The residential context of health in Australia: No longer the lucky country?

ABSTRACT

This paper introduces the special issue focused on the relationship between residence and health in Australia. We present six papers conducted in different Australian states that demonstrate different elements of the complex impact of residential context on health. Through this series of papers, we demonstrate the impact of housing quality and safety on vulnerable populations, but also the way in which processes around housing (e.g., data collection, renewal, allocation) can have either negative or positive outcomes. The broader residential context (i.e., neighborhood, community, geographic location) also must be considered in housing decisions, along with variables that closely track housing (e.g., stigma, poverty). Australia is in the middle of a housing crisis that can still be resolved in positive ways if adequate attention is given to the nuances and complexities of housing decisions.

KEYWORDS:

• Home
• homelessness
• housing
• place
• residential environment

Internationally, the link between health outcomes and the context within which people live has been well recognized and enshrined in policy (Hancock, 2011), but its centrality to government interventions has been dissipated in recent years (O’Neill, 2011). Although the complexity of this link has been established (Hartig & Lawrence, 2003), many subtle features of its impact remain unknown. At the most basic level, residential context matters because housing, or the lack of it, together with the quality of that environment, can have significant impacts on human health. The homeless usually have considerably poorer health outcomes than the general population (Kertesz, 2014), with significant levels of anxiety and depression, respiratory disorders, infectious diseases, and injuries (Baiaga et al., 2009, Lee et al., 2005).

Homelessness is a relatively new challenge for Australia. For over 50 years, Australia has been known internationally for its emphasis on home ownership. It was not uncommon to hear reference to the “great Australian dream,” meaning that the majority of Australians sought to own their own home. Indeed, post-war growth in Australia was so significant that over 70% of Australian families owned or were purchasing their homes by the 1960s (Bourassa, Greig, & Troy, 1995). However, Australia is no longer “the lucky country” in this regard, with over 105,000 homeless Australian citizens in 2011 or about 50 in every 10,000 (The Australian Bureau of Statistics, 2011). Further, there is a significant likelihood of a large unidentified cohort of homeless people in Australia due to reporting inaccuracies. From 1991 to 2011, the price of houses in Australia grew sharply by 263% in comparison to an after-tax income growth of only 95% (Phillips, 2011). Over the same period, average rental rates have increased and the availability of social housing has declined (Travis, 2011). As a result, we are currently facing a serious housing affordability crisis that has been labeled the great Australian nightmare (Travis, 2011). Some research has found that up to 16.2% of those aged between 20 and 29 years of age are experiencing housing stress (Tanton & Phillips, 2013). However, more detailed economic modeling has confirmed that pressures are felt by all types of Australian citizens, including Australians who are paying mortgages, those in the private rental, first home buyers, and the elderly (Tanton & Phillips, 2013). Using conservative measures, it is estimated that over 16% of Australian households require assistance because of tenuous housing (Yates, 2008). Extensive government initiatives have been established in the last five years to address this rising tide of homelessness but with little impact (McDonald, 2014).

Apart from the mere presence or absence of housing, a more nuanced definition of residential context highlights extremely complex and multifaceted relationships with health. Researchers, policy makers, and practitioners in this area need to give consideration to a range of factors, including the quality and physical design of housing, the social context within which housing is experienced, the socio-economic and psychological meaning that attaches to a home, the location of housing within a broader spatial setting, interactions with the natural and built environment, and the political context within which housing is delivered and managed. These factors all have potential to impact health outcomes in different ways. The articles in this issue each explore these complex factors within the general Australian population but also amongst our most vulnerable citizens. They each make a unique contribution to the ever-growing literature on residential contexts and health, but taken as a whole, the articles share several linking themes.

A major theme shared across several articles in this issue is housing quality. For those who do have access to some form of housing, its quality can impact heavily on health and wellbeing. Although there are mixed findings, poor housing quality has been linked to higher levels of psychological distress (Jones-Rounds, Evans, & Braubach, 2014), increased morbidity, and even mortality during periods of extreme temperature (Gibson et al., 2011; Santamouris et al. 2014). Hazards in the home are the leading cause of injuries in most countries, especially among the elderly, frail, or disabled, and yet there is a dearth of injury prevention strategies in this area (Keall et al., 2013). Relatively inexpensive interventions could address these health impacts, but little focus is given to health promotion through housing quality in Australia.

In their article on housing quality and health outcomes, Baker, Lester, Bentley, and Beer estimate that almost 1 million Australian families are living in housing that may be classified as being poor or derelict, and that health in these households was more likely to be rated as being only fair or poor compared to respondents living in better quality housing. Although those most at risk of living in poor quality housing are also those who are most vulnerable, the link between housing and health remains significant even after controlling for age, gender, and labor force status. In the more specific context of disability, Quinn, Zeeman, and Kendall describe the subjective quality of environments and the profound impact this can have on wellbeing. Similarly, Arthurson, Levin and Ziersch focus on the importance of renewal to generate safety and respect in housing estates.

Another major theme across the articles in this special issue is the significance of changes in dwelling quality or transitions between places of residence as a precursor to health impacts. Interventions designed to improve the quality of housing have focused on repairs to Indigenous housing hardware (Lea & Torzillo), deinstitutionalization to community settings for people with mental illnesses (Moxham), renewal of low-income housing (Arthurson et al.), and the development of enabling environments for people with complex disabilities (Quinn et al.). These studies all demonstrate that the responsiveness of housing to the specific needs of individuals or families as they change over time is critical to well-being but is rarely the focus of interventions.

The articles describe the importance of social networks (or social connectedness) and how it can be facilitated or hindered by housing structures or processes. Interventions designed to improve housing need to simultaneously preserve existing social networks (Arthurson et al.), promote social engagement (Quinn et al.), and minimize rejection, stigma, or discrimination (Moxham, Lea & Torzillo). Building capacity and socio-economic status of individuals will assist but building the status of whole neighborhoods as a collective may promote better health for all (Baum, Kendall, & Parekh). The role of neighbors is critical to the acceptability of housing, suggesting that residence is defined as being much broader than one’s own home (Moxham). Failure to attend to the stigma that can be experienced in small rural Australian neighborhoods can lead to extremely negative outcomes for people with mental illnesses (Moxham), but also unhelpful conclusions about the way in which lifestyle choices lead to poor housing careers, particularly for indigenous Australians (Lea & Torzillo).

A theme that pervades all the articles is the importance of adequate attention to psychosocial processes within housing interventions, including appropriate and timely consultation (Arthurson et al.), debunking of stereotypes through meaningful data (Lea & Torzillo), choice, independence, and engagement in decision making (Quinn et al.). The importance of housing as a source of identity, safety, worth, and value is emphasized by all authors. Control over one’s physical environment is important, as its absence leads to deterioration of disabling conditions (Quinn et al.), depression (Moxham), and avoidable health risks (Lea & Torzillo). Arthurson et al. demonstrates the role of control during the housing renewal process and the importance of ensuring that residents understand the choices that impact on their lives. Moxham describes the importance of autonomy and shows how easily living environments can delimit one’s choices. More importantly, several articles show us how assumptions made about people’s housing careers can be inaccurate and detrimental. For instance, Moxham and Quinn et al. both describe the way in which professional decision making can negatively influence housing choices and opportunities for vulnerable people. Lea and Torzillo demonstrate the importance of political agendas and powerful processes of data collection that can obscure reality and prevent the appropriate management of housing problems in Indigenous communities. Much greater investment is required to educate and train professionals in the importance of housing and the processes they adopt within and in relation to residential contexts.

Contemporary research on the residential context must involve considerations of broader notions of space as a mediator of health outcomes. What might be referred to as a “health and place” approach or a “place-based approach to health” is concerned with, among other things, variations in health across individuals as a function of the places in which they live (Catalano & Pickett, 2000). In this approach, neighborhoods can be seen as arenas of risk, opportunity, cultural, and social influence, which, if harnessed adequately, can impact on the health outcomes of residents (Ellen, Mihanovich, & Dillman, 2001). The broader residential context impacts on health through a range of mechanisms, including the presence of injurious or risky environmental vectors (i.e., pollution, excess noise, etc.), proximity to health promoting facilities or activities (i.e., health facilities, the availability of healthy food, or the presence of walkable neighborhoods), and the aggregate socio-economic context which may have positive or negative impacts on health (Baum, Kendall, Muenchberger, Gudes, & Yigitcanlar, 2010).

Arthurson et al. focuses on residence as a broad concept including access to the natural environment. She demonstrates that renewal of the residential context can stimulate increased use of outdoor green space, which has positive health impacts. Quinn et al. also describe the importance of physical designs that facilitate access to the natural environment due to its calming effects. The broad socio-economic issues associated with health and place are dealt with in the article by Baum, Kendall and Parekh. Focusing on the issue of social mix as a characteristic of place, their article asks how socio-economic characteristics of neighborhoods impact health. Their findings suggest it is possible to buffer people against the deleterious effects of low-income neighborhoods by addressing their circumstances of disadvantage. However, it may be equally effective to raise the status of the entire neighborhood. Importantly, the findings suggest that mixed-status neighborhoods may have a positive impact up to some unknown threshold but may have a negative impact on health beyond that point. Interestingly, in reviewing the efficacy of place-based approaches to health, Dunn (2014) noted that disappointing results might be attributed to inadequate attention to poverty, the most fundamental “place-based” determinant of health.

In summary, the articles in this special issue have presented a range of Australian perspectives on the residential context of health. Focusing on both qualitative and quantitative approaches, the articles make an interesting contribution to our understanding of health and residence. Although each article makes useful and worthwhile research or policy suggestions, they also provide a strong combined message: residence is a broad multifaceted concept that impacts on health in different ways. Place of residence is a critical and potentially convenient, but often neglected, site for intervention. This special issue has raised the importance of housing interventions that emphasize enabling designs, health promoting environments, responsive flexible settings, supported transitions, meaningful localized data collection, social connectedness, and the development of “homes” rather than just housing. Failure to attend to the entire concept of residence will clearly lead to unintended negative consequences and potentially costly, yet avoidable, health challenges.