Helped into Harm: Mediation of a Housing Voucher Intervention on Mental Health and Substance Use in Boys

Abstract

Background: Interventions can have harmful effects among subgroups they intend to help. The Moving To Opportunity experiment, in which families were randomized to receive a Section 8 housing voucher, was one example. Voucher receipt generally resulted in better long-term mental health and lower substance use and risk behavior outcomes among adolescent girls, but resulted in worse outcomes among adolescent boys. Reasons for this discrepancy and the unintended harmful health effects for boys are unclear. We used mediation analysis to estimate processes through which voucher receipt was hypothesized to affect adolescent mental health and substance use.

Methods: We used longitudinal data (10-15 years) on boys enrolled in Moving To Opportunity. We estimated interventional (also known as stochastic) indirect effects of voucher receipt on mental health and substance use outcomes through mediators capturing aspects of the school environment, neighborhood poverty, and instability of the social environment. We also estimated interventional direct effects not operating through these mediators. We used a robust, efficient, nonparametric substitution estimator in the targeted minimum loss-based framework.

Results: Housing voucher receipt increased long-term risk of any diagnostic statistical manual disorder, any mood disorder, any externalizing disorder, and cigarette smoking among boys. The majority (between 69% and 90%) of the total negative long-term effects could be explained by indirect effects through the mediators considered.

Conclusions: This evidence suggests that, even though the intervention had the desired effects on neighborhood poverty and the school environment, these "positives" ultimately negatively impacted the long-term mental health and behaviors of boys.