Vicky P.K.H. Nguyen , PhD 1 , Feroz Sarkari , PhD, MBA 2 , Kate MacNeil , MSW, RSW 3 , Laura Cowan , RN, BScN 4 , Joyce Rankin , RN, MN, MB 4
1 Undergraduate Medical Education 1T4, Wightman Berris Academy, Faculty of Medicine, University of Toronto, Toronto, ON;
2 MBA program, Health Sector Stream, Ivey Business School, Western University, London, ON;
3 The Good Neighbours’ Club, Toronto, ON;
4 Street Health, Toronto, ONBackground
Disadvantaged older adults living in non-family situations in Toronto are more likely than older adults living in family situations to have less economic security, less social support, and less choice in housing. Older adults who live in poverty and are precariously housed are more likely to be chronically ill, to live with multiple illnesses, to have poor nutrition, high stress and loneliness, all of which are strongly associated with the determinant of health social exclusion. The aim of this study is to: 1) evaluate the level of social disadvantage and exclusion experienced by low-income older adults 65 years of age and older living alone or in non-family situations; 2) assess the level of dependency on government and community services (support services) to maintain a reasonable standard of living (minimize effects of social exclusion); and 3) identify consequences of social exclusion not addressed by current available services.
Methods
Fifteen male older adult members of the Good Neighbours’ Club in downtown Toronto were interviewed. Semi-structured questionnaires assessed barriers to, utility of, and perceived impact of support services available to disadvantaged older adults living in the central core of southeast Toronto.
Results
Support services for income, housing, food security, social support, and health care do mitigate the effects of social exclusion in the study participants. Data gathered from interviews identified factors that counter the efforts by support services to increase social inclusion in this population.
Conclusions
Support services reduce social isolation experienced by these older adults. Evidence of the detrimental impact of low financial literacy suggests a need to design and implement training programs to build the older adults’ capacity to manage their own finances effectively, and resist falling victim to financial fraud.
Key words: social exclusion , social inclusion , financial literacy , social support , health resilience , urban-dwelling elderly
Social inclusion is the ability to access social, economic, political, and cultural resources regardless of age, race, class, income, gender, disability, sexual orientation, immigration status, and religion.(1) Poverty is both the main cause and consequence of the absence of full social inclusion.(1) Lack of social inclusion entails presence of one or more aspects of social exclusion, which have profound consequences on mental and physical health. Four aspects of social exclusion have been identified and described:(2) exclusion from civil society (systemic discrimination); exclusion from social goods (failure of society to provide for the needs of disadvantaged groups); exclusion from social production (lack of opportunities to contribute to and participate actively in society); and economic exclusion (lack of access to economic resources needed to maintain a reasonable standard of living). Older adults (individuals 65 years of age or older) experiencing age-related life transitions having to do with their family status, health decline, living conditions, independence, and/or economic circumstances, may disproportionately experience one or more aspects of social exclusion if their life transitions take place in the context of significant socioeconomic adversity. According to Galabuzi,(1) psychosocial stress of the experience of inequality and exclusion contributes to hypertension, mental health concerns, and substance abuse. Social exclusion is therefore a significant determinant of health in the context of chronic poverty.
Individuals who live in extreme poverty and insecurity in housing are more likely to be chronically ill, to live with multiple illnesses, and to have poor nutrition, high stress, and loneliness,(3,4) all of which can contribute to social exclusion. A vicious cycle may ensue whereby social exclusion perpetuates poverty, which perpetuates social exclusion.(1)
Many older adults living in Toronto may be trapped in such a cycle. Older adults from Toronto living in non-family situations, especially those living alone, are more likely to be living with income insecurity, social isolation, housing affordability issues, and increased dependency on support services.(5) Economic deprivations such as food insecurity, housing insecurity/inadequacy, income inadequacy, and cost barriers to health services are associated with poorer self-rated health, depressed mood, high stress, smoking, and illicit drug use.(6) Among older adults, socioeconomic disadvantage and social isolation significantly correlate with the adverse health outcome of malnutrition-based mortality.(7)
However, although poor health and social exclusion may be sustained by chronic poverty, they need not invariably or necessarily be outcomes of chronic poverty. For example, Sanders and colleagues(8) defined health resilience as the “capacity to maintain good health in the face of significant adversity”. The researchers concluded from their urban population study that in circumstances where poverty cannot be eliminated, health resilience can be protected by access to build environments (housing quality) and social environments (social supports)—that is, by reducing social exclusion.
This finding is corroborated by Quine and colleagues,(9) who interviewed elderly homeless men lacking the basic requirements of income and housing security for healthy aging. The researchers discovered that the men were motivated by health promotion campaigns to adopt healthy lifestyle habits, and to maintain their health and independence within the confines of their limited resource and adverse living conditions. These studies suggest that despite circumstances of chronic poverty, health promotion strategies and supportive services can help increase social inclusion and health resilience.
Given the link between socioeconomic adversity and poor health as discussed above, it remains important to evaluate the effectiveness of support services aimed at decreasing social exclusion and thus promoting health resilience. It is equally important to identify existing or emerging needs to inform policy decisions around provision of comprehensive services, to mitigate the effects of socioeconomic adversity on the health of older adults.
The target population of this study is male older adults at least 65 years of age living in the central core of southeast Toronto, in poverty and in unstable housing arrangements. More specifically, study participants are members of the Good Neighbours’ Club (GNC)* older adults. This study aims to investigate whether GNC members experience fewer needs and little social isolation as a result of the services provided by GNC. We also aim to discover any needs which continue to be unmet and contribute to any residual social isolation of the participants. This will help identify potential new services that can be added to the programs at GNC (and other similar agencies working in major urban centres across Canada) to meet these needs.
The target population is older adults (≥ 65 years of age) living in the central core of southeast Toronto. The study population is male members of the GNC who were recruited by Social Worker Kate MacNeil. Interviews were conducted at the GNC at 170 Jarvis Street. Candidates were recruited to complete the full-length interview based on their responses to the following three screening questions: 1) In what year were you born? (Alternatively, how old are you?); 2) Do you live with your family?; and 3) What is your monthly or weekly income? These three questions are intended to identify the sample of interest: older adults (65 years or older) living in non-family situations, on a before-tax income below Statistics Canada Low Income Cut-off (LICO, 2006), of $21,359(10) (below $1,779 per month). Fifteen candidates identified during the screening and were invited to the consent process to complete the full-length interview.
Fifteen questionnaires administered by one-on-one semi-structured interviews were used to assess the effectiveness of support (income, health, social, food, and housing) services used by participants recruited from the GNC. The questionnaire was designed to determine: 1) Which services are used and why?; 2) Which types services are available but not used and why?; 3) Which types of services are needed but not readily available and why? The questionnaires assessed the utility (accessibility + effectiveness) of services available and used by study participants (Item 1 listed), the presence of potential barriers (such as discrimination, transportation or cost difficulties, etc.) to accessibility of available services by study participants (Item 2 listed), and unmet needs (due to unavailability of services or lack of awareness of services available) of study participants (Item 3 listed).
A need is considered “unmet” if a mismatch occurs between the need identified and the level of utility (accessibility + effectiveness) of services available in the downtown core of southeast Toronto to address that need. To assess the level and type of need, participants were asked questions about whether they feel that they have any health problems attributable to their income and the environment in which they live (in- and outside the home). To assess their level of needs, participants were asked questions designed to assess their health status, the adequacy of their income level, food security, and social network support, the condition of their living space, housing unit, and neighbourhood. Participants were asked if any of the services available to them in the downtown core of southeast Toronto have helped them to improve their living situation and/or alleviate any difficult life circumstances. To identify potential barriers to services available, participants were asked questions about their educational level, computer literacy, language ability, presence of disability, and cultural background to determine potential barriers to service accessibility. Most importantly, participants were asked open-ended questions to allow an opportunity to explain any other reason why a particular need is unmet despite availability of matched services.
The questionnaire (see Appendix A) was designed to collect largely quantitative data, with provisions for qualitative data derived from descriptions participants may provide about their experience of services they have accessed. Participants were invited to explain, for example, why they may not have found a particular service readily available, or how the utility of various services they have accessed in the past may be improved. About 40–50% of the interview time was allotted for open-ended questions.
Each interview was approximately 1 hour (with provisions made for participants who voluntarily wished to spend more time sharing their experiences). Participants were financially compensated for their time (maximum $20) and were informed during the recruitment and consent process about compensation. Compensation was intended to reduce any hardship that participation in the study may have imposed on participants. The University of Toronto REB approved the compensation protocol, which was intended to be respectful of the participants’ time but not large in monetary amount to be coercive.
Discrete scales (both nominal and ordinal) are used to code participants’ answers to the structured component of the interview. Most answers to questions in this component have been defined by preset choices. Continuous scales were used for some demographic data and some types of quantitative information—for example, the amount of time a participant believes he can stay at his current accommodation. Evidence of social exclusion was derived from participants’ answers to questions assessing the participants’ living condition, stability of income and accommodation, food security, social support, and health status. The data collected from participants who remained anonymous were coded and recorded on an Excel spreadsheet. Statistical measures of centrality were applied to the very few points of data measured by continuous numeric scales.
Open-ended questions (non-quantifiable) in the interview questionnaire were used to uncover reasons that may explain potential mismatches between identified unmet needs and accessible services. These reasons cannot be predicted or adequately represented by the quantifiable component of the questionnaire. Answers were recorded by hand-writing on paper. Participant’s answers recorded on paper were analyzed for common barriers that may be preventing access to available services that mitigate social exclusion.
The mean age of male older adults in the study was 68 years (SD = 3.65; range 65–78). Table 1 is a summary of demographic data that were reported by study participants. Four were born in Canada and most of those who immigrated have lived in Canada for at least 40 years (64%). Eleven were born in various places in Eastern and Western Europe. Three were born in China, Guyana, and Iran. Three of the fifteen participants are not Canadian citizens. Compared to the entire Toronto population of older adults with only 17% born in Europe, a higher proportion of study participants were born in Europe (74%). Compared to the Toronto population of older adults, of whom 60% are single, divorced, or unattached, a greater proportion of study participants are so (80%). Furthermore, a greater percentage of study participants did not complete high school (33%) compared to 19% of Toronto older adults overall. These descriptions suggest the group of men interviewed for this study is sufficiently diverse, but is not perfectly representative of the Toronto elderly population at large.
TABLE 1.
Participant Demographics: Summary of study participant characteristics.
Nevertheless, the group of men interviewed for this study is part of the population of highly socially disadvantaged older adults living in Toronto. Of all Toronto older adults (65 years of age and over), 45% live in non-family situation, and 75% of these older adults live alone.(5) This represents about 90,000 older adults who are at risk of insecurity in income, housing, poor nutrition, high stress, and loneliness. These older adults are also more likely to be socially disadvantaged in that they have less economic security, less social support, and less choice in housing than older adults living in family-situations.(5) Significantly, all study participants live in non-family situations or alone. Two participants reported paying rent for apartments they share with their spouses, but reside in shelters due to conflicts. Two participants are facing eviction. These findings suggest study participants may be significantly socially disadvantaged.
Social disadvantage is further evidenced by participants’ reasons for losing previous accommodation. Two participants lost their apartments due to loss of income upon retirement. Two participants lost their apartments due to bank repossession of assets. Two lost their apartments due to fire. One participant lost his apartment after the building was sold. Most of these men now reside in shelters due to lack of social safety nets and savings. Together, these findings suggest study participants are some of the most vulnerable older adults living in Toronto.
The mean income of study participants is $1,100 (SD = 376, range $607–$1,900†). On average, study participants are $670 per month short of the poverty line (SD = 376, range $0–$1,173). The 11 participants who pay for accommodation, on average pay 23% of their income (SD = 19, range 14–61%). Table 2 summarizes income sources used by study participants. Most participants (80%) use Canada Pension Plan (CPP), as well as one or more other sources of income such as Old Age Security (OAS) and Guaranteed Income Supplement (GIS). Eleven participants use at least two sources of income (Table 2). Three participants reported doing undeclared part-time work for extra income. Eight participants expressed wish to work to earn extra money. Only five participants perceived their income each month to be adequate (each have monthly incomes of $850, $900, $1,000, $1,120, and $1,900).
TABLE 2.
Income: Summary of all income sources used by study participants.
Participants who believe their income to be adequate attribute adequacy to not using substances, to the use of support services, to subsidized housing, and to suppressing needs:
“I don’t drug, I don’t drink, I smoke, so two hundred is enough.”
“Income is adequate only because I use support services.”
“Six hundred more is needed if I don’t have subsidized housing.”
“I make do with whatever I got.”
“It would be nice to have money in the bank, to have a need, and be able to use it.”
Needs suppressed include saving money for emergencies, prescription medications, dentures, and dental care.
Participants who believe their income to be inadequate attributed inadequacy to substance use, debt problems, and expressed self-blame:
“Income is inadequate only because I have a [cocaine] habit.”
“When you make a mistake [get into debt], you have to pay for it.”
These findings suggest participants’ perception of income adequacy or inadequacy may not correlate with the fulfillment of basic needs such as food, health care, and housing. Study participants rely on GNC case workers and social workers to find subsidies to buy prescription medications, dentures, or pro bono services to obtain dental care. Without GNC, most of these study participants simply live without these basic essentials and simply desist in calling them “needs” (see “Basic Good Health”).
GNC provides two meals and a snack each day for $1 each to members. All participants are entirely dependent on GNC and other food services for their daily meals (Table 3). Figure 1 shows most participants use at least two or more food services simultaneously. Regardless of perceived adequacy of income, participants recognize the necessity of food services:
“I am not hungry because of food services.”
“If it wasn’t for them [food banks], I would not be making it.”
TABLE 3.
Food Sources: Summary of all food sources used by study participants on a daily basis.
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FIGURE 1. Study participants seldom used one food source listed in Table 3; most used at least two simultaneously |
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Most participants rated the quality of food from community agencies high. Most participants also recognized and were thankful for the effort of food providers to make available fresh fruits and vegetables:
“GNC provides fresh fruits and vegetables.”
“Fred Victor [shelter] charges money for meat but veggies are free.”
Only five participants indicated that food was not fresh or healthy enough:
“Nothing is fresh [at the shelter], highly processed foods...like instant potatoes and instant eggs, high starch. I like fresh foods better when I can cook and shop for myself.”
Participants who used to have their own kitchen and to cook for themselves were more likely to rate the quality of food from various food services to be low:
“I ate better when I was working as a painter. I had control over my living situation. I ate 3 meals and ate foods that were healthy.”
The inability to control food choices were frequently attributed to living situation factors such as shelter living, lack of space, and lack of own fridge space. Low income and rising prices were also mentioned by some participants as reasons for not having a healthier or more regular diet:
“Groceries are very expensive. I cannot buy fresh fruits and veggies.”
“Once in a while I go without food, food is too expensive, sometimes my stomach is empty, you know how it feels to go one day without food?”
Together, these findings suggest although food services are protecting older adults in the study from chronic hunger, dependency on food services and low income severely limit study participants’ food choices. Significantly, those who do not use substances and have their own living space still find it difficult to afford fresh fruits and vegetables on a daily basis, and therefore rely heavily on food banks and other meal services. Informally, two study participants expressed longing for steady employment so that they would be able to cook their own meals in their own kitchen.
Ten out of the fifteen senior participants in this study have family doctors who have seen them at least once in the past five years. This represents 67%, which is much lower than the national average of 95% of older adults in Canada enrolled with family doctors.(11)Table 4 summarizes health services used by study participants in the past five years.
TABLE 4.
Health service use and health issues not addressed by any service. Summary of the type of health and allied care services used by study participants. Despite the variety of health services available to participants, participants had many health needs not yet addressed that could be addressed by the same services available.
Most participants have used at least two of the services listed. Despite GNC support for members in making and keeping health appointments, the level of access by members ranged widely from full utility to no utility of health services:
“I don’t have as much [health] needs because they are met by services.”
“If I need help I get it from my doctor, have been for 10 years.”
“I get a check-up every year.”
“Last time I saw a doctor was a long time ago. Over ten years ago.”
“My health is not good because my ex-wife keeps buying voodoo dolls to hurt me.”
Also listed in Table 4 are health issues identified during the interview as not yet addressed by health care professionals. Most participants face two or more health issues not yet addressed (Figure 2). All participants have access to services provided by GNC staff to make, keep, and travel to health appointments. Despite the effort by GNC staff, many participants still have varied health issues not yet addressed by a health-care professional. Some identified barriers to health include low income, lack of insurance, mental health problems, boredom, perceived lack of utility of a health service, and availability of a family doctor of choice:
“If medicine is not free, I don’t get the prescription filled.”
“I need services to be free of charge, otherwise I can’t pay for them.”
“ODSP was cut and with it dental and vision care.”
“I feel depressed all the time. When I am depressed I smoke and drink.”
“I should lose weight. I am eating too much out of boredom. Sometimes when you don’t have anything to do you just go from one shelter to another and eat.”
“Psychiatrist cannot do anything for me. I saw him for two years after divorce.”
“I really need one but doctor I want cannot take any more patients.”
“I wish for a family doctor, I’m trying to connect to a Russian doctor.”
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FIGURE 2. Most study participants had at least two active health issues concurrently at the time of interview |
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Despite living with multiple concurrent health issues, most study participants self-rated their heath as fair, good, or excellent (Figure 3). All but one‡ study participant have accessed health services without impediment and rated their impact as very high. These findings suggest that personal factors, such as poor insight and poor mental health, significantly interfere with study participants’ engagement in their own health care. Many participants would benefit from available mental health and addictions services. However, despite the effort by GNC staff to remind members of, and escort members to, health appointments, poor adherence with medication and follow-up form real barriers to optimal health.
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FIGURE 3. Most participants rated their health status positively |
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The 11 participants who pay for accommodation, on average pay $237 per month (SD = 219, range $104–$700). Table 5 summarizes the type of accommodation in which study participants currently reside. Only two of the 11 participants paying a monthly fee for accommodation pay market rent (both of these men rely on the shelter system and do not live in the apartment they are renting due to conflict with their spouse). Others rely on rent-geared-to-income or subsidized rent. Seven participants indicated that they have had telephone, cable, Internet and/or electricity cut off in the past because they could not pay the bill. All participants have moved at least once in the past 5.5 years. Length of stay in current accommodation is an average of 21.2 months (SD = 20.2, range 1–66, median = 16). Length of stay in previous accommodation is an average of 45.6 months (SD = 59, range 1–180, median 12). Six participants indicated the wish to move within the next four months. Three study participants lost previous accommodations that they had held for 10, 12, and 15 years. Ten study participants are working with social, housing, or case workers on their housing situation to secure more stable accommodation. Most participants expressed dissatisfaction with their current accommodation and indicated low income to be a major cause of lack of choice in housing. Other reasons for lack of choice in housing include shortage of affordable housing and long wait lists:
“I’m in a shelter because of money shortage.”
“Things would be a lot better if housing moves faster.”
“The cost of housing is too high, ratio of rent to income is not fair.”
“I cannot live forever in Jarvis House [shelter], the rule is, you have to put your name into Housing Commission, and it can take 6 months to 6 years to find [affordable] housing.”
“I want to move from this environment. Because I cannot get a work permit, I can’t afford to move.”
TABLE 5.
Housing or Shelter: Summary of study participants’ living situation.
Study participants who live in shelters and hostels indicate lack of privacy and autonomy as reasons for wishing to move from the environment:
“I can’t complain, I got food and a roof over my head, the only thing missing is my privacy.”
“I want my own place. I would cook for myself if I had my own place.”
Study participants who live in shared spaces indicated problematic house or shelter-mates as reasons for wanting to move from the environment:
“I live in a shelter. You have to have a very thick skin.”
“I live with a psychopath...I’m in danger of becoming homeless...”
“My ex-wife is a prostitute. I have to leave when she has a John over.”
“I need to talk to [my wife] to work things out. It’s my own fault I drink too much.”
Taken together, these findings suggest study participants experience significant instability in housing as indicated by length of stay results, and significant dissatisfaction with their living situations. These results show personal factors (conflicts with co-inhabitants) combined with income shortage and systemic factors (unavailability of affordable housing) lead to an increase in the number of moves from one housing situation to another, and chronic shelter-dwelling. Most study participants displayed awareness that income shortage and systemic affordable housing scarcity are problems not immediately solvable by the housing, social, or case workers helping them.
Likert scales of 0–4 (0 = not a problem, 4 = major impactful problem) were used to assess the level of physical and mental safety experienced by study participants in the environment of their accommodation (Figure 4) and neighbourhood (Figure 5). Major problems with accommodation include bedbugs and rodents, shortage of space, and theft (Figure 4). Major problems with neighbourhood include drug dealing and use, drunkenness, theft, and vandalism (Figure 5). Regardless of type of accommodation, if shared, participants often live with conflict and stress due to incompatibility of fellow house or shelter-mates. Participants also expressed lack of police cooperation as a reason for distress:
“When people I don’t know knock on my door, I don’t answer. These people take over your apartment to use [as a] crack house if you open the door.”
“Other [shelter] residents are unpredictable, it’s a stressful environment.”
“It’s useless to go to the police, the police would just say ‘why don’t you go arrest them yourself’?”
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FIGURE 4. Bars represent group sums of Likert scores (0 = not a problem, 4 = major impactful problem) for the potential problem listed; the number of participants who agreed that potential problem is real in their case (in parentheses) |
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FIGURE 5. Bars represent group sums of Likert scores (0 = not a problem, 4 = major impactful problem) for the potential problem listed; the number of participants who agreed that potential problem is real in their case (in parentheses) |
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Over half of study participants showed evidence of severe financial insecurity in their answers to questions about income inadequacy and financial worry (Table 6). Risky behaviour and poor mental health, falling victim to financial fraud, indebtedness due to financial mismanagement, and lack of savings and insurance, were reasons that contributed to loss of accommodation, income shortage, and inability to cope with divorce, retirement, or adverse events such as accidents and fire.
TABLE 6.
Financial Insecurity: Study participants’ responses to interview questions regarding their financial status, sorted by themes.
Currently, none of the study participants are taking part in any formal program that addresses financial security. One participant was coerced into spending his life savings on a property that was in fact, not for sale. He lost his home, placed all his belongings in storage, and is currently attempting to regain lost property using pro bono legal services. Generally, study participants were reluctant to disclose full details of their monthly budgets. Most of those willing to disclose details of their finances talked about debt to people, pay-day loan companies, street dealers, and credit card companies. None of these participants have sought help for their financial problems, mainly out of shame. Many of these men hold themselves responsible for bad choices that led to their financial ruin. These findings highlight the need to explore the issue of financial illiteracy with further studies, and address personal factors (such as self-blame and lack of financial insight) that may form barriers preventing these men from seeking help for their financial problems.
One study participant with significant long-term mental health issues lives in fear of his “ex-wife” and gives most of his monthly income to a “psychic”. He refuses help from a psychiatrist and has not seen a family doctor in over 10 years. He has not been declared “financially incapable” in order that his assets be placed under the control of the public guardian and trustee. His case illustrates the unscrupulousness of the “psychic” in question, taking advantage of his delusion for financial gain. Although the details of the case of this particular study participant is not representative of other participants in the study nor is it representative of the population of older adults in Toronto as a whole, it does highlight the need to scrutinize this population’s vulnerability to financial fraud.
All participants have used social work in the past and expressed willingness to approach social work again to help them with their problems. All participants agreed that social work is invaluable to their safety and well-being. Contrastingly, all participants expressed unwillingness and in some cases apprehension with the idea of approaching family or friends for help of any kind:
“Social worker is helping me keep my place” (facing eviction for not paying rent).
“When I need anything I go to my social worker.”
“Most support I get is from the club (GNC).”
“I don’t have to sleep on the street. Without them (services) life would be much worse. They saved my life. I’m not hungry. I would starve or freeze to death without these people.”
“I have no friends to count on. I can count on social worker for sure. I don’t mind getting help from the social worker.”
“I don’t think I should ask for help from my family anymore. I feel it’s not right to go back to my family. There’s a limit.”
“I feel ashamed so I don’t want to talk to anybody. I understand that family should be there but I overused it, I cannot ask anymore. My brother would help me but it would have to be really extreme.”
For all participants, damage control by GNC social work and availability of the shelter system prevent homelessness when adversities such as loss of accommodation, loss of income, and other unpredictable events occur. These findings suggest that GNC forms an indispensible social safety net protecting members from falling into homelessness and ruin. The professionalism of GNC staff likely creates a distance that facilitates appropriate help-seeking behaviour for members, who often reject similar help from their own families out of shame. (Also see results from “Psychosocial Needs” indicating that study participants generally have very few close family contacts.) GNC is most study participants’ only lifeline.
Overall, study participants have weak family connections. The majority of participants are in contact with zero or one family member, with whom they speak infrequently over the phone. Neighbours are frequently sources of stress and not support. Only two participants reported that they are in an intimate relationship. However, neither man stably resides with his spouse in their shared space. The participant with the strongest family connection reported only one family member, his daughter, who he sees at least once a week face-to-face and the interaction is always positive. The participant with the strongest network of friends reported six friends who live close to him and the interaction is usually positive. Most participants reported no support or low level of support when asked if they were to need someone to talk to. For all participants, the GNC is the main source of feelings of belonging.
Most participants are aware of opportunities to volunteer at the GNC in exchange for free meals. These volunteering activities encourage participation in the community of the club. Study participants who actively participate displayed pride in their body language and facial expressions when they speak of what they do:
“I am always willing to help out around the club, happily.”
“At the GNC, you name it, I will [volunteer to] do it.” “I run the library for GNC.”
“I take care of the membership database for GNC” (for over 12 years)
“I raised money for the Japanese Tsunami, gave $800 to the Red Cross.”
Contrastingly, the participant who expresses shame and self-blame for financial and housing problems was also the participant who felt he had nothing to contribute to the community of the GNC:
“I can’t see anything of substance that I can contribute.”
Similarly, the participant who feels himself wronged by the government or society at large objects to making contributions to the community of the GNC:
“I don’t want to be part of the system. The system stinks.”
Volunteering opportunities seem to generate genuine feelings of accomplishment, self-respect, self-mastery, as well as encourage leadership, independence, and creativity. Opportunities to fulfill these psychological needs may be few for these men due to limited resources and motivation.
Support services are vital to the well-being of study participants. Support services delivered via GNC clearly mitigate the effects of social exclusion. GNC offers its members the benefits of belonging to a civil group in society, of improved access to social goods (food, clothing, shelter, health, and social services, etc.), and even opportunities to take more active roles in society outside of the club. Due to the effort of GNC staff, study participants have greater ability to access social, economic, political, and cultural resources as members of the club. In other words, study participants rely on GNC for social inclusiveness.
However, even though 60% of the participants self-reported their health to be in either excellent or good condition, we did not see clear evidence suggesting that efforts to increase social inclusion also increased health resilience. Study participants continue to live with chronic health issues that do not get addressed despite the availability of options to seek care through GNC services. This is not fully consistent with observations by Sanders et al .(8) who find improved health outcomes for those who experience more social inclusion. Our findings may be divergent because Sanders and colleagues did not focus only on older adults. Nevertheless, participants in their study who showed health resilience did not experience housing insecurity and mental health issues to the level experienced by those who showed weak health resilience. This alludes to the importance of stable housing and mental health for health resilience within the limitations of poverty. Therefore, ongoing housing insecurity and mental health issues may partly explain why the participants of our study do not exhibit attributes of health resilience despite the availability of support services through the GNC. Interestingly, one study of an elderly population does not find correlation between resilience and support service variables, but does report a positive correlation between resilience and self-esteem.(12) Most of the participants of that study were elderly women. Still, it is plausible that low self-esteem and low self-fulfillment reported by some of the participants of our study, and limited engagement in activities (volunteer or paid work) which can help with self-esteem, may mitigate the effects of other social support services in improving health resilience. Despite GNC’s long list of programs, study participants still live with unmet needs and housing instability. Factors that counter the effort by GNC staff in meeting the members’ needs are countered by systemic or policy problems such as affordable housing shortage, inadequate income support, and scarcity of job opportunities for older adults. Effort by GNC staff is also countered by personal problems such as poor health and financial insight, untreated mental health and addiction, financial fraud, shame, and self-blame.
For all study participants, GNC is the only social safety net. GNC staff responds to crises and works to reduce the impact of disruptions, such as divorce, separation, fire, and eviction, to the men’s lives. The GNC staff advocates for the men by connecting them to sources of free dental, eye, and hearing care. GNC takes care of the men holistically and addresses needs ranging from the basic to the psychosocially more complex such as self-worth. The only service not yet available to the men at GNC is financial literacy courses and resources to decrease vulnerability to financial fraud.
A study of 550 older adults by Bennett and colleagues(13) revealed a positive association between both health literacy and financial literacy and indicators of health status, which included cognition, functional status, and mental health. Interestingly, while health literacy was linked more strongly to health promoting behaviour, financial literacy was linked more strongly to mental health. Lack of financial literacy support at the GNC and stress and mental health combined being the most prevalent health issue with the participants of our study is consistent with the findings of Bennett et al . Evidence of the detrimental impact of low financial literacy suggests a need to design and implement programs to help these men build the capacity to manage finances and resist falling into debt or victim to financial fraud. GNC already implements computer literacy classes to its members quite effectively. The lessons learned from logistics of providing computer literacy classes for this population of male older adults may be applied to provide classes in basic financial literacy.
Limitations of this study include lack of validation for questionnaire design, sample selection bias, and lack of interview structure. Individual questions are based on validated surveys.(14,15) The questionnaire in its entirety is unique and has not been validated. The semi-structured interview format is not systematic and varies depending on the interpersonal dynamics between the interviewer and each study participant. Future directions aimed at addressing the lack of systematic process may employ more than one interviewer interviewing one research participant for results comparison. Sample size and selection also pose major sources of bias for study results. The exclusion of female older adults, home-bound older adults, and male non-members of GNC may be addressed in the future by actively seeking to interview members of these groups.
General Information and Demographics
1D/ How would rate your abilities in English?
1E/ Do you consider yourself to be (more than one answer is possible and you need not answer):
□ White or Caucasian
□ People of African Ancestry
□ Indigenous Peoples of Canada (First Nations, Inuit, Metis)
□ Hispanic or Latin American
□ East Asian
□ South Asian
□ Southeast Asian
□ West Asian
□ Other visible minority (go to question 1F)
□ Prefer not to answer
1F/ How would you describe your cultural or ethnic background? __________________________________
1G/ Were you a born in Canada?
1H/ If no, in what country were you born? __________________________
1I/ In what year did you come to Canada? ________ (At what age did you…? __ How long have you been…? __)
1J/ Do you have any disabilities?
□ Yes (answer 1K and 1L before moving on to section 2)
□ No (skip to section 2)
□ Prefer not to answer (skip to section 2)
1K/ How would you describe your most severe disability?_______________________________________
1L/ On a scale of 1 (least) to 5 (most), how much does your most severe disability interfere with caring for yourself (dressing, bathing, etc)?
1M/ On the same scale, how much does your most severe disability interfere with cleaning, shopping, cooking, banking, etc)?
Education / Computer literacy
2A/ What is the highest level of education you completed?
□ Did not complete high school
□ College or University
□ Prefer not to answer
□ High school graduate
□ Graduate or Professional Degree
2B/ How would you rate your ability to use the computer?
□ Able to use on my own (go to 2C)
□ Need assistance to use always (go to 2C)
□ I don’t need to use the computer (go to section 3)
□ Need assistance to use sometimes (go to 2C)
□ Not able to use the computer at all (go to section 3)
2C/ If you do use the computer, how would you rate your access to the internet?
□ Access from home (go to 2E)
□ Easy access from outside the home (go to 2D)
□ Difficult access from outside the home (go to 2D)
□ No access (go to section 3)
□ I don’t need access to the internet (go to section 3)
2D/ If access is not from home, where do you go to get internet access? ____________________________
2E/ How often do you use the internet to help you locate services that you need?
Income source / amount
3A/ Are you currently: (if you are working, please indicate what kind of work you do)
□ Working full-time
□ Working part-time
□ Performing casual or piece work
□ Not working
3B/ What is your monthly or weekly income? ________________________________________________
3C/ What is the source of your income? (More than one answer is possible, and you can prefer not to answer)
□ Canadian Pension Plan (CPP)
□ Old Age Security (OAS)
□ Guaranteed Income Supplement (GIS)
□ Own investments
□ Own savings
□ Family support
□ Other, please specify ______________________________________________________
□ Prefer not to answer
3E/ By how much are you usually short each month to make ends meet?
3F/ How much do you agree or disagree with the following statements?
3F-i. I am satisfied with my level of income. (If you disagree, please explain why.)
□ Strongly agree
□ Somewhat agree
□ Neither agree or disagree
□ Somewhat disagree
□ Strongly disagree
3E-ii. I worry about my financial future. (If you agree, please explain why.)
□ Strongly agree
□ Somewhat agree
□ Neither agree or disagree
□ Somewhat disagree
□ Strongly disagree
Social Support Network and Social Involvement
4A/ How many relatives do you stay in contact with? (if 0, go to 4E)
4B/ With the relative you are closest to, how often do you contact him or her?
4C/ By what method do you keep in touch with your closest relative? (more than one answer is possible)
□ Telephone
□ Face-to-face
□ Other method, please specify _________________________________________________
4D/ How would you describe your interactions with your closest relative?
4E/ How many friends do you stay in contact with? (If 0 go to 4I)
4F/ With the friend you are closest to, how often do you contact him or her?
4G/ By what method do you keep in touch with your closest friend?
□ Telephone
□ Face-to-face
□ Other method, please specify ________________________________________________
4H/ How would you describe your interactions with your closest friend?
4I/ How often do you speak to your neighbour(s)? (if not, go to 4K)
4J/ How would you describe your interactions with your neighbour(s)?
4K/ How much support do you get in the following situations? (Please consider support from people you live with, family and friends, and any other means of support. You do not have to answer if you do not prefer.)
4K-i. When you are in bed with illness and need help around the home.
4K-ii. When you cannot manage alone and need help with heavy household or gardening jobs (ex. moving furniture)
4K-iii. When you have an important change in your life and need help (ex. moving, new illness)
4K-iv. When you are in a conflict with someone and need help with resolving the conflict.
4K-v. When you need someone to talk to for any reason.
4K-vi. When you are in a crisis.
4K-vii. When you are in financial trouble.
4L/ Which, if any, of the following activities on this list have you done in the past 5 years?
□ Made my views known to my MPP or my MP
□ Written a letter to a newspaper
□ Urged someone outside my family to vote
□ Urged someone to get in touch with a political representative
□ Made a speech in front of an organized group
□ Taken a position of leadership in a community organization
□ Taken an active part in a political campaign
□ Helped on fund raising drives
□ Voted in the last federal/provincial/municipal election
□ Other activist activities, please specify _________________________________________
□ None of the above applies to me (go to 4M)
4M/ Are you currently an active member of any of the following organisations? Being an active member of an organization means you take part in the activities of the organization at least once every few months.
4N/ If you are not involved in any organization or activities activity, what do you feel prevents you from taking part? (no interest, no point,etc.) ____________________________________________________________
Living situation / Household composition
5B/ Who shares your accommodation? _________________________________________________________
5C/ What type of accommodation do you live in? (can be observed)
5D/ Approximately when was your property built? (Please make your best guess)
5E/ In which of the following ways do you occupy your place of residence?
□ Own it
□ Buying it with help of mortgage or loan
□ Pay part of mortgage
□ Paying market rent
□ Paying subsidized rent
□ Paying rent-geared-to-income
□ Live free rent
□ Squatting
□ Other, please specify____________________________________________________
5F/ Do you have any of these problems with your accommodation? (More than one answer is possible, and for each of the problem identified, I will ask you to rate the severity of the problem as: “very severe”, “quite severe”, “not severe”, and “varies”)
5G/ Have you taken steps to improve the conditions of your living situation?
□ Yes (please explain how)___________________________________________________
□ No (go to 5H)
5H/ What prevents you from taking steps to improve the conditions of your living? ______________________________________________________________________________________________________
5I/ Do you have any of these problems with your neighbourhood? (More than one answer is possible, and for each of the problem identified, I will ask you to rate the severity of the problem as: “minor problem” or “major problem”)
5J/ Have you taken steps to solve the above problem(s)?
□ Yes (please explain how)___________________________________________________
□ No (go to 5K)
5K/ What prevents you from taking steps to solve the above problems? ______________________________________________________________________________________________________________
Social / Housing support
6A/ How much do you pay per week or per month for your accommodation? _____________________
6B/ How long have you been staying at your current accommodation? __________________________
6C/ How long did you stay in your last accommodation? _____________________________________
6D/ How long do you think you will be able stay at your current accommodation? _________________
6E/ Have you ever been disconnected from the following utilities because you could not pay the bill?
6F/ Are you currently receiving support from one or more of the following services/agency to maintain your accommodation?
□ Toronto Community Housing Corporation (TCHC)
□ Private non-profit housing (operated by community-based non-profit organizations)
□ Co-operative housing (administered through the Agency for Co-operative Housing)
□ Private rent supplement programs (Rent-Geared-to-Income or RGI assistance)
□ Housing allowance programs
□ Other, please specify _____________________________________________________
□ None of the above
6G/ How much do you agree with the following statements?
6G-i. I am satisfied with my living situation. (If you disagree, please explain.)
□ Strongly agree (go to section 7)
□ Somewhat agree (go to section 7)
□ Neither agree or disagree
□ Somewhat disagree
□ Strongly disagree
6G-ii. I need help to stay in my current accommodation. (If you agree, please explain.)
□ Strongly agree
□ Somewhat agree
□ Neither agree or disagree
□ Somewhat disagree
□ Strongly disagree
6G-iii. I am at risk of losing my current accommodation. (If you agree, please explain.)
□ Strongly agree
□ Somewhat agree
□ Neither agree or disagree
□ Somewhat disagree
□ Strongly disagree
6G-iv. There are people who would help me if I lost my current accommodation. (If you disagree, please explain.)
□ Strongly agree
□ Somewhat agree
□ Neither agree or disagree
□ Somewhat disagree
□ Strongly disagree
Health Status
7A/ How would you rate your health over the last year?
7B/ If your answer is “Poor,” “Very poor,” or “Varies,” please explain_____________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
7C/ How much do you agree with the following statement?
7C-i. My income level makes it difficult for me to obtain medical supplies I need. (If you agree, please explain)
□ Strongly agree
□ Somewhat agree
□ Neither agree or disagree
□ Somewhat disagree
□ Strongly disagree
7C-ii. My income level has a negative impact on my general health and well-being. (If you agree, please explain)
□ Strongly agree
□ Somewhat agree
□ Neither agree or disagree
□ Somewhat disagree
□ Strongly disagree
7C-iii. My income level has a negative impact on my living situation. (If you agree, please explain)
□ Strongly agree
□ Somewhat agree
□ Neither agree or disagree
□ Somewhat disagree
□ Strongly disagree
7D/ Do you currently have any health problems (such as hearing problems, diabetes, cancer, etc) for which you have not obtained care (from a nurse, doctor or other health professional) in the past 6 months?
7E/ Please list the problems for which you have not obtained care and rate the severity:
7F/ Which of the following aspects of your home do you think has a negative impact on your health or well-being? (More than one answer is possible, and for each of the problem identified, I will ask you to rate the severity of the problem as having a “minor impact” or “major impact” on your health and well-being.)
7G/ On a scale of 1 to 5, 5 being most severe, how would you rate the degree your health problem(s) interferes with your activities of daily living, such as caring for yourself, feeing yourself, washing, putting on clothes?
7H/ On a scale of 1 to 5, 5 being most severe, how would you rate the degree your health problem(s) interferes with your house work (cooking, cleaning, shopping, banking)?
7I/ How On a scale of 1 to 5, 5 being most severe, how would you rate the degree your health problem(s) interferes with getting around (walking, climbing stairs)?
7J/ How On a scale of 1 to 5, 5 being most severe, how would you rate the degree your health problem(s) interferes with your social life (spending time with friends and relatives etc.)?
7K/ Have you taken steps to improve your health and well-being?
7L/ What steps have you taken to improve your health and well-being? ______________________
______________________________________________________________________________________
7M/ What prevents you from taking steps to improve your health and well-being? _________________ ____________________________________________________________________________________
Food security
8A/ A healthy diet involves consuming a balance of fresh fruits and vegetables, grains, meats and dairy or meat or dairy alternatives. How would you rate the quality of your diet? (please explain your rating)
□ Very healthy
□ Somewhat healthy
□ Somewhat unhealthy
□ Very unhealthy
□ Varies
8B/ How much do you agree with the following statements?
8B-i. My income prevents me from obtaining a healthy diet. (If you agree, please explain.)
□ Strongly agree
□ Somewhat agree
□ Neither agree or disagree
□ Somewhat disagree
□ Strongly disagree
8B-ii. My health problems prevent me from obtaining a healthy diet. (If you agree, please explain.)
□ Strongly agree
□ Somewhat agree
□ Neither agree or disagree
□ Somewhat disagree
□ Strongly disagree
8B-iii. My living situation prevents me from obtaining a healthy diet. (If you agree, please explain.)
□ Strongly agree
□ Somewhat agree
□ Neither agree or disagree
□ Somewhat disagree
□ Strongly disagree
8B-iv. Please state any other reasons that may explain why you have trouble maintaining a healthy diet.
__________________________________________________________
__________________________________________________________
Awareness of, access to and utility of government-provided and other community services
9A/ The telephone number 311 is for personal assistance, non-emergency City services, programs and information. How often do you use 311 to get information about services or help you need?
9B/ For what services did you gain information from calling 311? __________________________________________________________________________________________________________________________
____________________________________________________
9D/ Why have you not used 311 services? ____________________________________________________
9E/ The telephone number 211 is for social services and counseling referrals.
How often do you use 211 to get information about community, social, health, and governmental services that you need?
9F/ For what services did you gain information from 211? ______________________________________________________________________________________________________________________________
____________________________________________________
9G/ Why have you not used 211 services? ____________________________________________________
9H/ How often do you use the internet to get information about services you need?
9I/ For what services did you gain information from the internet?_______________________________
_____________________________________________________
9K/ Why have you not used the internet? _____________________________________________________
Awareness of, access to and utility of legal, housing, social, food and health services
10A/ How often in the past five years have you made use of legal and/or housing support services (such as Legal Aid Ontario, Tenant Hotline, Housing Help Centres, Rent bank, Home energy help, or Emergency Energy Fund)?
10B/ Which housing support services have you used? ______________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________
10D/ Why have you never used housing support services? ___________________________________________________________________________________________________________________________
10E/ How often in the past five years have you made use of social and/or community services (such as Social work services, ID replacement services, community income tax clinics, services at community centres)?
10F/ Which social and/or community support services have you used? ________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________
10H/ Why have you never used social and/or community support services? ____________________________________________________________________________________________________
10I/ How often in the past five years have you made use of food services (such as Food banks, Community kitchens, Meals on Wheels)?
10J/ Which food services have you used? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
10M/ Why have you never used food services? ______________________________________________________________________________________________________________________________________
10N/ How often in the past five years have you made use of health services (such as dental health services, vision/hearing care, home care services, doctors’s house call services, foot care clinics, addictions services, nutritional counselling, Telehealth Ontario, nursing clinics, walk-in clinics, hospital ER, family doctor)?
10O/ Which health services have you used? ________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
10Q/ Why have you not used health services? ________________________________________________
10R/ How often in the past five years have you made use of senior-focused services that I will list. (If you have used the service, I will ask you if you found the service helpful and why. If you have not used the service, I will ask you why you have not made use of the service, for example, you may not have heard of the service or needed it.)
Participants will be recruited by face-to-face, one-on-one conversation. Identification of potential interviewees and the recruitment process will be supported by Street Health staff.
“We are conducting a study to understand the health and housing needs of people over the age of 65, and to determine whether their needs are being met by various services and referrals. The research study involves completing an interview. The questions in the interview are about different aspects of your life, your health status, your housing status, and your use of health and social and health services. During the interview, you will be asked questions like whether you feel that you have any health problems, as these things are thought to be related to your living situation and life circumstances. You will also be asked some information about you (such as your educational level and cultural background). There are also some questions about your thoughts and feelings about your living situation and what could make life better for you. Your answers to the interview questions will not be linked to your identifying information. If you would like to participate in this study, we first have to ask you three questions to ensure that you are eligible. If you are eligible, we will make an appointment for you to sit down with our student investigator, Vicky Nguyen. She will go through the consent process with you and will conduct the interview. The interview itself will take about an hour. Participation is completely voluntary and you can choose to withdraw at anytime. You will also be compensated for your time.”
“Thank you for considering participating in the study. I will ask you three questions to ensure that you are eligible for the full-length interview. We want to interview seniors who are over the age of 65 and who are not living with their family and are living on an income of $1779 or less per month or $445 or less per week. Your answers are voluntary and everything you say will be kept confidential. Do you wish to go on? The first question is: In what year were you born? The second question is: Do you live with your family? The third question is: What is your monthly or weekly income?”
The authors declare that no conflicts of interest exist.
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†One participant has an income of $1,900 per month (more than $1,780 limit), but was included in the study because most of his income is used toward debt payments. ( Return to Text )
‡One participant is a US citizen and expressed wish to return to the US for healthcare when he is eligible. ( Return to Text )
*The Good Neighbours’ Club (GNC) is a non-profit, community-based agency that provides services to promote well-being, personal growth, health, and social inclusion to elderly, unemployed, and homeless men. Members of the club are welcomed into a supportive environment where they have access to meals, mail and phone services, laundry and showers, clothing, library and computers, transportation to appointments when public transit is not feasible, and other services according to individual member’s needs. GNC also provides friendly visits to members unable to come to the club, and funeral services to members who die without next of kin. GNC staff work diligently to identify needs and connect GNC members to appropriate resources. GNC thus may be thought to promote social inclusion for its members. In fact, for members of GNC, access to support services is frequently obtained solely via GNC staff consisting of case workers and social workers. For many male older adults of limited means, experiencing weak or absent social networks, GNC may be their only lifeline. See http://goodneighboursclub.org/services.html ( Return to Text )
Canadian Geriatrics Journal , Vol. 16 , No. 4 , 2013