Assessment of How House Ownership Shapes Health Outcomes in Urban Ghana

Round 1

Reviewer 1 Report

The paper presents a research that is quite interesting and which relevance is remarkable in the area of urban health and equity. Anyway, in the presented paper, there are some points to be clarified: (1) a more complete introduction of the context and (2) a more developed explanation of the research process should be developed better.

(1)  The first part may be more specific on the context and in particular on the topic of housing: the points 1.1 and 1.2 seem to introduce these issues, but without the strength that they should have to clearly explain the background of such specific topics (local laws, society, economy) that could be not so clear for international readers.

(2)  The methodology and the steps used are quite clear and show a respectable development of the research (for example, is a good point the use of the Institutional Review Board). Anyway, a clearer explanation of the development is missing. After the Results of the Socio-demographics (3.1), the explanation becomes vaguer: is not clear the way in which the interviews are conducted and the way in which the Nvivo software, Pearson Chi-square and Cramer’s V methods are applied.  Moreover, the final results are not clear: closing the research’s results with the sentence “The Cramer’s V=0.467 outcome indicates an association between the two variables” seems too much limitative (in particular because the value V=0.467 is not present in table 4).

Moreover, due to lacks in language fluidity and accuracy, if a revisited version of the paper will be required, deep proofreading is suggested. In particular, additionally to minor orthographic details, there are some elements to correct, for examples: at line 244 “The Table above” should become the “Table 3”, the link of reference 26 at line 550 cannot be open, etc.

Author Response

Comment: (1)  The first part may be more specific on the context and in particular on the topic of housing: the points 1.1 and 1.2 seem to introduce these issues, but without the strength that they should have to clearly explain the background of such specific topics (local laws, society, economy) that could be not so clear for international readers.

Response: (pp. 2-5) - A house is a vital safety need [4], the non-existence of which presents workers with one of the greatest challenges in post-retirement life. House acquisition is “the purchase or securing of a house for use as a residential facility with retirement in focus” [5]. In a study conducted by [6] on the topic ‘systematic preparation process and resource mobilization towards post-retirement life in urban Ghana: an exploration’, it was observed that the indirect financial actions undertaken in preparing towards post-retirement life entail among other things medical (28.13%) and place of residence to relocate to after retirement (50.63%), the most indicated options [6]. Well-established arrangements and structures that are part of the culture of society, for instance, competitive markets, the banking system and a system of property rights are examples of economic institutions.

Economics has made a substantial contribution to our understanding of the law, but the law has also contributed to our understanding of economics. Socio-economic rights have often been regarded as less enforceable than civil and political rights [7]. The right to adequate housing, even though protecting one of the most basic needs of human beings, has not escaped this classification. Despite its strong foundations in international, regional and domestic legislation, many people are still deprived of one or more of the different key elements that comprise adequate housing. The stock of housing in any given society including Ghana encompasses privately owned and occupied houses and apartments, privately rented and local authority rented accommodation, and property managed by housing associations.

Law is a system of rules that are created and enforced through social or governmental institutions to regulate behavior. It has been defined both as ‘the science of Justice’ and ‘the art of justice’ [8]. It is also a system that regulates and ensures that individuals or a community adhere to the will of the state. The law shapes politics, economics, history and society in various ways and serves as a mediator of relations between people. The national housing policy articulates that the Section 12(2) of the 1992 Constitution states that “Every person in Ghana, whatever their race, place of origin, political opinion, color, religion, creed or gender shall be entitled to fundamental human rights and freedoms of the individual contained in this, but subject to respect for the rights and freedoms of others and for the public interest”. Section 14 covers protection of the right to personal liberty. Section 17(2) ensures equality and freedom from discrimination on grounds of gender, race, color, ethnic, origin, religion, creed or social or economic status. Section 24 lays down economic rights, including the right to work under satisfactory, safe and healthy conditions and to receive equal pay for equal work. Section 27(1) promotes women’s rights, including paid leave during maternity. Section 28 covers among other things protection against exposure to physical and moral hazards. Section 36, subsection (10) safeguards the health, safety and welfare of all persons in employment [9].

The Labor Act ensures protection of working women. It outlines the fact that the result of the discrimination is the lower average earnings for women. However, this may even be a better indication for discrimination against females, generally, at the household and community levels [10, 11].

According to [12] steadily rising housing rents in many areas pertain. Rent and the associated control seems to assist current tenants in the short run, in the long run it decreases affordability, fuels gentrification, and creates negative spillovers on the surrounding neighborhoods. The benefits of rent control is expressed in its provision of insurance against rent increases, potentially limiting displacement. Affordable housing advocates argue that these insurance benefits are valuable to tenants. For example, if long-term tenants have developed neighborhood-specific social capital, such as network of friends and family, proximity to a job, or children enrolled in local schools, then tenants face large risk from rent appreciation. In contrast, individuals who have little connection to any specific area can easily insure themselves against local rental price appreciation by moving to a cheaper location.

Some studies, for instance, [13] examined the consequences of an expansion of rent control on renters, landlords and the housing market in the society, showing that small multi-family housing was now primarily owned by large businesses and should face the same rent control of large multi-family housing. Similarly, they examined rent control’s effects on tenant migration and neighborhood choices. They found that the beneficiaries of rent control are 19% less likely to have moved to a new address. These effects are significantly stronger among older households and among households that have already spent a number of years at their address. This is consistent with the fact that both of these populations are likely to be less mobile. Renters who do not need to move very often are more likely to find it worthwhile to remain in their rent controlled apartment for a long time, enabling them to accrue larger rent savings.

The major challenge facing the housing sector in Ghana is the development of a strategy in the short term to address the huge housing deficit, and in the medium to long term, ensure that the citizenry, particularly the low-income sector of society, are able to access housing either through ownership or rental purposes [14]. Government has a major role to play in the creation of an enabling environment for housing delivery through a variety of initiatives particularly targeted at low income groups.

Housing is a multi-dimensional commodity that includes physical shelter, the related services and infrastructure, and the inputs such as land and finance required to produce and maintain it. Housing also covers the solutions geared at improvement of the shelter and the environment in which it exist. The constraints against the nation's ability and capacity to resolve the housing crisis are many. On the supply side the factors encompass land cost and accessibility; lack of access to credit; high cost of building materials; outdated building codes and standards; and lack of effective regulatory and monitoring mechanisms. On the demand side, it is basically affordability in the face of general low level of incomes of the people [14].

“In order to meet the housing challenge in the country, Government aims to establish a sustainable housing process which will eventually enable all Ghanaians to secure housing with secure tenure, within a safe and healthy environment and viable communities in a manner that will make a positive contribution to a democratic and integrated society, within the shortest possible time frame” [14], (p. 10).

Housing does not only fulfil the basic need of shelter, but also plays a vital role in the economic health of the Nation. Economic growth and prosperity enhances the creation of integrated communities and foster a sense of pride, which could encourage family self-sufficiency. The greater the ability of households in the Ghanaian society to be self-sufficient, the less the anticipated input or responsibility of Government to support that household.

Comment: (2) The methodology and the steps used are quite clear and show a respectable development of the research (for example, is a good point the use of the Institutional Review Board). Anyway, a clearer explanation of the development is missing. After the Results of the Socio-demographics (3.1), the explanation becomes vaguer: is not clear the way in which the interviews are conducted and the way in which the Nvivo software, Pearson Chi-square and Cramer’s V methods are applied.  Moreover, the final results are not clear: closing the research’s results with the sentence “The Cramer’s V=0.467 outcome indicates an association between the two variables” seems too much limitative (in particular because the value V=0.467 is not present in table 4).

Response: Research Instruments

A questionnaire containing two sections was used in the process of data collection. Section one was on the socio-demographic characteristics namely age, educational level, and ethnicity. The second section explored issues of retirement aspirations, house acquisition and ownership. The questionnaire was created based on previous research, input from colleagues and also the study’s research interests. Examples of questions that have been previously used in published studies include questions about the housing issues [5, 37]. After the initial pool of questionnaire was written, qualified experts were made to review it, especially for grammatical corrections and accuracy. Before conducting a pilot of the questionnaire on the intended respondents, it was tested on a small sample of 30 individuals following the guidelines of [38]. Afterwards, a pilot test among the intended respondents for initials validation was undertaken. All participants completed the same questionnaire.

Together these were collectively contextualized to fit this study and the Ghanaian scenario. The survey questionnaire instrument’s reliability was ensured in diverse ways, namely, facilitation by clear instructions and wording of questions. The administration of the questionnaire took the form of face-to-face interviews including self-administration. The face-to-face interviews were conducted in both English language and Ghanaian languages namely Ga, Ewe, and Twi.  The questionnaire contained standardized instructions namely “please tick where appropriate.” Also, trait sources of error were minimized through interviewing respondents at their convenience. To attain this, interview appointments were scheduled severally. The validity of the survey data was attained following [39]’s guidelines. The validity of the data was obtained from face-to-face interviews. Also, the survey sought an alternative source for confirmation through further in-depth interviews.

Interviews

The sample for the qualitative phase was selected from that used in the quantitative phase as well as other stakeholders – near olds and retirees, utilizing the purposive sampling technique. Purposive sampling was used for diverse reasons including its importance in the selection of participants who had specific characteristics such as sources of information. The 10 participants were divided into three planned interviews based on their convenience (i.e., participants’ preference of time and location). The interview themes that emerged were related to the perception of social contact, house location and health outcomes and a host of others and suggestions for future studies.

The interviews were designed to gain an understanding focused on the connection between house ownership and health outcomes.  Initially, the researcher reminded participants about the aims of the study and that the discussion would be used to suggest future directions. In-depth interviews were used in the gathering of data. The interviews were conducted for a period ranging between 60 and 90 minutes. Prior to which permission to tape record discussions including informed consent were sought.

Each in-depth interview took the form of a semi-structured interview and was conducted individually in the participant’s office or chosen place. The interviews were audio-taped. Face-to-face interviews are endowed with the merit of providing pertinent information while allowing the researcher the opportunity of control over the line of questioning [40].

2.3. Data Collection

Institutional Review Board (IRB) approval was attained by the researcher from University of Ghana.  Confidentiality and anonymity were ensured.  

A questionnaire was used in the process of data collection in the first phase. The administration of which took the form of face-to-face interviews to eliminate the situation of unreturned questionnaires. The main strategies for finding appropriate participants comprised contacting key players in different organizations.

It is worth reiterating the fact that the quantitative study was not anonymous. To prevent it from affecting the results of the study, the participants were informed about information that was to be collected from them and how their identities were going to be protected. This information were included in the study’s informed consent form as the best way to explain the nature of the data collection and to assure participants that their privacy was going to be protected.

2.4. Data Analysis

Methodological triangulation was deployed to include the combination of methods to understand and explain [41] house ownership and health outcomes as earlier mentioned. The answered questionnaire was cleaned and serialized for easy identification. The survey data were entered into Statistical Package for Social Science (SPSS) and was analyzed with selected descriptive statistics namely frequencies, percentages, Chi-square statistics, and Cramer’s V test.

Use was made of Pearson Chi-Square statistics to test the following hypotheses: there is no difference in house ownership between age groups; there is a difference in house ownership between age groups, utilizing a 2 tailed test with at 5% level of significance as shown on Table 2b. In the same vein, the data were subjected to Pearson Chi-square statistics and Cramer’s V test for purposes of ascertaining the association between house ownership and health outcomes (See Table 4).

Transcripts from the interviews were subjected to thematic analysis. Thematic analysis entails the process of encoding qualitative as well as textual information. Despite the strict procedural nature of coding and themes that emerged from constant immersion with qualitative data, [42] contend that thematic analysis is more exploratory. For the interviews, data analysis was first conducted by the researcher and subsequently by an independent researcher with experience in qualitative data analysis to increase confirmability and dependability. Both researchers ensured dependability by keeping a coding manual, which entailed original extracts from the interviews and definitions of the emergent themes [43].

A combination of the following analytic strategies was employed in this paper. First, analytic induction which was related to reaching general explanations. Second, thematic analysis pertained to the examination of theoretical themes or hypotheses of a research through studying particular cases. Finally, narrative analysis was used to search for new themes or issues from the stories told by the research participants about their lives.

In this research, the five major themes identified from the literature review constituted the backbone for analyzing the data collected from fieldwork in Urban Ghana in support of thematic analysis technique. The analysis process was aided by the application of the framework method in which matrix-based comparisons such as comparative tables were undertaken. The framework table offered detailed analysis of the data within a particular theme. This therefore provided a clearer and deeper understanding of key themes within the context of the study. Efficiency of the thematic analysis carried out was ensured following a variety of principles in the course of data processing namely: repetition in search of issues that are commonly repeated by interviewees; and non-repetition in search of issues that were rarely mentioned by the interviewees; similarity and difference in a search of similar and different responses among interviewees on a given theme such as the frequency of health resource patronage; metaphor in a search of issues that are used in forms of metaphors; transitions in search of issues that link themes and sub-themes together. Theory linkage in search for linkage or connections to the outcome of research findings. These were undertaken to ensure the pursuance of the relationship between categories and themes of data, seeking to increase the understanding of the phenomenon. Each of the researchers read the scripts in detail, and then individually coded and categorized data from the same interview. Data from the interviews were coded by the researchers and across the entire interview data capturing diverse views. Through constant comparison, constant refining resulted in a list of themes (e.g., house acquisition and ownership, house location, social contact and interaction, and health consequences) with their importance determined by frequency, multiplicity of participants’ views as well as uniqueness.

Inductive thematic analysis using NVivo10 software was undertaken [44]. The NVivo software was employed in this study in order to obtain rigor in dealing with such data using five distinct steps. The first step was the creation of a project which comprised all the documents, coding data and related information that assisted in the process of data analysis as well as saving the NVivo project. Second, the transcribed audio-recorded interview files were named respectively. The third step entailed working with qualitative data files which entailed the preparation of documents for import, following which the requisite documents that I intended to analyze were then imported. The fourth step was related to working with nodes. Nodes store is a place in NVivo for references to code text. Both tree and free nodes were created and used.

Fifth, in data coding, a chunk of data in a project document under a particular node was taken through the highlight of the requisite text using the mouse and pulling the highlighted text to the identified node using the coder. This included finding obvious themes as well as auto-coding. Subsequently, multiple codes were assigned to the same chunk of the text including going through the same process. The codes formed a pattern. The passage of texts was compared and contrasted for ways in which they were similar and different. The emergent concepts for example were all health concerns or responses: limited health access etc. Others were the dimension of the use of accessibility of healthcare services—cost, exemption, etc. The final step pertained to going further which encompassed the following: the start of analysis, going further with concepts, categories and themes including narrative and discourse. Memos were used to tell the story of the research by adding descriptions. The knowledge developed from the data was reported.

The outcomes of these activities were recorded in discussion memos. These strategies were integrated into the process of learning from the data. A thematic multi-case analysis was employed, the comparative focus of which was on individual cases as well as the preservation of their uniqueness (pp. 11-15).

Response: The survey data was further subjected to Pearson Chi-square statistics and Cramer’s V test in order to ascertain the association between house ownership and health outcomes (Table 4). The Cramer’s V=0.750 outcome indicates a strong association between the two variables. This has implications for house ownership and health conditions and the negative effective there may be (p. 23).

 Comment: Moreover, due to lacks in language fluidity and accuracy, if a revisited version of the paper will be required, deep proofreading is suggested. In particular, additionally to minor orthographic details, there are some elements to correct, for examples: at line 244 “The Table above” should become the “Table 3”, the link of reference 26 at line 550 cannot be open, etc.

Response: “The Table above” has been replaced with “Table 3”.

Ghana Statistical Service. 2010 population and housing census: District analytical report – Accra Metropolitan. Available online: file:///C:/Users/User/AppData/Local/Temp/AMA.pdf. (accessed on 01.02.2016).

Note: If this link cannot open, perhaps it has been removed or corrupted.

Reviewer 2 Report

Dear authors,

It was my pleasure to review your manuscript. Following are my comments and suggestions.

1. Please, improve the grammar and style of your paper. I found multiple typos and mistakes, e.g. line 17 - missing comma, line 49-50 "deseases" instead of "deceases", line 62 - unnecessary repeat, in line 68 please change "avail" to "available", line 74, quotes in line 222 etc.

2. In line 58 please remove "tiers, 1, 2 and 3" .

3. Please, name the sections as they are given in the following text (Line 107)

4. Your quantitative study was not anonymous. Does this fact affected the results? If yes, how did you accounted it in your research and conclusions?

5. The main operating language in Nvivo software is English, but the survey was taken in Native languages too. Did you translated the questionary and replies? Did it affect the results of the study?

6. Every person has an education level. No education is level as well. Please, properly address this fact in Line 211. 

7. I recommend to add cross-tabulation in Table 2 to emphasize the significance of group divergence. 

8. Please, correct the style of the paper to be more scientific.

Nevertheless, my overall impression is good and I can warmly recommend your manuscript for publication after only a minor revisions.

Author Response

Comment: 1. Please, improve the grammar and style of your paper. I found multiple typos and mistakes, e.g. line 17 - missing comma, line 49-50 "deseases" instead of "deceases", line 62 - unnecessary repeat, in line 68 please change "avail" to "available", line 74, quotes in line 222 etc.

Response: Line 17 reads “found in these countries [1]. Persons aged 65 years and above, make up a bigger portion of the”.

Response: lines 49-50 read “of diseases affect older adults including dementia, increased cognitive impairment, Alzheimer’s diseases, sensory impairment, gait, falls and related medical conditions. Others entail hearing,”.
Comment: line 58 remove “tiers 1, 2 and 3”.

Response: “tiers 1, 2 and 3” has been removed.

Comment: line 62 line 62 - unnecessary repetitions.

Response: now reads “Housing is a major problem for many people especially older people [16], thus, they”.

Response: line 68 now reads “A variety of housing or residential facilities are available to workers before and after retirement”.

Comment: 3. Please, name the sections as they are given in the following text (Line 107)

Response: the sections have been named or labelled as directed.

Comment: 4. Your quantitative study was not anonymous. Does this fact affected the results? If yes, how did you accounted it in your research and conclusions?

Response: No, it did not affect the results.  However, it is worth reiterating the fact that quantitative study was not anonymous or confidential. To prevent it from affecting the results of the study, the participants were informed about information that was to be collected from them from them and how their identities were going to be protected. This information were included in the study’s informed consent form as the best way to explain the nature of the data collection and to assure participants that their privacy was going to be protected.

Comment: 5. The main operating language in Nvivo software is English, but the survey was taken in Native languages too. Did you translated the questionnaire and replies? Did it affect the results of the study?

Response: The Nvivo software was not used to analyse the questionnaire or survey data. The interviews conducted in native languages were translated into English, yet it did not affect the results.

Comment: 6. Every person has an education level. No education is level as well. Please, properly address this fact in Line 211. 

Response: Most of the respondents had some level of education and were constituted by the formal sector (221, 50%) and informal sector workers (221, 50%) (Table 1). Overall, the highest educational level attained by a near majority of the respondents (46.4%) was tertiary education. The no formal education designation is simply indicative of the attainment of non-formal classroom education including those who could not complete primary six (p. 15-16).

Comment: 7. I recommend to add cross-tabulation in Table 2 to emphasize the significance of group divergence.

Response: A cross-tabulation of the results aimed at ascertaining whether there was a difference between age groups in terms of house ownership, indicates that the respondents in the economically active age group 30-39 (62.4%) and 40-49 (61.3%) owned houses compared to the near olds – 50-59 (53.6%), (See Table 2a for details). However, the latter is comparatively lesser in percentage value compared to the former groups.

Table 2a. Cross tabulation statistics on age and house ownership.

        Source: Field data

In furtherance to the above, in order to emphasize the significance of group divergence on the issue of house ownership, the data were further suggested to Pearson Chi-Square statistics where the following hypotheses were tested: there is no difference in house ownership between age groups; there is a difference in house ownership between age groups, utilizing a 2 tailed test with at 5% level of significance. The resulting p value of .000 is less than 0.5 (Table 2b). This implies by interpretation that there is a difference in house ownership between age groups.

Table 2b. Pear Chi-square Test statistics on age and house ownership.

        Source: Field data

Comment: 8. Please, correct the style of the paper to be more scientific.

Response: This has been done throughout the entire article.

Round 2

Reviewer 1 Report

While the work to better introduce the topic is acceptable (now the introduction provides a quite clear framework of the local reality) and the methodology better explained, is still missing some work in the points 4.discussion and conclusions to make them better referred to the results of the research. (in these two points there are no actual references to the results or to the tables).

Author Response

Author response

Comments and Suggestions for Authors

While the work to better introduce the topic is acceptable (now the introduction provides a quite clear framework of the local reality) and the methodology better explained, is still missing some work in the points 4.discussion and conclusions to make them better referred to the results of the research. (in these two points there are no actual references to the results or to the tables).

Response:

4. Discussion

            Old age expectations come in two distinct forms namely individual and state level expectations as depicted on Figure 1. Old age oriented expectations of individual workers comprise the acquisition and ownership of houses and the attendant health outcomes. Such a house when acquired may be known as what [5] termed ‘retrilocal residence’. This house may not be the same as an aging community per se. The latter may be possible if the state links the pension system induced housing purchase mechanism to the affordable schemes, e.g. the affordable housing system. Whereas individual level old age expectations are geared towards owning a house, the state oriented ones focus on healthcare expressed in NHIS. The state level expectations and its attendant provisions denote OAEs as mentioned earlier. Workers’ house acquisition and ownership bids. The latter was also boosted by ESB packages from employers and/or organizations. The existing OAEs in Ghana include healthcare expressed in NHI and property rebate. These form the state dimension of care, which are supposed to create conducive age friendly environments or contexts for older adults. However, these are inadequate and need to be scaled up appreciably for older people’s sustenance.

Collectively, these depict house acquisition and ownership, streams have healthcare linkages, since both variables have significant health outcomes. Workers’ state level expectations pertaining to state support in house acquisition was addressed in the national pension system dimension of house acquisition (see [5] for details).

The results also show that comparatively in Table 2a with the economically active workers owned houses than the near olds. This may be due to consciousness on the former’s part, high rates of investments among the younger generations, the fact that retirement is about experiencing the future from today, availability and accessibility to retirement planning information [6,26,44]. Statistically, housing was observed to positively correlate with health outcomes with repercussions for health conditions albeit negatively. It alludes to the fact that age friendly environments are key. Significantly, there is a difference in house acquisition and ownership, and age groups. This was attested to by a p value of .000 (see Table 4 for details). Mostly, the houses were acquired through state housing schemes, pension system induced mechanism as well as ESBs.

This creates an enabling environment for workers to better plan towards retirement in a more organized manner, particularly with respect to housing arrangements. It stresses the complex factors or contexts that shape preparations towards later life, addressing the individual’s attempt to forestall uncertainty with regard to the future [45]. Finally, the notion of ESB suggests that workers’ preparations towards retirement are supplemented to some extent by employers’ designated occupational benefits, especially in the formal sector. The latter confirms what [46] found. As indicated earlier, Act 766 [48] mandates that funds accrued in tiers two and three can be used to acquire a primary residence. In confirmation, [49] indicate that using retirement savings and pensions have been pursued for a range of merit expenditures namely health, housing and education.

Living in own houses to a greater extent guards against financial frailty, alongside the preferences for living with life partners. The essence of this is made viable in the proffering of social contacts and interactions, particularly because retirees’ social networks would have relatively dwindled especially those of men. Social contact, social interaction and house/ residential location are the three elements of age friendly communities in the study. Age friendly communities and positive outcome variables also have implications for retirement communities. An age friendly environment/community therefore depicts the firming up of relationships as people age. This implies that love and care in old age illuminate older people’s lives, affecting their health and well-being. The health of human populations is shaped by certain ‘social determinants’ such as social ties, poverty and low education [49].

This is because social relations and interaction irrespective of the form they take may need to be relatively regular. This experience may vary based on the number of children and grandchildren including financial and other resources an individual may possess in readiness for post-retirement life. The situation may be different for people who are childless or have lost their children due to travel to other countries and regions, and death. Social relations contribute to the phenomenon of age friendly communities, barring loneliness and ostracization of the older person. These two - loneliness and ostracization fester worry that can contribute to ailing health conditions and the related healthcare service solicitation.

However, house acquisition and ownership is better undertaken in an age friendly environment in the purview of increased nucleation of the family including the weakening of the extended family system [50,6]. It has further been argued that there are people who have never joined a pension system, neither have they had sufficient resources in aid of preparation towards a formal pension for their old age [46]. This notwithstanding, houses are acquired through ESBs, individually including via the medium of gifts. The connection between housing and healthcare, obtainable from the qualitative data have dwelt on the repertoire of location, families; acceptance of location, and social support at designated location(s). This type of environment is also constituted by healthcare dynamics. Two comorbidities presented in this paper are hypertension and diabetes, both of which are NCDs [51]. Perceptions about situational and environmental factors for example proximity, familiarity as well as urban features contribute to the way people act or react [49] to house and health matters.

Spending pension incomes on housing issues in old age is not age friendly, since it saps away financial resources that could be conserved and used for other exigencies proffered by NCDs and other related diseases in lieu of a sound solicitation of healthcare services and the related outcomes.

‘Sound mind’ as mentioned in one of the quotes in the previous section is here associated with mental health, since healthcare emphasizes mental health. For that matter an age friendly housing environment has health and well-being outcomes, as it puts the minds of (older) people to rest, a sign that an individual has one less thing to worry about. Stated differently, worrying about the lack of a house or a residential facility including the need to pay rent at old age has healthcare repercussions, as this may be a precursor to non-communicable diseases (NCDs) such as hypertension, diabetes, among others. Previous studies [see 30,52 for example] show that NCDs do not constitute a core component of Ghana’s healthcare provision as a formal social support infrastructure [52]. For instance, [30] found that “the NHIS prescribes the same basic healthcare without taking into consideration the tertiary healthcare needs of older people especially in the area of NCDs including retention of urine, incontinence, prostrate and colon cancers” (p. 11). Pensioners’ association membership nationwide, has benefits of which encompass participation in the pensioners’ medical scheme, a complement to NHIS, among others [20,49].

Thus far, the discussion has focused on housing system at the individual level. At the group level, old age homes or retirement homes may serve as an alternative to the former, which is not too well entrenched in lower and middle income countries including Ghana, yet is worth mentioning here because although it seems to be a ‘rejected’ concept on cultural grounds [30] (p. 11), it is worth taking into consideration. 

As such age friendly living environment regimes for older adults may entail adult day care, retirement communities whatever the form, private or governmental, older adults’ space and conditions. There is also the hospice dimension that must be accounted for, including end-of-life care, call practices, and the involvement of home care agencies. Collectively, these will offer medical care, physical and occupational therapy, psycho­social support and home care. It is worth reiterating the fact that retirement communities should be structured around independent living, assisted living, skilled nursing homes equipped to offer and perform activities of daily living (such as mobility, dressing, bathing, use of the toilet, eating) and hospices [49].

This confirms [53]’s assertion that adjustment to aging may be reached by balancing personal experiences, self-standards, personal aims, core motivations and values with external influences. Such facilities and their tenants might require supportive services because they may have some combination of age-based chronic illnesses, disabilities, and limited social supports, in addition to having modest incomes [4].

However, [54] contends that:

I have always considered it is degrading in industrialized societies; that old people are put in old people’s homes where they are visited by their children from time to time. We must desist from creating or introducing such life’s dead ends into Ghanaian life. For me, the day we adopt such a culturally humiliating system will be gloomy one indeed. Let us continue to keep the aged in their homes with their children and grandchildren (p. 19).

The above statement implies that in the 1980s, when Sarpong made this observation, most people lived predominantly in the rural areas with their extended families. But, with the emergence of social change, people have found themselves in urban centers due to rural-urban migration and the search for white collar jobs, where they have grown old at. Most of such people may not return to the rural centers. In assessing the connection between living in institutional homes and attendant adjustment, [54] intimated that institutional homes have never been a part of the Ghanaian culture. Instead, a feature of a foreign culture adopted due mostly to the weakening of the extended family support system.

Wealth accumulation, gender and environmental inequality have occurred for decades or more as a result of patriarchal structures, controlled by the few in power. The multiple indirect ways through which these concepts have evolved to function in modern day societies further complicate attempts to resolve them and transform the social and natural world towards a more sustainable paradigm. Partly relying on queer ecology, this paper opens the space for uncovering some hidden mechanisms of asserting power and patriarchal methods of domination in family relationships. Patriarchy and gender inequality have a substantial impact on power relations and control of resources [55]. The retiree depicted dead in the study articulated in the longest and last qualitative quotation tried to exhibit male power and patriarchal tendency of being the one with the financial resources for house purchase, and needed not to pay attention to the wife’s admonition by deciding to build in a remote area in Ghana. The wife on the other hand, was unequal with the husband in terms of access to and availability of financial resources. Thus, his interest prevailed. Such a factor must be taken into account when planning for an age friendly environment at the individual level.

House or accommodation arrangement in the context of this paper is a reflection of a risky situation if it is not properly addressed taking into account relocational attributes and outcomes. On the one hand, such arrangements may yield certainties such as having close family relations relocate with the retiree across boundaries with them to their preferred destinations and live happily thereafter. This may depict the ideal situation though. On the other hand, relocational sojourns are not undertaken together with the relocators in question as this study depicts. This is a recipe for an aging risk and uncertainty ramifications, and which foster future oriented aging spaces, without considerations for future housing or accommodation security vis-à-vis the implications for health conditions and/or outcomes. (see pp. 24-30).

5. Conclusion

Among several others (namely finance, disrespect, loneliness), accommodation and health are some of the major challenges of retirement. Availability and affordability of houses have implications for the outcomes of health conditions. House acquisition and ownership can potentially improve the overall physical and mental health and wellbeing of individuals. House ownership has the propensity to facilitate healthy living. It shapes health outcomes in two distinct ways when carefully considered. First, through social contacts and social interaction in neighborhoods. These in turn serve as a buffer against loneliness. The notion that loneliness is likely to cause the death of inmates of institutional homes may find expression in less social engagement, which [56] argues may result in insufficient attention provision that may be received with some reactions, perhaps violence. Second, in the context of this paper, an age friendly community finds expression in an environment in which social contact and social interaction as well as the location of houses are notable variables for eminent consideration.

Therefore the paper catalogues the outline of workers’ retirement aspirations namely living in own house and being surrendered by family relations shown on Figure 1, and the actualization of the same. Yet, this is affected by the location of housing facilities as well as the associated social dynamics and physical well-being implications for health outcomes. It is concluded that a lackadaisical housing arrangement has negative consequences for health outcomes as observed in the paper, gleaned from the qualitative data, notwithstanding the fact that house acquisition and ownership, and health outcomes are positively correlated (see Table 4).  (see pp. 30-31)

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