Fresh perspectives
Article Type: Editorial From: Housing, Care and Support, Volume 15, Issue 3
O wad some power the giftie gie us,To see oursel’s as others see us.
The poet and Scottish national bard Robert Burns suggests that the ability to see our own lives from another’s angle is a gift. This is, perhaps, the promise and the ultimate intention behind all social science research. But it is, we have argued, especially valuable when looking at the social determinants of health, and the role of social factors such as housing both in locating the problems, and in identifying potential partnerships, for new solutions.
Human health is generally assumed to be largely as generic and universal as the human frame; but social and cultural forms vary widely. The physical fabric of housing, and the financial frameworks for both housing and care are both highly “socially constructed”. Identifying what works in housing for care and support, and for public health, has to be highly sensitive to circumstances and the broader cultural and social policy worlds in which we operate.
The essential internationalism of research in health and healthcare therefore needs to be balanced and informed by a better recognition of the potentially complex and local relationships between health and the social context. The ways that particular societies respond to health and other un-met needs may affect both the expression of the need, and the life courses then available. An awareness of the social determinants of health will need to be reflected in better recognition of the significance of hyper-local, national and broader cultural factors, with different funding regimes and welfare philosophies, all impacting on both the efforts of specialist care and support services, and the nature of informal community, alongside the still broader determinants such as overall inequality.
We suggest, therefore, that in research, a broad diversity of perspectives is good, if it contributes to a better, later, underlying unifying of the picture. This is how science progresses – in seeing the bigger picture behind apparently contradictory findings. At the very least, for research findings to be truly insightful, we need to recognise the significance of such contexts for the efforts we make, and evaluate.
In the editorial of the previous issue of this journal, for example, we asked: “how far is the experience and the social meaning of homelessness variable according to climate, cultural beliefs and expectations?” Thus,with the advent of “psychologically informed environments” in homelessness resettlement, we asked how far can these concepts be as meaningful,as necessary, and how much will homelessness research and practice make sense at all, in countries where there is no substantial development of resettlement services, or of welfare services, in the first place? How meaningful can it even really be, to talk in terms of psychological needs, in countries where the principle motivation for philanthropic outreach is faith-based?
Such questions are not simply academic. At a time when the development of a comprehensive welfare ambition within the “advanced” Western economies seems to be stalling, even going into reverse, we may need to look outside our own familiar world, to see what we can learn from other and more cross-cultural perspectives. In this collection of papers, we look at a number of such themes, from new angles.
The current selection of papers starts with, for comparison, two papers on homelessness, from two countries both in the developed world, where welfare state provision has attempted to intervene.
The paper by Sonya Jakubec and her colleagues in Canada locates the development of services squarely within a context of national and local policy frameworks, and is very aware of funding constraints. Their assertion that homelessness is about “more than a house” stresses the necessity to engage with and address the whole person’s needs; and that this will also mean support to navigate – and for agencies, this will mean a need to integrate – a multiplicity of services.
The picture presented by Jakubec and her colleagues may therefore be familiar to UK readers, where for ten years the Supporting People programme has funded and endorsed resettlement work to signpost to other agencies and to support more vulnerable homeless people in their recovery from homelessness and other attendant problems. For UK readers, this paper is a welcome confirmation that these needs are internationally recognised, at least in the more developed welfare systems. For others, the paper may offer a useful summary of the issues.
It is interesting to note that the Canadian team’s research also involved a range of disciplines, including “experts by experience”– formerly homeless people as members of the research team, bringing something new and especially credible to their efforts. In their approach, they also take care to give equal weight to the views and experience of service users.
Meanwhile, returning to the UK context – where so many of this journal’s earlier papers have their roots – in our second paper, Angela Daly and her team take this a stage further in their participatory research approach. Their conclusion directly echoes that of the Canadian team – that services need to be co-ordinated. The involvement of formerly homeless people as co-researchers considerably enriches their involvement of narratives to identify the life course events and issues. The result is a paper that has a focus as much on homeless people’s and service users’ real strengths as on their needs and vulnerabilities.
This second conclusion echoes earlier papers in this journal –including those by Smeaton and Harrison in the last issue (Housing, Care and Support, 15:2) – which stressed that being more “psychologically aware” (Keats et al., 2012) does not mean medicalizing problems or pathologizing individuals. The recognition of the complexity of needs, including mental health needs, found among homeless people, is welcome. Whilst we need,certainly, to work with emotional intelligence in dealing with any individuals in a precarious state, we must also be alert to the psychology of resilience,and of aspirations.
Another perspective entirely on the interaction of psychological needs and the environment comes in the paper by Will and Sam Boex on the role of conscious design in healthcare buildings, and what we might learn from that for the design of the social and the built architecture in community settings. The high cost of healthcare interventions has meant that there is now research effort devoted to seeing how to maximise the service by enlisting the environmental design,signage, etc. to support the overall aims of relieving pain and distress. Some of the lessons, and much of the approach, promise to have broader applicability,in special needs housing in particular and in the development of more ‘psychologically informed’ environments.
The Jakubec, Daly and Boex papers are each in their way pragmatic –using psychological research selectively, and in conjunction with users’experience, to inform the development of services. But we also do need to explore the roots of well-being from a more rigorously theoretical perspective;to identify and isolate one or more of what in medicine we would call the“active ingredients” in folk remedies. In a field as complex as the interplay of environment and health, there might well be more than one such ingredient coming into play, in particular circumstances.
Questions over design are central to the next paper in this collection. As another perspective again on the interplay of housing and well-being, we have Li’s paper from Hong Kong on the impact of housing, as one of the key environmental attributes affecting children’s educational attainment. Adding historical to geographical perspective, Dr Li’s approach in his paper on housing in Hong Kong is to explore and un-pick all the possible “ingredients” as potential areas for research, and use methodologically scrupulous argument to pin-point an area where we might expect research to be able to shed most light.
Dr Li’s paper then challenges the findings of a number of earlier reports. Several studies from Europe or the US had suggested that high rise housing, and high density, was proving bad for social capital and mental health;and that homeownership by contrast was positive. Li’s paper is explicit in contrasting the conclusions of (largely) European and US research with the different findings from this rather different, island and Asian culture.
This Hong Kong study suggests that these effects of objective housing environment attributes may perhaps be more localized, than first thought; and may be to some extent culturally bound. It is worth bearing in mind here that Hong Kong was until very recently a British colony, and retains much of an administrative infrastructure inherited from the colonial era, and a social welfare philosophy modelled upon the prevailing Western cultural worldview. But here too much high-rise development has been associated with social housing,first with and for slum clearance, and later for housing those in greatest housing need, which otherwise may explain the association in UK.
It is a moot point how far we may take the impact of children as a sentinel measure, a barometer or proxy measure of more generally beneficial or toxic housing circumstances. Perhaps adverse circumstance has a more severe effect on children, coming at sensitive developmental stages; certainly this effect is shown in other studies which suggest that the effect of housing instability– such as a period of homelessness – shows rapidly in children’s progress. But perhaps this impact on children is simply the more immediately visible effect.
Whatever broader conclusions we may think to draw on the relevance of educational attainment, it is when empirical findings conflict, we suggest, that we first start to glimpse the presence of deeper underlying issues, broader influences, and the further questions we need to ask.
Dr Li’s paper is also unique – at least for this journal –in proposing a formal calculus of possible factors for influences and disadvantage, in the form of an equation; this is an entirely new approach to managing the bedevilling complexity of multi-factorial data which promises to stimulate further discussion on the weighting of different elements in particular circumstances.
But how then does this compare with areas where there never was a welfare state, or such a national policy commitment? What do we see there; and what might we learn? The final paper by Nicholas Boamah describes a study attempting to assess just how poor the housing is in some of the poorest districts in Ghana. Also considering the impact on children as a barometer of poor housing,and of wider concerns for other vulnerable adults, especially the elderly,Boamah’s paper on the growing dilapidation of housing in Ghana offers a remarkable insight into a world far outside the experience of most of our readership – except from on our TV screens.
Beginning with a survey on housing conditions, with some striking findings,Boamah then goes beyond simple economic explanations, to attempt to understand the cultural frameworks that may impact on attitudes to upkeep. Boamah’s analysis argues that cultural factors play a large part, with both ancient beliefs and a very contemporary erosion of traditional community patterns equally implicated and interweaving to produce this sorry picture.
He thus explores the social context of housing, and the role of kinship systems and beliefs, and cultural change, as deeply implicated in the meaning of home, the resulting usage of home and the state of the housing stock, and therefore the factors that must be addressed, in all their complexity. It is certainly tempting to see parallels here in our understanding of the impact of modernity, and the constant uphill struggle of urban and social regeneration programmes, in the more deprived and marginalized areas of Western cities.
These papers between them raise many questions, not only in the range of their findings, but also in their range of approaches to evidence, research, and analysis. It is for this reason, in addition to their internationalism, that we have chosen to publish them together. If we are to explore the role of housing,and the successes of housing practice and housing policies, in advancing community care and tackling the root causes of poor public health and inequalities, we must use the full range of possible perspectives, in order to uncover the range of cause and effect chains in a densely complex subject. But it is clear that studies of housing offer an exceptionally rich vein of analysis in the social determinants of health.
Robin Johnson
