HOUSING AND HEALTH IN OLDER PEOPLE: AGEING IN PLACE.

• Author: Howden-Chapman, Philippa

INTRODUCTION(1)

Housing has a clear impact on the health of occupants (National Health Committee 1998, Howden-Chapman et al. 1996). Affordable and appropriate housing protects people from hazards and promotes good health and well-being (WHO 1989). The older population is as diverse as any other in our society and older people in New Zealand live in all kinds of dwellings: detached and semi-detached houses, apartments, units, boarding houses, institutions, papakainga housing clustered around marae and "granny flats" on the grounds of a family member's home. But regardless of the diversity, there are a number of common housing hazards older people face, which could be minimised by creative public policies. Older people deserve special consideration in government policy, community support and industry response, but they are often a low priority for resource allocation or policy innovation because of their relative lack of economic and political power.

In this paper we briefly review the demography and housing patterns of older people in New Zealand. We describe the impact of New Zealand's climate and housing construction on health, before reviewing some significant health problems exacerbated by the indoor environment: respiratory conditions, coronary disease and hypothermia. We then analyse a variety of policy measures that could be used to improve the housing conditions of older people, paying particular attention to the assistance older people can be given to age in the communities where they have lived during their adult lives.

THE OLDER POPULATION

While many older people do not require special consideration, as a group they do -- clearly -- have some distinct population characteristics, such as a higher incidence of disability. Demographically, the impact of the baby boom means that the proportion of the population 65 years and older will rise for the next few decades. Disability associated with ageing increases the possibility of housing and health problems, which can lead to stress and costs to older people, their families, the community and the government. Older people with dementia, whose numbers are growing, will need particular housing assistance.

During the next 30 years, the proportion of people aged 60 or over will increase from 15.4% in 1996 to 25.3% in 2030. Some of the key trends associated with population ageing are an increase in lone-person households (associated with longevity and widowhood) and an increasing proportion of people over the age of 80 (Zodgekar 1993).

As people age, their income is increasingly made up of self-employment and investment income, rather than wages and salaries (Statistics New Zealand 1998b). One-person-superannuitant households have among the lowest incomes of any household type in New Zealand. Further, the household types most concentrated in the bottom quintile of income in New Zealand, in addition to sole-parent households, are older people living alone and, to a lesser extent, older couples. There are also gender differences: women between 60 and 74 years have lower incomes than men in the same age group (Davey 1998).

The existing housing stock in New Zealand presents some significant issues for an ageing society. More than 35% of New Zealand houses were constructed before the Second World War (Isaacs et al. 1995). These houses, being older, often lack modern conveniences and therefore are potentially in need of significant repair and refurbishment. Housing built before April 1978 was not required to have insulation.

HOUSING TENURE AND THE HEALTH OF OLDER PEOPLE

The housing circumstances of older people are directly linked to the social and economic processes that govern the disposition of life chances. Ownership of a house is one of the results of life chances that favour the better educated, and those with more skilled jobs who have earned higher incomes for longer periods, but it also reflects the impact of the larger economic, policy and social cycles that generations live through. For example, those who have lived through prolonged periods of unemployment have had less opportunity to save the necessary deposit for home ownership. Those who have brought up children as sole parents, in a period where there has been a relative decline in government benefits, are also more likely to be tenants than homeowners in old age. For the present generation of young adults, high student debt may delay young adults' entry into the home buying market.

Housing is increasingly seen as part of an interlocking network of markets and institutions that can increase or mitigate the impacts of social and economic inequalities (Smith 1990). While the range of income distribution is narrower among older people, from the limited evidence we have, the disparities in wealth, in terms of assets, appear more marked in those over 65 than in other age groups.

Housing tenure has a direct impact on the health and life expectancy of occupants. People in rented properties, particularly those in the public-rental sector, have higher death rates than people in owner-occupied households, even after other key socioeconomic variables are considered (Macintyre 1998). What explains this relationship?

There is now overwhelming evidence of a social gradient in health. Those who are better educated, are employed in higher status jobs, have higher incomes and live in socioeconomically advantaged neighbourhoods, will have better health and longer life expectancy than those with less education, less-skilled jobs and less income, and who live in more deprived neighbourhoods (Evans et al. 1994, National Health Committee 1998). Yet, the contrast is not just between the extremes, there is a consistent relationship throughout the gradient. The key factor seems to be not just material, but the degree of control people have over their lives. It is likely that home ownership provides a degree of control over accommodation -- a secure sense of home -- that is crucial to well-being. Chapman (1982), in a survey of Auckland private tenants, found that a desire for autonomy was an important factor in tenure choice. The autonomy afforded by owner-occupation was seen as highly advantageous: 95% of the tenants agreed that owners had more freedom and independence in what they do with their homes. This may be particularly true of older people, who are no longer in the paid workforce.

Historically, New Zealanders have had a strong ethic of home ownership. In 1996, three-quarters (76.4%) of New Zealanders were "owner-occupiers". More adults lived in homes with a mortgage (41.7%) than without a mortgage (31.3%), with a quarter of households (23.6%) renting their accommodation. Most people over 65 live in their own homes, which are mostly mortgage-free, but there are ethnic differences. Three-quarters of Pakeha people lived in mortgage-free housing and 87% in owner-occupied housing in 1996, while at the same time only half of older Maori lived in mortgage-free housing and 70% lived in accommodation which they owned. For older Pacific people, only 25% lived in mortgage-free housing and 54% in accommodation which they owned. For the age group over 75 years, there is slightly less home ownership for each ethnic group, although the same ethnic pattern of differences in housing circumstances occurs. The marked differentials between ethnic groups have increased in the period 1981 to 1996 (Davey 1998).

Many older homeowners in New Zealand are dependent on government pensions for day-to-day living expenses, leaving little left over to pay for repairs and modifications to housing. Most older home owners would never seek any kind of government assistance to modify their home, either they can cope by themselves or with the help of their families or friends. But for those who are not so well placed, such assistance may well be crucial to their continued stay in the community and to their "healthy ageing".

Housing for older people, both public and private, has typically been clusters of bed-sitter units, with little consideration of indoor or outdoor space or disability needs. The assumption that older people do not need or want much space has recently been challenged in Australian work, which has emphasised manageability rather than space and resulted in public housing authorities redeveloping many of their bed-sitter units to provide one- or two-bedroom accommodation (Roberts 1997). In New Zealand, qualitative work with older Pacific peoples has stressed the importance of acknowledging the reality of extended family living by providing appropriate public housing stock (Pene et al. 1999).

Compared with younger people, a smaller proportion of older people are tenants, living in private or public rental accommodation. A 1995 survey of local authorities found that all 74 had some pensioner housing with a total of nearly 14,000 units. Seven authorities had sold units in the previous...