown in Fig. 1 . Fig. 1 illustrates how these vulnerabilities combined with stressors and threats associated with the pandemic (theme 1) and limited power (theme 2), leading to the development and exacerbation of common mental health problems (theme 3). Fig. 1 also shows the coping strategies used by the renters we interviewed (theme 4). The themes are presented below and supported by excerpts from the data with the gender and age of participants to assist with greater contextualisation (see Fig. 3) (see Fig. 4) (see Fig. 2).

Fig. 1

A framework for understanding the increase in mental health problems during lockdown for people in low-quality housing.

Fig. 3

A sketch provided by one participant illustrating the limited living space in her city centre apartment.

Fig. 4

Example of area demarcated for work.

Fig. 2

An example of mould inside a living room.

Social and material stressors associated with COVID-19 and lockdown

The first theme interpreted from the interviews related to social stressors associated with living in poor quality housing and financial worries, as exacerbated by lockdown and the pandemic. It is important to note these stresses were often understandable and not irrational, and that the lockdown worked to amplify existing stresses because of relentless and intensified exposure to them. This theme is further elucidated by detailing five sub-ordinate themes.

Increased exposure to poor housing conditions

Renters described how poor housing conditions were impacting their mental health and suggested cold, damp, noise and limited space were key stressors. Many highlighted the experience of cold housing environments, and how they had been able to counteract this prior to lockdown by spending time outside their home, particularly during summer months. Working from home and home schooling within a cold domiciliary environment were also discussed, with participants describing these conditions as ‘upsetting’, ‘stressful’ and ‘painful’. In addition to the cold, and the financial constraints making it difficult for renters to counteract this, residents reported the physical and mental health impacts of living with damp and mould. The participants talked of ‘stress’, ‘emotional wellbeing’, ‘anxiety’ and ‘frustration’ associated with living in the constant presence of damp, being unable to leave the home and spend time elsewhere, with no prospect of the situation being addressed.

“Spending more time in the home is making me face that reality even more, because obviously for my own mental health and everything … I knew that some of these problems were there, but it's like anything else, you can gloss over problems in your head, you justify things in your own head … but because I'm literally spending hours and hours and hours in my own home, you notice every time you walk down the hallway to the kitchen, all the wallpaper bubbles off the wall where it's damp behind” (female, 44).

Renters also spoke of the impact of increased noise, predominantly from neighbours, specific to their housing situation, on their mental health, describing this in terms of ‘stress’, ‘anxiety’ and ‘‘wellbeing’.

“With the noise, it's disrupted our sleep and that can add to anxiety and not getting good sleep isn't good for your health in itself. That can cause stress, and I'd say it has done that” (male, 24).

Lack of space also impacted the participants' mental health, particularly where residents were living, working and home schooling children within the same small space. Renters spoke of ‘mentally struggling’, ‘being very stressed’, ‘being anxious’ and ‘not been able to regulate emotions’.

“It's just made me feel confined, made me feel very stressed, and anxious” (female, 49).

Increased financial concerns

The impact of increased financial pressure was one of the most common concerns discussed by renters. This included the day-to-day reality of the increased cost of living (heating, electricity, food) due to more time spent within the home; the fear/threat of unexpected costs that could no longer be covered due to reduced income and increased expenses; the uncertainty of not knowing when the situation will improve – as a result of the risk of redundancy, financial worries or landlords being unable/unwilling to address poor housing conditions, and feeling trapped within a situation that could not be improved due to limited finances. The very real concern regarding increase in living costs, and the impact that this had on ‘worry’, ‘fear’, ‘stress’ and ‘low mood’, was evident throughout the interviews. Renters spoke of increasing electricity, heating and food bills due to working from home and home schooling. This caused concern for almost all renters who discussed the associated impact on their mental health and wellbeing.

“… it was difficult due to being at home all the time and the heating having to be put on when it was a bit cooler, just using electricity more.” (female, 34).

Others spoke of the impact of reduced income – due to redundancies, furlough and the real difficulties of juggling rent and household bills with little or no income. Some renters had experienced leniency from landlords, utility companies and banks, but the majority expressed how these worries had negative impacts on mental health.

“I do think that my landlord could have been a bit less money-grabbing … there was no empathy or understanding, and I was lying awake at night worrying how I was going to pay my bills because I didn't have any income coming in until I got a new job” (female, 36).

Renters also discussed the impact of financial uncertainty and how this impacted their mental wellbeing, articulated in terms of ‘anxiety’, ‘stress’ and ‘insecurity’. ‘Uncertainty’ was linked to job security and the threat, or reality, of redundancy and income loss, as well as the insecurity of not knowing when lockdown and the restrictions placed on individuals and businesses would end.

Loneliness and isolation

A smaller number of renters also discussed the impact of lockdown, as experienced in poor housing conditions, created or exacerbated feeling of being alone, isolated and unable to draw on networks that might have provided support. Renters regularly used the terms ‘trapped’, ‘isolated’, ‘stuck’, ‘lonely’ and ‘the lack of seeing other people’ and this was discussed with reference to their housing situation, opposed to the more general feeling of isolation that many people felt throughout lockdown.

“Lockdown has been a very difficult time for everyone and when you're living in mould and damp and struggling with costs, that adds to everything and you can feel quite lonely with the situation” (female, 34).

Magnified sense of relentless and ongoing stresses

Renters spoke frequently of the negative impact of the relentless exposure to these poor housing conditions during lockdown, the inability to find respite and the constant reminder that the noise, cold, damp and limited space, was their lived reality. Renters spoke of this being ‘depressing’, ‘making me feel down’, ‘trapped’, ‘upsetting’ and ‘heightened stress’. Many spoke of having been aware, and to some extent, impacted, by their housing conditions prior to lockdown, but finding the relentless everyday presence much more stressful. This supports the view that the ongoing adverse housing conditions should be considered ‘social vulnerabilities’ to experiencing mental health problems, and that stressful life events, such as the pandemic and lockdown, combine with those social vulnerabilities can lead to threats and various emotional and behavioural consequences.

“I'd say probably lockdown has heightened the stress that I feel from this because all it is, I see it every day, every minute of every day, so it's probably heightened my stress for sure, and probably made me feel a lot worse than I would normally” (female, 22).

Reduced scope for positive behaviours and coping

Renters not only experienced an increase in stresses, but restrictions during the lockdowns and being confined to their home, with limited space, prevented them from accessing support and activities that were normally important to their mental health and wellbeing. Renters also described the inability to call on those support networks – be it friends, family or neighbours to help with their housing situation, and how this had impacted their mental wellbeing and led to feelings of isolation. In some cases, the support they missed was practical as well as emotional. They also reported an inability to use positive techniques that had improved their mental health prior to lockdown. It therefore also posed a threat to maintaining their wellbeing despite ongoing mental health problems.

“I've pretty much been confined to my house for four months. Which, for me, and the way I've learned to cope with the issues I have mentally is to not be stuck in the house, so not having a choice to just go out when I do wake up when I'm having those bad days, that's the way that it's really, really impacted me the most” (female, 21).

Limited power to deal with stresses and threats

The second theme to emerge was feelings of helplessness and the lack of control over their housing situation. This was rooted in an inability to get landlords to carry out required improvements and ‘not knowing’ when this uncertainty might end. Many renters expressed the view that landlords were using the lockdown restrictions as an excuse for not addressing improvements or repairs that were needed, and again, because this was, to some extent, a reality, renters felt helpless to control this situation. This is an example of the negative operation of power in the PTMF which contributes to mental health problems.

“I suffer from depression anyway, and I'm one of these people where if something's broken, or needs sorting, or whatever, it sort of stays on mind. I try to let it go - there's much more interesting and better things to worry about, and chill out with the family - but when it's frustrating you, impacting on your mind and wellbeing and feeling down about it, and you don't feel like you're getting any help from it, then yes, it has impacted me, definitely” (male, 43).

An additional impact of financial pressures described earlier was the feeling of being trapped in a situation that was out of their control, that they had no ability to change, be that increased costs, reduced income or the inability to secure improvements to their housing conditions.

Anxiety and depression as a response to current stresses and threats

When describing the impact of their housing conditions and situations, renters routinely used the term ‘anxiety’, whilst others spoke of ‘heightened stress’, ‘worry’, ‘fear’ and ‘panic’. A common demonstration of this anxiety related to what renters described as ‘disaster thinking’, and this often related to financial concerns that materialised during lockdown period. The term ‘depression’ was used by some renters whilst others referred to feeling ‘low’ or ‘down’. They also discussed familiar features of low mood and depression such as not having the energy to prepare food, having little interest in activities such as watching television or being with their family as well as lack of energy. Twelve renters reported they had experienced some form of mental ill-health prior to the onset of the lockdown. All reported that their conditions, anxiety and/or depression, had been made worse by their current living conditions. Reference to anxiety worsening over time was tied to financial worries and concerns, a lack of social support, and social isolation, whilst reference to an exacerbation of depression was framed around the lack of control or power to improve their situation.

“Personally, it’s made my existing anxiety a lot worse and added a lot of stress because of financial hardship and the uncertainty of work moving forward” (male, 24).

Coping strategies

Whilst the participants reported that living in poor housing conditions had contributed to existing and not previously experienced depression and anxiety, renters showed that despite limited ability to change their situation they had developed a range of ‘coping strategies’. Within this super-ordinate theme there were four sub-ordinate themes, namely: spatial, psychological, social and taking control.

Spatial strategies

Renters described various approaches to altering limited housing space. This was viewed as a way of improving their housing situation and therefore minimising the impact on their mental health. A common response was the alteration of layout to their space to ensure that was some form of demarcation between work, school and the ‘home’ activities such as relaxing, sleeping, or playing. Renters highlighted the difficulties of trying to focus on their work whilst children were watching TV/playing, or sharing space with their partner, who may also be trying to work.

“I've now got it where I'll work in one room but then I'll spend my leisure time in another room, which is a good way of separating it. Then I can go into another room to exercise and keep fit. I've tried to just build our world so we get a little bit more of what we need from within our space” (male, 29).

In addition to using spatial strategies to help create a demarcation between work and home life, renters also altered the layout of their accommodation to reduce noise and to help improve sleep, particularly where they had children. Spending all day in their place of residence often exacerbated, or highlighted for the first time, issues related to noise from neighbours, for example, from music or differing work patterns.

“We’ve actually moved our two-year-old downstairs into the living room and one of us will sleep on the sofa just because obviously he's [neighbour] playing music in his bedroom, and his bedroom is next to our bedroom” (female, 21).

Social strategies

Whilst the national lockdown prohibited social activities and the ability to mix with people outside the householder (an approach many renters had taken to coping with poor housing conditions prior to the pandemic), the participants described new approaches to achieving social contact within the boundaries of their home. This included conversing with neighbours over the garden fences, swapping home grown or baked produce and/or assisting with shopping or other external trips. Several participants reported these new forms of ‘social’ contact helped with coping with the negative impacts of the housing situation they were living in.

Psychological strategies

Renters also talked of using psychological techniques as a coping strategy. This included grounding themselves – often using nature, as well as techniques such as meditation.

“Definitely meditation, being closer to nature because I am really grateful for the big garden that I've got” (female, 36).

Taking control

Despite the powerlessness of renters, there was an acceptance that a landlord's inability or unwillingness to rectify problems could be bypassed by either rectifying housing problems themselves or paying for somebody else to fix the problem.

“We've actually done things in the house without the permission of the landlord as well, just because we're willing to take that risk that we're making improvements to the house” (male, 38).

This, of course, presumes that the participant is in a financial position to be able to pay somebody (on top of their rent) to fix the problem. In many cases, renters opted to make some attempt to temporarily remedy the problem, despite knowing this would not address the issue in the long term.

“I'm in my home, I'm trying to fix some of the problems myself, but again, I can't afford to actually fix the problems, so all I'm actually doing is putting a band-aid on them” (female, 44).

Discussion

This paper contributes to literature on the relationship between place of residence and mental (ill)health (Wolch and Philo, 2000; Corburn, 2009; Marquez et al., 2019; Piat et al., 2017). Similar to how the social crisis brought on by the COVID-19 pandemic can be seen as the confluence of an external shock with pre-existing structural inequalities (Byrne and Sassi, 2022; see also Haase, 2020), we found the mental ill-health of our participants was the result of already poor quality or precarious housing that predated the pandemic. The literature on the mental health impacts of poor quality and precarious housing for renters during COVID-19 contains evidence about the impact of containment in cold, damp and cramped conditions, concerns about raising maintenance issues with landlords (for fear of rent reprisals or revenge evictions), uncertainty about the future and/or a general lack of awareness about their rights and available support (Horne et al., 2021; Byrne and Sassi, 2022; Waldron, 2022). This in turn resulted in households enduring poor housing conditions which affected mental health and wellbeing, with the vulnerabilities of these conditions and situations creating emotional distress that led to experiences of common mental health problems including anxiety and low mood/depression. With particular emphasis on the subjective dimensions of precarious and poor quality housing, we argue our renters experienced housing as a social and material vulnerability that contributed to their mental ill-health.

An overarching finding was how these processes were underpinned by powerlessness and limited control. Similar to Lupton and Lewis (2022), it was striking how restricted engagement in activities that could ordinarily produce a sense of enjoyment and achievement (such as socialising and exercising) restricted options for positive coping activities. Whereas Lupton and Lewis (2022) found some of their participants could balance the mental health impacts of restrictions by developing new coping strategies including animals at home and building relationship though social media, we found restrictions further increased the stress of our participants by creating more time in residential places preoccupied with worries. Whilst some were able to develop positive coping strategies, the overall limited control participants felt they had over their environments compounded their feeling of powerlessness. This finding about the mental health impacts of limited control of the housing environments is widely echoed in the literature on tenant's experiences of ‘home’ (Bate, 2018; Soaita and McKee, 2019; Chisholm et al., 2020; Author 5 et al., 2022). At a broader level, it is also consistent with evidence that perceived control mediates the effects of inequalities on self-rated health (Bobak et al., 2000), and that low control increases the risk of developing depression and anxiety (Griffin et al., 2002).

The PTMF (Johnstone et al., 2018) provides a useful framework for understanding these findings by highlighting the importance of powerlessness and lack of control in understanding the mental health impacts of living in poor quality and precarious housing during lockdown. We have shown how these feelings were heightened by the experience of lockdown, and this emphasises the importance of seeing the emotional responses of anxiety and depression as understandable given the situations and environments people find themselves in. This adds weight to the argument that anxiety and depression should be seen as such rather than something being ‘wrong’ with the person (Harper and Cromby, 2020; Johnstone et al., 2018). In explaining the development of emotional distress for the occupants of poor and precarious housing, we highlight the limitations of the Stress Vulnerability Model (Zubin and Spring 1977) and medical model, which sees feelings, thoughts and behaviours associated with anxiety and depression as symptoms of a disorder. Acknowledging the importance of ‘social and material vulnerability’ provides a more holistic view of mental health vulnerability that is consistent with the bio-psycho-social framework (Engel, 1977). For example, psychological vulnerabilities to depression in the cognitive behavioural model include unhelpful beliefs about the self, world and future (Beck et al., 1987), and this study identifies examples of social and material vulnerabilities as also linked to mental health problems. Our findings suggest this could be considered to include ongoing environmental factors such as poor housing as well as other social inequalities which are known to increase the likelihood of mental and physical ill-health (Marmot, 2010). We feel that applying the PTMF framework offers a new way for housing, public health scholars and environmental psychologists to understand the lived experience of poor and precarious housing within and beyond the COVID-19 pandemic, ahead of developing collaborations to act on housing-driven mental health problems.

This paper provides a unique contribution by using the PTMF to understand how threats associated with these conditions became exacerbated by lockdown, coupled with a sense of powerless, which in turn created and exacerbated the mental ill-health of renters.

Practicalities and usefulness

The treatment of mental ill-health now predominately takes place in community settings, with recognition of the importance of housing within the recovery process (Fields 2011; Piat et al., 2017). The COVID-19 pandemic has brought into sharp focus the importance of housing as a physical place from which to shelter. However, with increased time spent indoors, the pandemic has simultaneously exacerbated mental-ill health associated with housing environments, particularly private-rented housing known to lack decent standards and security of tenure (Rugg and Rhodes, 2018) Within this context, the paper argues for a greater focus on viewing provision and quality of housing as integral to the work of mental health practitioners, as well as the amplification of housing policy which seeks to tackle mental ill-health in general populations.

The findings of the paper demonstrate the importance of mental health practitioners becoming actively engaged in national debates on housing and housing equity in order to ensure place of residence is part of an preventative health and wellbeing system. Whilst the UK Government's recent commitment to the Renters Reform Bill and the implementation of the Decent Home Standard in the private-rented sector is welcomed (UK Government, 2022), continued inaction around reforming renters' rights with a mental health emphasis will add to the burden on the increasingly stretched National Health Service, as people present with acute mental health conditions more damaging, harder and expensive to treat.

The economic cost to the UK economy of mental ill-health in the north of England was recently estimated to be £2 billion (Bambra et al., 2022), whilst in mainland Europe the estimated cost of people living within inadequate housing was €194 billion per annum (Nicol et al., 2016; Eurofound, 2016). As the cost of living crisis accelerates the implications, financial and human, will likely be even more acute. Within this context, it is clear those working in mental health practice, together with other health practitioners, should engage with the issues raised in this paper as part of preventative care. Whilst there are examples of strong working practices between housing and health at a variety of levels, these are not yet systemically embedded and instead operate mainly in intervening in the consequences of poor housing or of a dysfunctional housing system (e.g. homelessness, fuel poverty, physical adaptations or hoarding).

This paper adds to the call that strategic health practitioners have an equal, direct and critical role to play in the design of policies and the development of future housing systems more broadly. As an example, in contrast to social housing in the UK, which tends to provide a higher quality of housing with more secure tenure, private-rented housing continues to expand as a sector. This paper reminds us that tenure matters for health outcomes. Whilst the paper did not draw on comparisons of peoples’ experience of the pandemic between tenure it is clear that increased risk of insecurity of poor conditions have a direct impact on health and wellbeing. As well as regulating the private-rented sector, the evidence in this paper point towards the damage done to public health by the public sector austerity in the UK, housing financialisation and the inability for public authorities to invest in new social housing at scale as part of a transformative approach to preventative care.

Conclusion

This paper has explored private renters’ experiences of COVID-19 lockdown in the north of England. Overall, the paper has shown the social and material vulnerabilities associated with poor quality and precarious conditions which, underpinned by powerlessness, resulted in threats that contributed to and exacerbated the mental-ill health of renters at a time of broader structural fragility. Drawing together, our paper calls for urgent reform of private-rented housing systems and for health practitioners to become involved in these process.

Limitations of this research

In order to access participants, we sought to undertake the work in areas where the study team had existing strong links which may have led to some selection bias. Furthermore, whilst the study is focussed on a study area with a high prevalence of poor housing in the private-rented sector, we are aware that there may be different challenges faced in both social and owner-occupied sectors. As a result, the study context may provide some degree of limitation in terms of wider applicability.

Uncited References

Chimed‐ Ochir et al., 2021, Cresswell, 2005, Department for Communities and Local Government, 2006, Jones and Moon, 1987