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Summary

A preliminary survey of local Age Concerns and district and city councils (Territorial Authorities or TAs) suggests that people living in severe domestic squalor exist throughout Aotearoa New Zealand. There are significant health risks for these individuals as well as risks for those they live with, their carers, their visitors, their neighbours, and their pets. Respondents ranked having a lead agency that coordinates a multi-agency response and having a budget for cleaning homes as the most important suggestions for helping these people in their area.

What is severe domestic squalor?

In every community there is a small subset of people who live in homes so unclean, messy, and unhygienic that most people would consider the house to be unsuitable for human occupation.1 An extreme example is where “the home is cluttered with rubbish and infested with vermin. Excrement and decomposing food are strewn around the floors, and the stench emanating is unbearable to all but the occupant, who is blissfully unconcerned by the situation”.2 This level of environmental uncleanliness has been defined as ‘severe domestic squalor’.1 Common features for people living in these conditions include lack of concern, social withdrawal, hostile attitudes, being older, and in many cases a stubborn refusal of help.3 Eighteen people living in severe domestic squalor referred to the Public Health Service in Taranaki between 2014 and 2016 had a median age of 65 years with the youngest person being 4 years old and the oldest 97 years old.4   

There are significant health risks for these people as well as risks for co-habitants, their carers, their visitors, their neighbours, and their pets.5 Because of the social isolation and distrust of others, people who live in squalor can suffer a “lonely death” and remain undiscovered for a long period of time. Houses with hoarding/squalor can also pose a significant fire risk.6 In Australia it is estimated that 0.1% of people aged 65 years and older live in conditions of severe squalor.But there is limited data on the level of severe domestic squalor in Aotearoa New Zealand (NZ). Given this background, we aimed to make a preliminary estimate of the scale of severe domestic squalor by its impact on two key agencies (Age Concerns and Territorial Authorities) and make recommendations on best practice service delivery based on the feedback from respondents. Our survey Methods are detailed in the Appendix.

Survey results

Thirteen out of 31 Age Concern organisations (42%) and environmental health officers from 15 out of 67 Territorial Authorities (22%) completed the questionnaire. The Age Concern responses represented 70% of the NZ population and the TA responses represented 49% of the NZ population. Nearly all the Age Concerns (92%) had been involved with clients with severe domestic squalor in the previous 12 months (n= 133 clients nationally), with a mean rate of 4.0 clients per 100,000 total population. The time involvement for each client ranged from 6 hours to more than 6 months. Similarly, nearly all TAs (93%) were involved with people living in severe domestic squalor (n=54 clients nationally) but with a lower number of clients per head of population with a mean of 2.3 clients per 100,000 total population and lower time involvement with a range of five hours to more than 80 hours for each client. Respondents gave examples of the worst homes they had seen in the previous 12 months (see Box). Additional results are in the Appendix One.

Selected quotes on examples of squalor

"Single older female, living with faeces and urine throughout the house, piles of rubbish and magazines/newspapers filling all major doorways, hallways, and rooms. Rotting food in fridge and kitchen with added food in lounge. Multiple rats and dead mice were observed and removed. Over 12 cats had been defecating in the home. The client was seriously ill and had multiple hospital visits per year."

"Older person living rurally. Got unwell from the water and ended up in hospital. Allowed family and myself to assess (had previously never let us inside the home). No power, human faeces throughout the home. Dead cats discovered under the bed where the older person has been sleeping. Rotting home. No access to see or use any facilities. Shower floor used as a toilet. Rotten floors, roof caving in etc. Even following clean up efforts by family, the house was deemed uninhabitable."

photo of severe kitchen squalor

Photograph of kitchen illustrating severe domestic squalor. 

Discussion

This preliminary survey of two key stakeholder agencies suggests that people living in severe domestic squalor are present throughout Aotearoa NZ and that it can be very time consuming for agencies to help these people. It is possible that the difference in caseload between Age Concerns and TAs reflects the difference in agency approaches. Age Concern is an organisation that wants the best outcomes for their older clients while TAs take a more statutory-based approach with the aim of abating environmental conditions that are likely to be injurious to health.

Legal solutions such as public health legislation unfortunately can be costly and prolonged. Arranging clean-ups when the occupants of homes with hoarding and squalor have no money have left local authorities with large bills.1 Research in the UK concluded public health legislation can provide short-lived relief in some situations but that “longer-term, less formal approaches by social and mental health services are likely to show better success rates”.(see Appendix two)

Severe domestic squalor is a complex mixture of medical, mental health, public health, social and legal issues in a group of high-risk people who are usually resistant to improving their living conditions. Most helping agencies have limited resources and often struggle unsuccessfully by themselves. A coordinated multi-agency approach as highlighted in our survey is consistent with international best practice 1,6,8,9  as “the law is not enough by itself and neither are health services, social services, families or the voluntary sector”1. One of the challenges is balancing the health of the public and impacts on others while keeping the interests and human rights of the person living in squalor central.

What is new in this Briefing?

  • This preliminary survey of Age Concerns and Territorial Authorities has found that people living in severe domestic squalor are a significant problem in many parts of Aotearoa NZ.
  • Survey respondents ranked having a lead agency that coordinates a multi-agency response and having a budget for cleaning homes as the most important suggestions for helping these people in their area.

Implications for public health practice and policy

  • People living in severe domestic squalor are a vulnerable group at high risk of adverse health outcomes as well as posing a public health risk to others at times.
  • The number of people living in these conditions is likely to increase as the population ages.
  • There needs to be a consistent evidence-based approach throughout Aotearoa NZ for helping these people and reducing the associated risks to others.

Author details

Dr Jonathan Jarman, Public Health Medicine Specialist and retired Medical Officer of Health

Hanny Naus, Professional Educator: Elder Abuse and Neglect Prevention, Age Concern New Zealand

Janette Turner, Manager and Registered Social Worker, Age Concern Southland

None of the authors have any commercial competing interests.

Acknowledgements

In addition to all the Age Concern and Territorial Authority participants, we would like to thank Tanya Morrison (the current NZIEH President) and Louise Rees (Age Concern New Zealand) who helped us.

Appendix one 

Survey Methods

In July 2023, a SurveyMonkey questionnaire environmental was sent to each Age Concern organisation in the country and to the environmental health officers of each TA (with distribution via the NZ Institute of Environmental Health). It was intended that there was one response per discrete Age Concern organisation or TA rather than multiple responses by individuals. The SurveyMonkey questionnaire contained 15 questions about the scale of severe domestic squalor in the locality, the impact on staff time, and questions on what was the favoured approach for managing people living in severe domestic squalor (full questionnaire available on request). There was no disclosure of identifiable health information, and the results were anonymised so that no separate Age Concern or TA would be identified. Population data from the 2018 NZ census10 was used to calculate rates.

Additional Survey Results

Most clients were NZ European (87%), and Māori made up 4.3% and Pacifica 2.1%. The majority of people owned their own home (64%) while 21% were in Council/social housing accommodation, 14% privately rented, and 1.0% were in temporary accommodation. Funding clean-ups was mentioned as a specific problem where it was usually expected that the client or their family would pay.

Nearly two thirds (62%) of Age Concerns rated severe domestic squalor as a big problem or a major problem in their area, compared with 13% of TAs (see Chart 1). The top two suggestions for helping people living in severe domestic squalor were (1) a lead hoarding and squalor agency which coordinates the multi-agency response and provides advice, and (2) a local budget for cleaning homes with severe hoarding and squalor. Other main suggestions were mental health input and realistic funding. The National Public Health Service and Te Whatu Ora were the two main preferred agencies for leading a multi-agency approach.    

Appendix two

A survey of local authority environmental health departments in England, Wales and Northern Ireland found that 28% of people with hoarding problems remained non-compliant and many cases remained ongoing. In one example, despite the involvement of seven environmental health officers, social services, the probation service, 19 court appearances and some £14,000 of work, the hoarding and squalor problem recurred over a nine-year period without satisfactory resolution. It was concluded that public health legislation can provide short-lived relief in some situations but that “longer-term, less formal approaches by social and mental health services are likely to show better success rates”.7  

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Public Health Expert Briefing (ISSN 2816-1203)

References

  1. Snowden J, Halliday G, Banerjee S. Severe Domestic Squalor. New York: Cambridge Oxford Press; 2012.
  2. Cooney C, Hamid W. Review: Diogenes Syndrome, Age and Ageing, Volume 24, Issue 5, September 1995, Pages 451–453, https://doi.org/10.1093/ageing/24.5.451.
  3. Snowdon J, Shah A, Halliday G. Severe domestic squalor: a review. Int Psychogeriatr. 2007 Feb;19(1):37-51. https://doi.org/10.1017/s1041610206004236
  4. Jarman J (2017). Hoarding and Squalor - Improving Patient and Public Health Outcomes Using Intersectoral Collaboration. Presentation at New Zealand Institute of Environmental Health Annual Conference, Palmerston North.
  5. Murray Primary Health Network’s Partners in Recovery. Hoarding and Squalor Training. Available from: https://arcjustice.org.au/wp-content/uploads/2020/08/hoardingandsqualortrainingwebslideshow-150731045900-lva1-app6891.pdf. [Accessed 13 November 2023]
  6. Ageing and Aged Care Branch (2012). Discussion paper hoarding and squalor 2012. Department of Health, Victorian Government. https://vgls.sdp.sirsidynix.net.au/client/search/asset/1285400 
  7. Holroyd S, Price H. Professional Practice Note: Hoarding and how to approach it – guidance for Environmental Health Officers and others. Chartered Institute of Environmental Health. Updated 2015. https://www.cieh.org/media/1248/hoarding-and-how-to-approach-it-guidance-for-environmental-health-officers-and-others.pdf 
  8. Health Protection Programs (2013). A foot in the door: stepping towards solutions to resolve incidents of severe domestic squalor in South Australia. South Australian Department for Health and Ageing. http://tinyurl.com/yc2ynub5 
  9. Haighton, C., Caiazza, R., & Neave, N. (2023). "In an ideal world that would be a multiagency service because you need everybody's expertise." Managing hoarding disorder: A qualitative investigation of existing procedures and practices. PLoS One, 18(3), e0282365. https://doi.org/10.1371/journal.pone.0282365
  10. Stats NZ (2019). 2018 Census population and dwelling counts. Available from: https://www.stats.govt.nz/information-releases/2018-census-population-and-dwelling-counts. [Accessed 13 December 2023]

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