Health Promotion International, Vol. 19, No. 2, 157-165, June 2004
HEALTH PROMOTION INTERNATIONAL Vol. 19. No. 2 © Oxford University Press 2004. All rights reserved
Health promotion for socially disadvantaged groups: the case of homeless older men in Australia
1School of Public Health, 2Faculty of Health Sciences and 3School of Behavioural and Community Health Sciences, University of Sydney, Sydney, Australia
Address for correspondence: Associate Professor Susan Quine, School of Public Health, Building A27, University of Sydney, NSW 2006, Australia, E-mail: sueq{at}health.usyd.edu.au
SUMMARY
There is extensive evidence that health promotion routinely benefits those who are already most socioeconomically advantaged. While the government's healthy ageing policy recognizes that improving health outcomes will require a range of strategies involving different target groups, recommendations focus on the issues and needs of the comfortable majority. This paper examines the scope and relevance of health promotion for one disadvantaged minority with extensive health needs: homeless older men. In an ethnographic study of older men (
50 years of age) living alone in the inner city (Sydney), 32 men were identified as homeless and are the focus of this paper. Face to face semi-structured interviews were used to record the men's accounts of their everyday lives, including their health and use of services. The conditions in which these men were living were observed and recorded, and the researchers were aware of health and other services available in the geographic area. All informants were living on or below the poverty line. They reported a range of health conditions, for which many accessed available mainstream and specialist health services. Some obstacles to accessing services were noted. Information relevant to widely endorsed prescriptions for ‘healthy ageing’ also emerged. These included physical activity (especially walking), healthy eating, social activity and adopting healthy lifestyle habits. Findings highlight the extent to which these men lack the basic requirements for healthy ageing, notably adequate incomes and housing. At the same time, within the constraints of the lifestyle they lead, they are motivated to maintain their health and independence. While there are limits to what can be achieved for such people at a local level of service delivery, it is possible to identify feasible health promotion goals and service strategies.
Key words: aged; health; homeless; lifestyle
INTRODUCTION
It is widely acknowledged that health promotion routinely benefits those who are already most advantaged. Healthy ageing policies and programmes [e.g. (Bishop, 1999
)] seek to maximize the ‘independence, wellbeing and quality of life’ of older people and assist them to ‘cope with the transitions and challenges of later life’ [(Australian Coalition '99, 2000), p. 5]. However, research in Australia confirms overseas evidence that health-promoting actions are associated with socioeconomic status over the life course and, particularly for men, with marital status in later life (Kendig et al., 1998a; Kendig et al., 1998b). For older homeless people living alone, the relevance of traditional approaches to health promotion has therefore been questioned:
The statistical ‘promise’ of better health or reduced risk can be expected to have only limited success with many subgroups of elderly, who may have existing difficulty meeting basic needs for adequate food, shelter, and transportation. [(Rakowksi, 1986Indeed, it has been noted that elderly men in general have been ‘relatively invisible’ [(Thompson, 1994When the state of homelessness is added to existing social disadvantage and health problems, a particular challenge is presented to the public health community to provide health promotion which is appropriate. How can such goals be made relevant to people who are so deficient in resources? [(Public Health Association of Australia, 1996
), p. 1] in ageing research. In comparison to older women, older men are numerically less significant and lead more comfortable and privileged lives. In stark contrast, older men are a large and highly visible group amongst the homeless population (Chamberlain, 1999). In Australia these are predominantly single men with an income under A$12 000 per annum, who live in insecure accommodation including lodging houses, homeless shelters or on the streets (Council to Homeless Persons, 1999). In recent years these ageing men have come to be identified as the ‘old homeless’ (Rossi, 1990). They are distinguished from the ‘new homeless’ of families, women, young people and children who increasingly occupy the attention of policy makers and service providers (Sydney City Mission, 1995; Wesley Mission, 1997; South East Health, 2000). Arguably this is because the latter are seen as ‘worthier’ subjects of assistance (Horton, 1995).
This reduced attention to homeless older men is paradoxical given their poor health and limited access to services (Purdon Associates, 1991; Zuk, 1995; Abdul-Hamid, 1997; Crane, 1999). Poor physical health both results in and is the result of homelessness (Wright, 1990). Older homeless people experience significantly more physical health conditions than both younger homeless people (Gelberg et al., 1990; Kutza and Keigher, 1991; Vance, 1995) and their non-homeless, elderly peers (Brickner, 1985; Doolin, 1986; Cohen et al., 1988; Cohen and Sokolovsky, 1989; Keigher and Greenblatt, 1992). Indeed, it is widely proposed that homeless persons may age prematurely (Cohen and Sokolovsky, 1989; Gelberg et al., 1990) and that the ‘older homeless’ should be defined as those aged 50 years ‘because at 50 many homeless persons look and act 10–20 years older’ [(Cohen, 1999), p. 6].
As ‘homeless’ people, older men under-utilize homeless services (Council to Homeless Persons, 1999) and as ‘older’ people they seldom access aged care services (Lipmann, 1997). Shiner reports that the ‘inverse care law’ is in effect: services are least used by those in greatest need (Shiner, 1995). Both external and internal barriers to accessing services have been identified for homeless persons (Jahiel, 1992). External barriers include rigidity of the health care system, unavailable services, lack of funds to pay for services, and inadequate or no transport. Internal barriers include denial of health problems, fear of loss of control, fear of providers' actions, concern about financial resources and personal feelings. MacWilliams suggests that in recent years, Australian health services have become more responsive to the needs of homeless people, but that there is still a long way to go (MacWilliams, 1997).
This paper draws on data from the Ageing Men's Health Project, a 3-year, nationally funded ethnographic study of low-income, non-married, older men. Just under half of the men who participated in in-depth interviews for this project can be characterized as homeless according to Chamberlain and Mackenzie's widely used definition, i.e. they are experiencing primary homelessness (living on the streets), secondary homelessness (have access to shelters and lodging houses on a short-stay basis) or tertiary homelessness (in marginal housing but on a more permanent basis) (Chamberlain and Mackenzie, 1992). Here we document these men's use of health services and examine their capacities and motivations for healthy living. The findings add to the small amount of literature on health promotion specifically for socially disadvantaged groups and identify specific needs and issues associated with improving health outcomes for older homeless men.
METHODS
We investigated the health, housing and service use of older (aged 50 years), low-income, non-home-owning men living alone in the inner city of Sydney. We selected this study population because all of the following factors are associated with elevated risk of poor physical and mental health outcomes in later life: being male, a low income, never or previously married, living alone and living in insecure housing (Mathers, 1994). The age category reflects the fact that many such disadvantaged men do not survive into old age. When such intense vulnerabilities occur among those who are most bereft of financial and informal social resources, there are significant implications for policy development and services delivery (Keith, 1986).
An ethnographic approach was adopted in order to understand the men's own views and the patterns and situations of their daily lives. Our study site, the Local Government Area of South Sydney, is a cluster of suburbs on the fringe of the Sydney commercial business district that contains a substantial concentration of men in our target group, and we chose it for this reason. It affords a range of habitats for low-income single persons, including private rental accommodation in lodging houses and cheap hotels, public housing, aged care facilities and homeless shelters. During 1999 and 2000, two fieldworkers conducted participant observation in a number of community and welfare service settings, as well as in other places frequented by those in the target population, such as streets, parks and pubs.
While conducting fieldwork in these locations, they also recruited for interview men who met our eligibility criteria: aged 50 years, in receipt of a pension or benefit, effectively single, and non- home-owners living alone. Other less mobile men were accessed with the assistance of local community service workers. This sampling approach is grounded in a theoretical rather than statistical logic (Silverman, 2000). It is probable that the recruitment strategy selected relatively fewer men who were extremely isolated and who were relatively more likely to be involved with services systems. The extent of this bias is not known because the census and other sources of population data do not accurately enumerate single men in vulnerable housing circumstances, particularly those who are homeless or in short-term, non-private housing. The theoretical, ethical and practical dimensions of sampling and recruitment in a project such as this have been discussed in detail elsewhere (Russell et al., 2001a; Russell et al., 2002).
A total of 67 men participated in face-to-face, semi-structured interviews around the broad topic areas of work, health, housing, family and social networks, and use of supportive services. Understanding better the pathways through which some men enter later life with multiple social deficits was an important aim of the project, and life history materials were collected for this purpose. A second aim, and the one that underpins this discussion, was to examine the ways in which the men's social deficits are experienced in everyday life.
Where permission was given, interviews were tape-recorded and transcribed in full using the qualitative software package NVIVO (Richards, 1999). Detailed notes were taken for the remainder. The interview process has been described in detail elsewhere (Russell et al., 2002a). A preliminary coding framework based on the interview topic areas and key sensitizing concepts was progressively elaborated as data collection proceeded, and emergent themes were identified inductively [e.g. (Russell et al., 2001b; Russell, 2004)].
During the interview we asked the informants about the patterns of their daily lives, including open-ended questions about health and use of health services (How would you say your health is at the moment? Have you had any major health problems? Do you see anyone for your health?). The line of questioning did not focus explicitly on health promotion or on specific health problems.
RESULTS
At the time of interview, just over half (35) of the 67 informants were living in housing where a lease agreement had been signed between tenant and landlord providing some security, with 22 in public housing and 13 in residential aged care. The other 32 informants were living in insecure housing, including single rooms in private rental lodging houses or hotels (12), those who had no fixed abode (14) and long-term residents of older emergency shelters (6). For the purpose of this paper on homeless older men, we report on the 32 men in the latter three categories, who are without secure accommodation and the associated benefits.
These 32 men ranged in age from 50 to 89 years, with a mean age of 66 years. Two-thirds were born in Australia and one-third overseas. Of those born overseas, half were born in an English-speaking country. All informants were living alone. Half were never married, one-third were divorced or separated, and the remainder widowed. Their financial resources were extremely limited, with all living on or below the poverty line, and reliant for their income on a government pension or benefit.
Most of the men of no fixed abode (NFA) were fully mobile. Seven of the lodgers, however, were seriously impaired in their mobility by a variety of conditions, including arthritis, respiratory problems and poor eyesight. Overall, some two-thirds of the men reported significant health difficulties. They mentioned a number of health conditions, including recent cardiovascular problems (angina, high blood pressure, heart attack, stroke), arthritis, pneumonia and earlier bouts of cancer. In addition, many men were observed by the fieldworkers to have dental and eyesight difficulties.
Use of health services and perceived barriers
Three-quarters of the informants had accessed a primary health service in the past 12 months. Of these, two-thirds frequented a mainstream primary health service such as a medical centre or private medical practitioner, and the remaining one-third frequented a voluntary agency primary care clinic that targets disadvantaged and homeless people. Health services also linked them with other important services, including specialist practitioners (7), community nursing services (3) community-based aged care services (2), mental health services (2) and supported accommodation such as shelters (2).
Few men talked about having encountered major barriers in accessing health services. Of those who did, lack of transport was most often reported as an obstacle. For instance, one informant recently diagnosed with prostate cancer made his treatment decision solely on the basis of minimizing the number of hospital visits he would need. There were other concerns, however. Five of the informants reported that they had received impractical or inappropriate treatment advice. For example, Edwin (72 years old) who lived on the street had been diagnosed with pneumonia and was given the following advice: ‘Doctor says I need to sleep in a bed, keep warm’.
Not being taken seriously was mentioned by four informants, and in one example complaints about ‘tired bones’ were dismissed, but later diagnosed as Paget's Disease. Four informants reported their belief that treatment had resulted in further health problems. Gerald, an 89-year-old private hotel resident, lost most of his sight after an operation on his eyes 10 years ago. Nowadays he says ‘I try not to go to doctors’. Nonetheless he was appreciative of the health service he received from a particular practitioner:
This time I would have gone and seen the same one who was here last year. A young Irish man, he was very understanding. He didn't give me anything for my cold but he used to examine me and watch me.However continuity of care with a preferred provider was not always achievable:
Interviewer: Do you have a local doctor or someone you see for your health?Grady (65 years old, lodging house): ... I did have one just up the way but it's too far getting around for me so I'm going to another one on the bus line.
Health maintaining/promoting activities
In recent Australian research (Kendig, 1996), older people identified the most important actions they could take to improve their health. These included undertaking physical activity, particularly walking, healthy eating, social activity and healthy living habits. As we have already noted, we did not ask the men specifically to comment on their beliefs or practices in relation to such activities as strategies for ‘health promotion’. Nonetheless they emerged as topics of conversation in many interviews, as we document below. What is clear is the extent to which these men's chances of following prescriptions for ‘healthy ageing’ are curtailed and constrained by their disadvantaged circumstances.
Physical activity (walking)
Not surprisingly, for informants of no fixed abode, an ‘average day’ typically entailed walking considerable distances:
Well I get up and I'm in the shower ... It's a good walk [to a meals centre] and they put on a hot breakfast. Two eggs, bacon, tomato and toast. You can have too much bacon though. Walk back to the [homeless health service] clinic. Get my vitamins and see the nurses if I have to for the feet. Then I go down to the supermarket in the city. I just pick up what I need for the day. I come back here [proclaimed place] about two or three o'clock ... and go up to have a sleep. I come down for supper and that's it. [Colin, 68 years old, NFA.]One or two of the lodgers also reported that walking was one of the few cost-free ways of filling time.
Earl (75 years old, lodging house): Stop and watch some sport if it's on [television], tennis or cricket ... if there's something on like a movie worthwhile I'll watch that and if there's not I'll go out for a walk for an hour and come back.
However, the men's disadvantaged circumstances meant that any potential health benefits of walking could be outweighed by other factors such as the lack of adequate footwear or untreated foot problems:
I need new shoes. Look at my shoes. Falling away, falling away. [Does a little tap dance whilst still sitting down.] Shoes that will let me walk. I walked here you know. Walked up that hill. [Oscar, 55 years old, NFA.]Colin (68 years old, NFA): See my toenails. They can't cut them. They tried but they're too thick. I told them to buy a hacksaw [laughing].
Interviewer: Do they give you pain?
Colin: No. Only when I wear shoes. I went into hospital a while back and they couldn't cut them either.
Many others reported that until recently they had been physically active, but a health condition had hampered their ability to continue. For example, Addison, an 86-year-old lodging house resident and regular drinker, lived an active life until the deterioration of his health which has ultimately limited his lifestyle:
I generally go for a walk. I give that away now. I used to walk about a quarter of a mile up and around the block and back here and then of an afternoon do the same thing but it wasn't improving me you know. Now I still get out and do a bit of shopping or I go up to a certain hotel and have a couple of drinks. Well that's my life now. I've got nothing else. I've had no pain here [shoulder] now since this morning. No pain at all, but sometimes I've had to sit around like this in a funny position to get rid of it. Well it's an aggravating bloody thing you know.
Healthy eating
As we have reported elsewhere (Russell et al., 2001b), men in all housing types experienced food insecurity associated with low incomes and poor health. Public housing tenants, however, fared much better in their access to sufficient and nutritious food. Lodgers fared less well, many lacking access to even basic food preparation and storage facilities, while those of no fixed abode were even more vulnerable to hunger, let alone dietary inadequacies. Men in all housing types patronized one or more of the area's charitable meal centres, where a hot lunch could be obtained. For many of those we are categorizing as homeless, this seems to have provided most, if not all, of their daily food intake. While we were not qualified to assess the dietary properties of food consumed in such places, research has raised serious questions about the quality of food offered by emergency food aid providers. Studies in Britain (Balasz, 1993; Rushton and Wheeler, 1993; Evans and Dowler, 1999) and the United States (Derrickson et al., 1994; Bell et al., 1998) have documented the dietary failings of meals provided to homeless persons. Certainly our fieldworkers' observations suggest that the offerings, while usually filling, are not particularly healthy and are sometimes prepared under unhygienic conditions.
Social activity
All informants were living alone without family support, and many talked spontaneously about the importance of social interaction in their lives. They reported attending meal centres and clubs as much (or more) for the company than the food. For example:
I come here for lunch every day ... Good meals. Cheap. Get out of my room for a couple of hours. I've got lots of mates here, we have a yarn. [Edward, 68 years old, hotel.]For others, failing health had curtailed this option as they can no longer walk as far as the closest centre. For example:
For the last couple of years I've gone to [ex-service mens' club] but I didn't bother renewing it this year because I can't get over there. I came out of hospital last September and the furthest I've been is across the road to those shops. I might go a week and I won't go off the floor here. [Francis, 68 years old, hotel.]
Healthy living habits
Men who live on the streets clearly face an uphill battle in achieving even the most basic of environmental supports for healthy living such as a warm and secure place to sleep and access to facilities for personal hygiene. While those in hostel dormitories or lodging house rooms fare somewhat better, the conditions of the premises they inhabit leave much to be desired. The recent Burdekin Report, for instance, described conditions in Australian lodging houses as ‘depersonalising, depressing and completely unconducive to any dignified normal life’ (Burdekin, 1993), while the Report of the National Inquiry into the Human Rights of People with Mental Illness described lodging houses as ‘a national disgrace’ (Burdekin, 1993). Our observations generally confirmed these assessments (see also Russell et al., 1998).
A number of the past and present rough sleepers spoke of how important it was for sheer survival to be able to access a temporary shelter such as a proclaimed place (PP; a supervised dormitory-style environment where intoxicated persons may be detained for 8 hours or until sober), particularly in severe weather or when they had consumed large amounts of alcohol:
I come in [to shelter] when I've had enough to drink, sometimes when I've had too much ... and sometimes when I know my body's had enough. [Rover, 50 years old, NFA.]Another informant explained his (possibly fanciful) scheme to keep warm and maintain hygiene:We'd sleep in empty houses, in parks around Surry Hills, Haymarket and Woolloomooloo. It didn't make much difference, I didn't care as long as I could get a drink. They didn't have PPs back then. They're a godsend. PPs have saved many lives. They saved my life—I wouldn't be here if they weren't around. I personally know of lots of street people who would have died if they couldn't get a bed for the night. [Matthew, 58 years old, community housing.]
In the park near the pool at Newtown ... there's a bus shelter and it's just been done up and it's got plastic all around so it's not so cold, and I'm joining the Uni for $40 for six months and I can get in before the students and use the toilet, shower and bath. [Oscar, 55 years old, NFA.]While not all the men (contrary to popular stereotype) were currently or ever had been heavy drinkers, unsafe alcohol consumption was clearly a significant contributor to poor health in many cases. Some heavy drinkers who recognized this as a health problem had managed to stop, or at least modify their drinking:
They put me in [names] Hospital, two doctors, kept me there all week and when they told me to give up drinking I said ‘fair enough’. And not only them two, but others told me as well and I thought well there must be something in it see. [Jerome, 60 years old, lodging house.]A local primary care clinic operated by a voluntary agency provided street people with vitamin injections to help offset deficiencies due to heavy alcohol consumption and/or an inadequate diet, and several men in our sample reported regularly using this service. Yet other services, notably appropriate detoxification and rehabilitation facilities, were difficult to access. A number of men told us that the only way they could hope to stop drinking was to spend time in a residential facility, such as the special purpose nursing home attached to one of the emergency shelters, but these beds were almost always full.I'm slow with my drinking. I don't drink fast or anything like that ... When I drink I only drink beer. I don't touch spirits or anything. I take my time ... I'm not fast with my drinking, I like to sit and watch the TV and everything. I don't touch whisky or anything like that. [Wilbur, 80 years old, NFA.]
Health and independence
For most older people, independence is a core value [(Russell, 1995), p. 90] and these men were no exception. Despite the exigencies of their present circumstances, few were willing to contemplate the loss of independence they associated with relocation to a more ‘supported’ environment such as a residential aged care facility. For example:
Until recently even [names] Hospital and [charity organization staff] thought I should move out and go into [charity] run places. But I don't fancy that. I had to listen to them [health professionals] because I was too weak to do for myself. Now I think I can find somewhere on my own. I don't fancy this community-controlled affair. [Sidney, 78 years old, lodging house.]I know they provide meals and everything else but I don't like the idea of somebody telling me, ‘Hey you, have your breakfast at 7 o'clock and have your lunch at 12 o'clock’. I've had too many years of ‘I'm hungry, I'll eat now’ ... I reckon I'll last three months if I ever go into one of those places. [Francis, 68 years old, hotel.]
DISCUSSION AND CONCLUSION
Many of the homeless men in our study reported significant health problems, and, while based on self-report, their health was similar to that reported by homeless people in other studies [e.g. (Wright, 1990; Trevena et al., 2001)]. The finding that most of the men of no fixed abode were fully mobile is not surprising given that this is virtually a capacity requirement for them to continue to live independently.
Overall these men proved resourceful, adaptable and motivated to maintain their health and independence, within the constraints of the lifestyle they lead. In the absence of basic requirements such as heating, bathing and food storage facilities, it is obviously extremely difficult, if not impossible, to follow mainstream prescriptions for ‘healthy ageing’. Such strategies, as with health promotion programs generally, implicitly target—and are mostly responded to by—the educated middle class. While the National Strategy on Ageing (Bishop, 1999) recognizes the need for the inclusion of disadvantaged groups, little attention has been paid to the specific health needs of the men who are the subjects of this paper. Many of these men experienced health problems, but would benefit from opportunities to maintain and improve their health. However, in a review of health promotion articles published during 1989–1999, Buetow and Kerse report ‘... that although the concept of health promotion has always included people with ill-health, the practice of health promotion has continued to neglect them’, and recommend that health promotion activity should explicitly include people with ill health [(Buetow and Kerse, 2001), p. 73].
Our study has reported a range of health needs, and also the kinds of services that older homeless people perceive as maximizing their independence and improving their health outcomes. An often overlooked approach to improving health services is to consult older homeless people themselves about their preferences for health information and assistance (Crane and Takahashi, 1998; Quine and Kendig, 1999). This has been done with homeless people before; those who have tried suggest we listen closely to those who need help (Camiel and Wolf, 1995) and that they often hold the answers for us (McInnis, 1991).
Clearly, of course, there are limits to what can be achieved for such people at a local level of service delivery. Such efforts would yield greater benefits if comprehensive, multi-sectoral policies could provide these men with the foundations for healthy ageing, i.e. adequate income, housing and transport. But our data suggest that local services can contribute more than they currently do to health promotion goals. What would a ‘health promotion’ strategy explicitly developed with the needs and issues of this specific target group in mind look like? To begin with, it may address issues that are not normally prioritized in healthy ageing strategies, such as foot care (podiatry and footwear). Secondly, it may adopt a different approach to mainstream issues. In relation to healthy eating, for instance, optimally effective strategies would target organizational settings (such as emergency food aid centres) rather than providing nutritional information to older individuals. Finally, it may need to contribute a voice to unfamiliar policy areas, such as those related to alcohol rehabilitation or crisis accommodation.
While this study was conducted in Australia, the general findings and implications contribute to our understanding of health promotion for homeless people in other countries, and add to the limited international research literature on this topic. In particular, they highlight the importance of qualitative research as a way of filling the gap between population-level data and the specific circumstances and needs of vulnerable minorities. Health-related behaviours and service use need to be understood in context as the product of differential opportunities for, and constraints on, a ‘healthy lifestyle’. As Lincoln has remarked: ‘we build policy on the basis of gross demographic data, essentially legislating for the majority and hoping that the minority can find ways to meet its own needs’ [(Lincoln, 1992), pp. 388–389]. Good public policy must always start from the perspective of those most affected [(HelpAge International, 1999), p. 4]. Yet groups such as the homeless older men we have described are precisely those whose voices are most likely to be excluded from the public domain.
ACKNOWLEDGEMENTS
The research reported here was funded by the National Health and Medical Research Council (NHMRC) of Australia.
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