Stable Housing Research Articles

Housing Instability Screening and Referral Programs: A Scoping Review

Housing instability in the United States is a critical social determinant of health, influencing health outcomes and health care utilization. This scoping review aimed to analyze literature on US health system screening and response programs addressing housing instability, highlighting methodologies, geographic and demographic variations, and policy implications. Adhering to PRISMA-ScR guidelines, the review included studies focusing on US health systems that screen and refer for housing instability. Major scholarly databases, including PubMed and Scopus, were queried. Screening and response program characteristics, methodologies, and outcomes were characterized. Thirty studies published between 2003 and 2023 were included in this study. Included studies were primarily cross-sectional (26.7%) or quality improvement (20.0%), among 9 other designs. Screening programs were predominantly implemented in academic hospital systems (46.7%) and in the Northeast (63.3%). Of the 25 adult population studies, 68.0% were in outpatient settings, and of the 23 studies providing detailed information on their process, 52.2% used electronic health record entry. Of the 22 studies that describe their screening tool, 15 used institution-specific tools, and only 4 of the remaining 7 studies used identical tools. Of the 20 studies that described their response to positive screenings, 13 provided patients with a paper or electronic referral to a collaborating community partner, while only 6 aided the patient in connecting with community resources. This study found significant variability in screening and response programs for housing instability among US health care providers. A lack of standardized definitions and methodologies hampers effective comparison and implementation of these programs. Future research should focus on standardizing screening methods and measurement of interventions and outcomes to address housing instability.

The Effects of the 2021 Child Tax Credit on Housing Affordability and the Living Arrangements of Families With Low Incomes

Access to safe and stable housing is important for child and adult well-being. Yet many low-income households face severe challenges in maintaining stable housing. In this article, we examine the impact of the 2021 temporary expansion to the Child Tax Credit (CTC) on housing affordability and the living arrangements of families with low incomes. We employ a parameterized difference-in-differences method and leverage national data from a sample of parents who are receiving or recently received Supplemental Nutrition Assistance Program benefits (N = ∼20,500), many of whom became newly eligible for the CTC. We find that the monthly CTC reduced parents’ past-due rent/mortgages (both amounts and incidence) and their reports of potential moves due to difficulties affording rent/mortgages. The CTC increased the likelihood that parents reported a change in their living arrangements and reduced their household size, both effects driven by fewer mothers living with a partner (and not a reduction in doubling up). We find some differences in effects by race and ethnicity and earnings. Our findings illustrate that the monthly credit improved low-income parents’ ability to afford housing, gain residential independence from partners, and reduce the number of people residing in their household.

Health at Home: Investigating Low-Income Housing Quality on Colfax Avenue

Abstract: Addressing housing insecurity contributes to health care programs as stable housing has positive health benefits. Home environmental hazards may reduce these potential health benefits and could increase morbidity for conditions such as asthma. This study examined housing and indoor air quality among urban low-income households in Colorado to inform housing-insecurity interventions. We conducted a community-engaged study among residents of motels, mobile homes, apartments, and single-family homes that included a survey on the home environment, health, and sociodemographic factors, spirometry, and indoor air quality measurement. We enrolled 60 households: 50% single-family homes, 37% apartments, and 13% residential motels. Perceived stress and depression were higher among motel residents compared with other housing types. We did not find differences in lung function by housing type. Indoor fine particulate matter (PM2.5) and black carbon concentrations were higher in motels than in other housing types. The differential health impacts of housing type support housing programs that jointly address security and quality.

Positive Associations between Women’s Employment at the Community-Level and Opportunities and Interpersonal Sharing within Recovery Homes

The background of this study was an investigation of a sustainability issue involving how to deal with increasing deaths due to substance use as well as housing instability among those with substance use problems. Our study investigated the relationship between community-level women’s employment and two key variables within Oxford House recovery homes: levels of employment and the sharing of resources among residents. These variables are crucial for the sustainability of recovery homes as they contribute to maintaining an ecological balance in communities. For our methods, we gathered data from recovery homes located in three different regions of the United States. The focus was on examining how women’s employment rates in these communities correlate with the employment statuses of house residents and their resource-sharing behaviors. Regarding the results, we found a positive association between rates of employment among women in these communities and employment within the recovery housesand resource lending among residents. We conclude that women’s employment at the community-level appears to be a significant macro-level factor that promotes supportive social and environmental policies. These community-level policies enhance employment opportunities and encourage interpersonal sharing within recovery homes, contributing to ecological balance and sustainability in terms of environmental, economic, and social dimensions.

The Intersections and Invisibilities of Rurality, Houselessness, and Health

The purpose of the qualitative research study was to identify factors and challenges that led to insecure housing among rural residents in Manitoba, Canada. Using a case study approach, five participants and two key informants were interviewed. When the participants were asked about personal factors and challenges affecting housing insecurity in rural Manitoba, their responses were focused on past and current health issues. Health, including acute and chronic conditions, became the critical intersection of housing insecurity and rurality. Systemic barriers such as invisibility, stigma, and lack of access to healthcare services in the rural setting created additional challenges for participants who required assistance and support to obtain and maintain stable housing. Integration of and collaboration among health, housing, and social service providers and informal supports in the rural community are required to address housing insecurity. Rural communities tend to be unique, therefore, strategies and interventions to diminish or prevent houselessness need to be flexible, targeted, and community-specific.

Strategic planning and investment analysis for affordable housing: Enhancing viability and growth

Strategic planning and investment analysis are critical to enhancing the viability and growth of affordable housing projects. As urban populations rise and housing affordability challenges persist, effective strategies are needed to ensure that affordable housing developments are both financially viable and scalable. This paper explores key aspects of strategic planning and investment analysis in the context of affordable housing, emphasizing their role in fostering sustainable growth and maximizing impact. Strategic planning involves setting clear objectives, identifying key success factors, and developing actionable plans to achieve desired outcomes. In affordable housing, this includes assessing local housing needs, understanding market dynamics, and aligning development goals with community priorities. Effective strategic planning ensures that housing projects are responsive to the needs of low- and moderate-income populations while addressing broader urban development goals. Investment analysis plays a crucial role in determining the financial feasibility and sustainability of affordable housing projects. This includes evaluating funding sources, estimating costs, and projecting financial returns. Key components of investment analysis include financial modeling, risk assessment, and scenario planning. By employing robust analytical tools, stakeholders can identify potential financial challenges and opportunities, optimize resource allocation, and ensure that projects are financially sound. Case studies from various regions highlight successful strategic planning and investment practices. For instance, the Low-Income Housing Tax Credit (LIHTC) program in the United States has demonstrated how targeted investment incentives can stimulate the development of affordable housing while achieving financial and social returns. Similarly, initiatives in European countries have illustrated the importance of integrating strategic planning with innovative financing mechanisms to address housing shortages. Despite these successes, challenges remain, including securing adequate funding, navigating regulatory environments, and managing project risks. Addressing these challenges requires a collaborative approach involving government agencies, private investors, and community organizations. By leveraging strategic planning and investment analysis, stakeholders can enhance the viability and growth of affordable housing projects, ultimately contributing to more sustainable and inclusive urban development. In conclusion, strategic planning and investment analysis are essential for advancing affordable housing initiatives. They enable stakeholders to navigate complex financial landscapes, mitigate risks, and achieve long-term goals, fostering the growth of affordable housing and improving housing stability for underserved populations.

Foreclosure, memory decline, and dementia probability: A longitudinal cohort study.

Housing insecurity is rising among older adults; health researchers know little about how this may impact their cognitive health. We investigated links between foreclosure and older adults' memory and probability of dementia. Using the Health and Retirement Study (2008 to 2018), we fit mixed models comparing the memory and dementia probability scores of 249 older adults who experienced foreclosure (treated) with 15,645 who did not. Baseline covariates included sociodemographics, health, and cognition. Models were stratified by age group. Foreclosure was associated with faster memory decline among middle-aged (50 to 64) older adults (-0.007 standard deviations/year, 95% confidence interval: -0.13, -0.001). Compared to average memory decline among middle-aged older adults who were stably housed, foreclosure equated to 3.7 additional years of aging over 10 years. Among those 65+, differences between those who were and were not foreclosed upon were short-lived and less clear, potentially driven by depletion-of-susceptibles bias. Foreclosure may endanger older adults' memory. Housing instability is a key determinant of cognitive aging. We examined foreclosure and levels and changes in memory and dementia probability scores in the US older adult population. Foreclosure was associated with faster memory decline among middle-aged (50 to 64) older adults, equivalent to 3.7 additional years of cognitive aging over 10 years. Foreclosure yielded sharp memory declines and increases in dementia probability among older adults 65 and above. Foreclosure imposes a greater risk for older adults' cognitive decline.

Assessing anxiety and depression trajectories among single homeless adults receiving rapid rehousing following placement in housing

Despite growing international interest in using rapid rehousing (RRH) to address homelessness, there is little information about the mental health outcomes of RRH participants. We examined changes in anxiety and depression symptoms over time following placement in housing among a cohort of 98 single homeless adults receiving RRH services from a major city in the United States. We also assessed the extent to which sociodemographic characteristics, and factors related to RRH participants’ ability to maintain independent housing, were associated with the trajectory of change in anxiety and depression symptoms. We found statistically significant linear decreases in both anxiety and depression symptoms. Factors identified as having the strongest association with changes in anxiety and depression symptoms over time included age, race, monthly income, having a poor credit history as a barrier to housing and reporting that a mental health problem made it difficult to live on one’s own. Our findings suggest that the benefits of RRH may extend beyond improved housing stability and point to the need for additional and more rigorous research to test the impact of RRH on mental health outcomes.

Harm reduction nursing and the path toward developing best practice: Lessons from caring for people with xylazine-associated wounds in Philadelphia, PA

Xylazine-associated wounds are a distinct, novel clinical entity characterized by co-occurrence with substance use, progressive necrosis of skin, muscle, tendon, and bone, and slow healing. In Philadelphia, the specter of limb loss, stigma, and shame has hung over hospital-based care for xylazine-associated wounds among people who use drugs (PWUD) and kept many people away from engaging in care. Continued engagement in harm reduction wound care nursing, however, offers an opportunity for PWUD to address their wounds and their fears with members of the medical world. In the absence of established best practices, harm reduction’s model of risk-reductive care offers a way forward for patients and practitioners alike. Here, “harm reduction” describes an ethic of practical, trauma-informed, patient-centered care. It is this integration of harm reduction into medicine and public health that effectively promotes the safety, survival, and recovery of PWUD across all spectrums of drug use habits and housing stability.

Predictors of recurrent stroke and subsequent mortality among patients experiencing housing instability

BackgroundThe experience of homelessness has been linked with developing poor health outcomes. Little is known about the risk of recurrent stroke among these individuals. This study investigated the correlates of developing recurrent stroke and subsequent mortality among Veterans with housing instability. MethodsUsing a national sample of Veterans from the U.S. Department of Veterans Affairs who had an indicator of housing instability between 2014–2018 (n=659,987), we identified 15,566 Veterans who experienced incident stroke. We compared characteristics of Veterans who experienced incident stroke and did and did not experience recurrent stroke and conducted logistic regressions using a discrete-time survival framework to assess two outcomes: recurrent stroke and all-cause mortality. ResultsAmong our cohort, 91.3% did not experience recurrent stroke while 8.7% did during the observation period. The receipt of any level of primary care outpatient visits was associated with a reduction in the odds of recurrent stroke. Several medical diagnoses were also associated with increased odds of recurrent stroke, including hypertension (aOR 1.35, 95% CI 1.15-1.59), diabetes (aOR 1.21, 95% CI 1.07-1.36), and renal disease (aOR 1.17, 95% CI 1.02, 1.35). Veterans who used any level of VA Homeless Programs had reduced odds of all-cause mortality (high level: aOR 0.65, 95% CI 0.60-0.71; low level: aOR 0.66, 95% CI 0.60-0.73). ConclusionOur study found several predictors of developing recurrent stroke and subsequent death in a population of Veterans experiencing housing instability. Implications include the need to monitor closely high-risk patients who have experienced incident stroke and have other co-occurring needs.

A thematic analysis of perceptions of VHA emergency care and suicide risk assessment among Veterans experiencing homelessness

ABSTRACT Introduction: Veterans who are homeless are at elevated risk for suicide, and often access Veterans Health Administration (VHA) emergency services to address their health needs. We sought to explore experiences of homeless Veterans utilizing these services, and barriers and facilitators to suicide prevention engagement. Methods: Semi-structured interviews with 25 Veterans who self-reported past 12-month history of homelessness and accessed VHA emergency services. Interviews explored perceptions of VHA emergency care and suicide risk assessment. Results: Interviewees described a complex array of factors contributing to housing instability. Participants detailed challenges navigating interrelated, yet at times disconnected, systems of healthcare and homeless services. Veterans’ experiences receiving care and suicide risk screening in VHA emergency services were generally positive. However, some described rare, striking experiences, feeling stigmatized for “being homeless”. Services following discharge tended to be fragmented. Given numerous contextual factors (e.g. transportation difficulties, timeliness of referrals) complicated by homelessness, individuals tended to routinely rely upon VHA emergency service for future acute care needs. Conclusions: Overall, perceptions of emergency services, including suicide risk screening in this setting, were largely positive and deemed acceptable. However, findings illustrate multiple avenues for optimizing service delivery, including post-discharge services, among homeless Veterans accessing VHA emergency services.

Economic and social impact of affordable housing policies: A comparative review

Affordable housing policies play a pivotal role in shaping the economic and social landscapes of nations, especially in the context of growing urbanization and income inequality. This comparative review examines the economic and social impacts of various affordable housing policies across different countries, providing a comprehensive analysis of their effectiveness and broader implications. Economic impacts of affordable housing policies are multifaceted, influencing job creation, economic growth, and household stability. By increasing the supply of affordable housing, these policies can stimulate construction and related industries, leading to significant job creation and economic activity. Affordable housing also enhances household stability by reducing housing costs, allowing for greater disposable income and increased consumer spending. This review explores how policies such as tax incentives, subsidies, and inclusionary zoning have been utilized to promote affordable housing development and their resultant economic benefits. Social impacts of affordable housing policies are equally significant, affecting community cohesion, health outcomes, and educational attainment. Stable and affordable housing contributes to improved mental and physical health by reducing stress and exposure to poor living conditions. Furthermore, it enhances educational outcomes for children by providing a stable home environment conducive to learning. This review discusses policies such as rent control, public housing initiatives, and housing vouchers, highlighting their role in fostering social inclusion and reducing disparities. Case studies from diverse regions, including the United States, Singapore, and Brazil, illustrate the varied approaches and outcomes of affordable housing policies. In the United States, the Low-Income Housing Tax Credit (LIHTC) program has been instrumental in increasing affordable housing supply and promoting economic development in underserved areas. Singapore's Housing and Development Board (HDB) has successfully provided high-quality, affordable housing to a majority of its population, significantly enhancing social stability. Brazil's Minha Casa Minha Vida program showcases how large-scale public housing initiatives can address housing deficits and improve living standards for low-income families. The review concludes that while affordable housing policies have distinct economic and social impacts, their success largely depends on contextual factors such as policy design, implementation strategies, and local economic conditions. Policymakers must consider these factors to create effective and sustainable housing solutions that promote both economic prosperity and social well-being. Keywords: Economic, Social: Impact, Affordable Housing, Policies.

Epidemiology and association of neighbourhood marginalisation on violent knife assaults in Ontario: a population-based case-control study

BackgroundViolent knife assaults (‘stabbings’) are underappreciated as a source of morbidity and mortality. The two objectives of this study were to describe the epidemiology of stabbing injuries in the population...

“I May Lose My Home, but I Won’t Lose Myself”: Assessing the Needs of Translatinas Experiencing Housing Instability in San Francisco and Elevating Their Visions for Change Through Participatory Research

“I May Lose My Home, but I Won’t Lose Myself”: Assessing the Needs of Translatinas Experiencing Housing Instability in San Francisco and Elevating Their Visions for Change Through Participatory Research

Barriers to initial COVID-19 booster among U.S. adults who completed a primary vaccine series in the CHASING COVID cohort, September 2021 - October 2022.

It is crucial to understand factors associated with COVID-19 booster uptake in the U.S. given the updated COVID-19 vaccine recommendations. Using data from a national prospective cohort (N=4,616) between September 2021-October 2022, we examined socioeconomic, demographic, and behavioral factors of initial booster uptake among participants fully-vaccinated with the primary COVID-19 vaccines series. Cox proportional hazards models were used to estimate the associations of each factor with time to initial booster uptake. Most participants (86.5%) reported receiving their initial booster. After adjusting for age, race/ethnicity, education, region, and employment, participants with greater risk for severe COVID-19 had similar booster uptake compared with those with lower risk (aHR: 1.04; 95% CI: 0.95, 1.14). Participants with greater barriers to healthcare (aHR: 0.89; 95% CI: 0.84, 0.96), food insecurity (aHR: 0.82; 95% CI: 0.75, 0.89), and housing instability (aHR: 0.81; 95% CI: 0.73, 0.90) were less likely to report receiving initial booster compared with those without those barriers. Factors motivating the decision to vaccinate changed from safety-related concerns for the primary series to perceived need for the booster. It is key to address economic and health access barriers to achieve equitable COVID-19 vaccine uptake and continued protection against COVID-19.

Transactional Sex, HIV, and Bacterial STIs Among U.S. Men Who have Sex with Men

Men who have sex with men (MSM) and are engaged in transactional sex (MSM-TS) experience complex social and structural vulnerabilities that increase their HIV risk. This study aimed to estimate the prevalence of TS and associations between TS and sexually transmitted infection (STI) outcomes among cisgender MSM in the U.S. Using 2017-2021 data from an online survey of U.S. MSM, characteristics of MSM-TS were summarized, and adjusted prevalence ratios (aPRs) calculated for the associations between past-year TS and bacterial STI diagnosis, HIV status, and either antiretroviral or pre-exposure prophylaxis use. Analyses were conducted in 2023. TS prevalence was 3.7% (n=1,848/49,539). Compared to other MSM, MSM-TS more commonly reported homelessness, being uninsured, condomless anal sex with partners of any HIV status and condomless anal sex with serodifferent partners, and illicit drug use. TS was associated with increased HIV (aPR 1.44, 95% CI 1.25-1.66) and bacterial STI prevalence (aPR 2.40, 95% CI=2.09-2.52) and lower antiretroviral therapy use (among MSM living with HIV; PR 0.92, 95% CI=0.87-0.97). Structural and behavioral risks converged among U.S. MSM engaging in TS leading to greater HIV and bacterial STI prevalence in this group. HIV interventions for U.S. MSM-TS should address individual as well as structural risks, including poverty and housing instability.

Suicide prevention providers' perspectives on addressing social determinants of health for at-risk Veterans

ObjectiveSuicide prevention is a top clinical priority within the Department of Veterans Affairs (VA). While research consistently shows that suicide risk is associated with adverse social determinants of health (SDH, e.g., housing instability, unemployment, justice involvement), less is known about the extent to which suicide prevention staff are aware of and able to address these risk factors. This study aimed to understand the experiences of VA Suicide Prevention Coordinators (SPCs) with referring Veterans at risk of suicide to services that address SDH. MethodIn January–February 2022, 171 VA SPCs completed a questionnaire about their experiences connecting Veterans with SDH-focused services. Descriptive statistics summarized closed-response items and a thematic analysis was conducted for open-ended responses. ResultsThe majority of SPCs agreed that adverse SDH contribute to suicide risk and that services to address SDH could reduce suicide risk for Veterans. While most SPCs were aware of on-site SDH services, many reported barriers to connecting Veterans with those services including insufficient resources, lack of staff time, and eligibility criteria. ConclusionChanges at the organizational and policy levels are needed to provide comprehensive suicide prevention services that connect at-risk Veteran with services to address adverse SDH.

Screening rates for hepatitis B and C among low-income US veterans: Data from the National Veteran Homeless and Other Poverty Experiences Study.

Screening for viral hepatitis is considered a high-priority area in the Veterans Health Administration (VHA). Yet, few studies have examined viral hepatitis screening test use among low-income veterans who are considered high-risk with limited healthcare access. Using cross-sectional data from 933 participants in the 2021-2022 National Veteran Homeless and Other Poverty Experiences (NV-HOPE) study, we examined rates and correlates of lifetime screening for hepatitis B (HBV) and hepatitis C (HCV) infections. Multivariable logistic regression models evaluated characteristics associated with HBV/HCV screening. Nearly 16% and 21% reported lifetime HBV and HCV screening, respectively. These rates are considerably lower than HBV (47.3%) and HCV (92.9%) screening rates documented among contemporaneous veterans in VHA electronic health records. In the NV-HOPE data, veterans 50-79 years were more likely than those ≥80 years of age to ever-screen for HBV/HCV. Whereas, household income was inversely related to lifetime screening behaviours, veterans reporting 'other' employment types (vs. full-time/part-time employment) were more likely to ever-screen for HBV/HCV. Ever-screening for HBV was more likely among veterans reporting non-Hispanic 'other' (vs. non-Hispanic 'white') race, housing instability, Medicaid insurance, as well as drug use and cognitive disorder histories. Living with ≥5 members (vs. alone), histories of alcohol use, cancer, and liver disorders were also correlated with ever-screening for HCV. HIV/AIDS history correlated with ever-screening for HBV/HCV. In conclusion, fewer than one-third of low-income US veterans ever-screened for HBV/HCV, with lower screening rates among those less likely to be exposed to viral hepatitis, thereby informing interventions aimed at promoting available screening, treatment and vaccinations for HBV/HCV.

Medical-Legal Partnerships: a promising approach for addressing health-harming legal needs among people with HIV.

People with HIV (PWH), particularly those at the intersection of sexual and gender identities, face enduring obstacles to accessing HIV care, including structural stigma, structural racism and discrimination, housing instability, and limited access to health insurance. To address these challenges, Medical-Legal Partnerships (MLPs) in HIV care offer an innovative approach that integrates medical and legal services. By targeting health-harming legal needs (HHLN), MLPs aim to enhance the HIV care continuum outcomes for PWH. This study examines the benefits and challenges of MLPs within organizations serving PWH through the social-ecological model. MLP providers (n=111) identified organizational-level challenges such as funding limitations, resource integration issues, and staffing constraints. MLPs demonstrated numerous benefits, including patient impact and benefits, comprehensive service provision, enhanced staff support and capacity, and potential for policy influence. These results underscore the feasibility of MLPs while offering valuable insights into their efficacy and challenges, guiding the implementation of MLPs to address health-harming legal needs, including discrimination, and thereby improving HIV care outcomes.

O-243 Promoting family building strategies - a global call to action

Promoting family building strategies - a global call to action Study question Are there any strategies that can be improved or implemented to promote family building and slow down the global decline in fertility rates? Summary answer Fertility rates are dangerously decreasing worldwide, therefore current strategies need to be improved and new ones should be developed to face present-day challenges. What is known already Although to different extent, almost half of the countries in the world are below replacement level due to generalized fertility decline. Through the years, many of them have put in place policies to promote natality, with variable results depending on the kind of strategy adopted, on socio-cultural factors and on other local peculiarities. Most commonly used policies include prevention and education, plans aimed at allowing couples to have children (ensuring work stability, financial stability, housing stability), benefits and incentives for families and implementation of childcare services and facilities. Assisted Reproduction Techniques (ART) have also been considered a potential tool to boost fertility rates. Main results and role of chance Quite surprisingly, however, even countries who have been adopting high-quality family-friendly policies are experiencing a decline in fertility rates (e.g. Finland) and strategies that have been effective in the past century may be even counterproductive nowadays. In fact, cultural, psychological, biological and cognitive factors should also be taken into consideration (alongside social and economical ones) and it should not be forgotten that attitude towards having children is not stable and may be subject to sudden, unpredictable changes (e.g. war in Ukraine and Middle East). With specific reference to ART, it has been undergoing tremendous scientific and technical development in the last few decades, fueling the unrealistic expectation that it might solve all fertility problems and allow people to have children at any age. Actually, however, ART success rates are relatively low, especially in specific categories of patients. On the other hand, costs of these treatments are particularly high, which also affect accessibility for some of the patients in need. Financial, physical and emotional toll even of a single ART cycle can be burdensome for most couples, who tend to give up after a couple failed attempts. However, data in literature show that in specific categories of patients, repetition of up to 5-6 cycle can importantly increase success rates. Based on this assumption, the scientific community worldwide should start considering an ART treatment not as a single cycle, but a succession of more cycles, as deemed appropriate based on the patients’ characteristics. Number of cycles offered, planning and pricing should of course be adjusted accordingly. This paradigm shift might be difficult to instill in both professionals’ and patients’ minds, but it might turn out to be tremendously useful for ones as well as the others. Limitation, reasons for caution Although a global intervention in favour of family building is required, individual countries should design multidisciplinary strategies taking into account local and regional peculiarities. The above mentioned paradigm shift might initially encounter resistance from couples and professionals until its benefits are clearly documented. Wider implications of the findings Data show that it is essential that policymakers, healthcare professionals and other institutional stakeholders team up to raise awareness on infertility and to develop long term plans aimed at inverting this insidious trend that is already affecting all society and is destined to get even worse if not immediately tackled in a determined and cooperative way.