Places and health: A qualitative study to explore how older women living alone perceive the social and physical dimensions of their neighbourhoods

Abstract

There is growing interest in the impact that neighbourhood environment might have on the health of older people. Although the number of older Australian women, particularly those living alone, is projected to increase in coming decades, their experiences of neighbourhood have not been exclusively examined. The aims of this paper are: (1) to explore, from the perspective of these women, the social and physical dimensions of neighbourhoods and (2) to investigate variation in these accounts according to whether women lived in areas of higher or lower socioeconomic status. Twenty women aged between 75 and 93 years, residing in metropolitan Adelaide, South Australia (SA), participated in a series of two in-depth interviews. Women's perceptions of their neighbourhood, and accounts of every-day activities in the community were analysed to determine how both social and physical aspects of neighbourhood might relate to health and wellbeing. Findings suggest that a reciprocal and trusting relationship with neighbours underpinned older women's sense of satisfaction with, and feeling of security within, the neighbourhood. Other factors such as living in close proximity to services and existing social networks were also seen as important. Women's stories demonstrated that they were able to draw on both existing social networks and neighbours to sustain their independence and social connection within the community. Women living in more disadvantaged areas were more conscious of social disconnection in their neighbourhoods, and to the way that traffic noise and pollution detracted from their neighbourhood environment. These findings indicate that, for older women living alone, trusting and reciprocal relationships with neighbours are likely to form an important part of their broader social support network and should be recognised in relation to the process of maintaining the health of older women living in the community.

Introduction

Australia, like most developed countries, has an ageing population. South Australia (SA) has a higher percentage of older people than any other Australian State, with 14.5% of the population aged 65 or over (Australian Bureau of Statistics (2001a), Australian Bureau of Statistics (2001b)), and this figure is expected to increase to 24% by 2051 (ABS, 1999a). Women, particularly those living alone, represent a higher proportion of the older population and this proportion increases with age due to longer life expectancy than men (Australian Bureau of Statistics (1999b), Australian Bureau of Statistics (2002)).

Over the past two decades, much research has sought to examine how health outcomes vary according to where one lives (Ellaway, Macintyre, & Kearns, 2001; Macintyre, Ellaway, & Cummins, 2002; Sooman & Macintyre, 1995). This research examined how characteristics associated with place of residence might affect the health of inhabitants, irrespective of characteristics of the individuals themselves. Quantitative understanding of such ‘area effects’ on health have predominantly been addressed using the analytical strategy of multi-level modelling (Diez Roux, 2003a). This body of research has been pivotal in investigating how residential environments might affect individual risk for cardiovascular disease, for example (Diez Roux, 2003b; Diez Roux, Merkin, Hannan, Jacobs, & Kiefe, 2003). Some commentators have, however, pointed out, “characteristics of places are typically distilled in this type of analysis to a few limited variables..place is frequently considered a black box (of variable sizes and shapes) in which unidentified “non-individual” processes take place” (Tunstall, Shaw, & Dorling, 2004, p. 6). While such approaches have advanced our understanding of how place of residence can affect health outcomes, they do not (nor do they aim to) address the complexities which underlie individual relationships with neighbourhood environments and how these might impact on health. Exploration of the connection between place and health through accounts and perceptions of those living in the communities studied (Campbell & Gillies, 2001; Cattell, 2001; Schulz & Lempert, 2004; Sixsmith & Boneham, 2003) is adding to the empirical evidence linking the social and built environment with health.

Emerging from such research is the notion that social capital—mutually beneficial social relationships between citizens characterised by interpersonal trust and norms of reciprocity (Kawachi, 1999; Putnam, 1995)—might be an important factor for health. It has been suggested that the extent of social capital in an area might explain differences in overall levels of health (Mohan & Mohan, 2002). Research by Kawachi (1997) and Kawachi and Kennedy (1999) suggested that living in areas characterised by higher ‘stocks’ of social capital is associated with lower mortality rates, and that disinvestment in social capital or breakdowns in social cohesion can have both indirect and direct effects on health. The exact mechanisms through which social capital influences population health, and indeed how the notion itself should be conceptualised, remains the subject of considerable scrutiny (Hawe & Sheill, 2000; Mohan & Mohan, 2002). Largely absent from most debates is an examination of how social capital operates for specific subgroups, such as older people (Boneham & Sixsmith, 2006).

Older people's perceptions of place or neighbourhood may be particularly relevant (Rowles, 1994). In Australia, the majority (90%) of older people aged over 75 live in private dwellings (Qu & Weston, 2003) and tend to remain at the same address (AIHW, 2002). Older women are more likely than older men to live alone (Qu & Weston, 2003). It is generally understood that older people prefer to ‘age in place’ rather than move to aged care facilities (AIHW, 2002, p. 6) and this notion is reflected in government policies and services that aim to maintain older people in their homes. Improving our understanding of the effect of place on health with respect to older residents is particularly pertinent in relation to social exclusion (Scharf, Phillipson, & Smith, 2003) and to better articulate the dynamics of how such concepts as social capital might operate in relation to older people (Boneham & Sixsmith, 2006; Campbell & Gillies, 2001; Putnam, 1995).

The field of ‘health geography’ (Kearns & Moon, 2002) seeks to understand the relationships between people, health and place (Andrews, 2002) and is increasingly focusing on the experience of ageing and place. This reflects demographic and cultural changes occurring in most western countries such as ageing populations, changes in family roles and responsibilities and transformations in the settings in which social and health care are delivered to older people, and the places in which they are ageing (Andrews & Phillips, 2005; Milligan, 2003; Wiles (2005a), Wiles (2005b)). Since social geographer Graham Rowles emphasised the meanings that older people ascribe to their home environment in the early 1980s (Rowles, 1986), current perspectives in geographical gerontology have increasingly focused on “constructed meanings and the experiential aspects of place” (Kearns & Moon, 2002, p. 609). For example, Phillips, Siu, Yeh, and Cheng (2005) researched quality of life issues for people over the age of 60 living in Hong Kong. They found that psychological wellbeing was highly correlated to how older people perceive their housing environment, particularly with respect to their housing needs and expectations (e.g satisfaction with factors such as lighting, stairs, etc.).

Social gerontologists have pointed out that older people are acutely aware of the changes, both social and physical, occurring around them. This is particularly so for those who tend to remain living in the same house and area for many years. Phillipson, Bernard, Phillips, and Ogg (1999) focused on older people's experiences of community change in three urban areas of England. They surveyed over 600 older people and interviewed a smaller group of people aged 75 and over. They found sentiments of ‘belonging to a place’ or ‘investment’ in place were dominant, and were strongly related to gender. Older women were seen as ‘neighbourhood keepers’ in that they were more attentive to changes occurring in local neighbourhoods and were more distressed by community deterioration than older men.

Research in the relatively disadvantaged inner-Sydney area of Surry Hills also found that older men and women might experience neighbourhood life in different ways (Russell, Hill, & Basser, 1998). Researchers conducted in-depth interviews with 40 residents to inform the development of a health promotion strategy to support the wellbeing and independence of older people, particularly those seen to be neglected. They concluded that, overall, inner-city elderly needed to be recognised as a diverse group who are not particularly vulnerable, and in fact had adapted to their surroundings, finding ways to create a safe and self-reliant way of life. The older women participants, in particular, were found to have created a meaningful and independent existence, including utilising public transport to visit friends and family, whereas some of the older men, particularly those with a disability, had limited social interaction and seemed resigned to the restrictions placed on them by their surroundings.

In summary, there is an emerging body of interdisciplinary research on the perspectives of older people toward their neighbourhood, which builds on health geography and geographical gerontology research on places as having social, physical and symbolic meaning (Wiles (2005a), Wiles (2005b)). This paper extends such research and contributes to an understanding of the perspectives of very old women in particular, while also investigating how notions of social capital might affect this particular subgroup. The aim of this paper was to reveal the processes by which neighbourhood, as it is perceived by older women, might impact on their health. It aims to highlight which dimensions of the neighbourhood are particularly relevant to older women, in order to support successful ageing and social inclusion and whether these dimensions vary according to socioeconomic advantage.