Alexandra Ruina
Supervisor: Dr. Aslan Zorlu
Second Reader: Dr. Karin Pfeffer
A Thesis submitted in partial fulfillment of the
requirements for the Degree of Master of Science in
Human Geography
At the Graduate School of Social Sciences
University of Amsterdam
August 2015
Ageing in Place in Amsterdam
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“Population ageing and urbanization are two global trends that together
comprise major forces shaping the 21st century”
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Abstract
The rise in the ageing population creates both opportunities and challenges
for policy and planning. In Amsterdam the ageing population is encouraged
to age in place, maintaining their independence and shifting the provision of
care to the individual and the community. Consequently, an analysis of the
spatial accessibility of community resources was conducted to uncover
whether the elderly can access important community resources within a
cycling and walking distance. The accessibility of these resources can
impact directly and indirectly on the health and well-being of this
population. It is imperative that the needs of the elderly are considered and
addressed at the community level as well as through global initiatives.
Key Words: The elderly population, ageing in place, community resources,
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Acknowledgements
I would like to sincerely thank everyone that provided me with support, guidance and understanding during the research and writing process. First and foremost, I extend thanks to my supervisor Dr. Aslan Zorlu. His support and positivity was greatly
appreciated. I would also like to thank Dr.Karin Pfeffer, my second reader, for taking the time to read my thesis.
I am so grateful for my experience at the University of Amsterdam this past year, I was able to learn and grow both as an academic and as a person.
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LIST OF FIGURES
Figure 1. The eight domains to identify and address barriers to the well-being and participation of older
people ...- 17 -
Figure 2. Moving balance of people 65 and over ...- 23 -
Figure 3. A model of residence ...- 25 -
Figure 4. Conceptual Framework ...- 37 -
Figure 5. Flow diagram of the 2SFCA method...- 45 -
Figure 6. Amsterdam City Districts ...- 50 -
Figure 7. The study area: Amsterdam, Netherlands Source ...- 51 -
Figure 8. Density of community resources in Amsterdam ...- 60 -
Figure 9. The elderly population in Amsterdam, 2014 ... 63
Figure 10. Amsterdam Oost neighborhoods with the distribution of community resources ... 64
Figure 11. Health Resources Accessibility Scores for the Population 75+ at a 1400m Cycling Distance .. 66
Figure 12. Health Resources Accessibility Scores for the population 75+ at a 700m Walking Distance ... 67
Figure 13. Urban Environment and Public Space Resources Accessibility Scores for the 75+ Population at a Walking Distance of 700m ... 68
Figure 14. Urban Environment and Public Space Resources Accessibility Scores for the 75+ population at a Cycling Distance of 1400m ... 68
Figure 15. Community Support Resources Accessibility Scores for the 75+ population at a walking distance of 700m ... 69
Figure 16. Health Resources Accessibility Scores for the 65-75 population at a cycling distance of 2600m ... 70
Figure 17. Health Resources Accessibility Scores for the 65-75 Population at a walking distance of 900m ... 71
Figure 18. Urban Environment and public Space Accessibility Scores for the 65-75 Population at a Walking Distance of 900m ... 72
Figure 19. Community Support Resources Accessibility Scores for the 65-75 Population at a walking distance of 900m ... 73
Figure 20. Community Support Resources Accessibility Scores for the 65-75 Population at a Cycling Distance of 2600m ... 74
Figure 21. Health Resources Accessibility Scores for the 55-65 Population at a Walking Distance of 1000m ... 75
Figure 22. Health Resources Accessibility Scores for the 55-65 Population at a Cycling Distance of 2750m ... 76
Figure 23. Community Support Resources Accessibility Scores for the 55-65 Population at a Walking Distance of 1000m ... 76
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Figure 24. Social Engagement Resources Accessibility Scores for the 55-65 Population at a Walking Distance of 1000m ... 77 Figure 25. The Urban Environment and Public Space Accessibility Scores for the 55-65 Population at a Cycling Distance of 2750m ... 78 Figure 26. Bar chart of the population with high and low access………...79
- 6 - TABLE OF CONTENTS Abstract ... 2 Acknowledgements ... 3 List of Figures ... 4 INTRODUCTION ... CHAPTER 1 ... 8 THEORETICAL FRAMEWORK ... CHAPTER 2 CONTEXTUALIZATION: THE POLITICS OF AGEING ... 11
2.1 The Neoliberal Ageing agenda ... 11
2.2 The Active and Successful Ageing Approaches ... 13
2.3 The Ageing in Place Approach ... 15
2.4 The Age Friendly City... 16
2.5 Political Background of Ageing and Elderly Care in the Netherlands ... 19
2.6 Changes in Policy – Ageing in Place ... 20
CAPTER 3 THE SPATIALITY OF AGEING ... 24
3.1 Age, Space, and Place... 24
3.2 Spatial Accessibility of Community Resources ... 26
3.3 Ageing and Accessing the Urban Built Environment ... 29
METHODOLOGY AND RESEARCH DESIGN ... CHAPTER 4 RESEARCH INTEREST AND FRAMEWORK ... 32
4.1 Research Motivation ... 32
4.2 Problem Statement ... 34
4.3 Research Question and Sub-questions ... 35
4.4 Hypothesis ... 36
4.5 Conceptual Framework ... 36
CHAPTER 5 METHODOLOGICAL BACKGROUND AND FRAMEWORK ... 38
5.1 Background to Spatial Accessibility and Geographic Information Systems ... 38
5.2 Spatial Unit of Reference ... 40
5.3 Aggregation Method ... 40
5.4 Measuring Spatial Accessibility – Approaches and GIS Methods ... 41
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5.7 Mobility and Measuring Distance ... 45
CHAPTER 6 RESEARCH DESIGN: DATA AND METHODS... 50
6.1 Study Area ... 50
6.2 Data Collection: Community Resources Domains and Sub Domains ... 52
6.3 Data Selection: The Elderly Population ... 55
6.4 Data Collection and Processing in GIS ... 56
6.5 The Approach to Measuring Spatial Accessibility ... 57
DATA ANALYSIS ... CHAPTER 7 RESULTS ... 59
7.1 Density of all community resources: The Supply ... 59
7.2 Elderly Age Groups: The Demand ... 60
7.3 Community Resources Accessibility per Neighborhood ... 63
7.4 Walking (700m) and Cycling (1400m) Access to Community Resources for Those Ages 75 and over ... 64
7.5 Walking (900m) and Cycling (2600m) Access to Community Resources for Those Ages 65-75 .. 70
7.6 Walking (1000m) and Cycling (2750m) Access to Community Resources for Those Ages 55 to 65 ... 74
7.7 The Population of Elderly People with High and Low Access ... 79
DISCUSSION ... CHAPTER 8 Discussion... 80
8.1 The 2SFCA Approach ... 80
8.2 Accessibility to Community Resources ... 81
8.3 Recommendations for Further Research ... 82
8.4 Amsterdam as an Age Friendly City? ... 84
8.5 Limitations ... 86
8.6 Conclusion ... 86
REFERENCES ... 88
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INTRODUCTION ……….……….
CHAPTER 1
The global population is ageing rapidly, with the population over 60 expected to rise to two billion by 2050. For the first time in history the number of people aged 65 and over will succeed the number of children under five years of age (WHO, 2011). This marks the brink of a worldwide demographic shift. As a result, creating, maintaining, and supporting opportunities for health and wellbeing over the life-course and especially into old age is now of vital importance (WHO, 2014). As the ageing population rises,
governments and institutions are responding through encouraging individuals to maintain their health, well-being and independence as they age (Kemp and Denton 2003). However, the ability to maintain one’s health and independence into old age varies greatly from place to place. This relationship between health and place has been realized, along with the opportunities and challenges it poses. What’s more, further to this realization is that at the core of the relationship between health and place is accessibility to community resources, which are necessitated to live a healthy life. (HAPI, 2014). It is the mix of services in place, such as health and social services, technical aids, and support and informal care which is vital to the future sustainability of health and long-term care systems (WHO, 2011). The recent emergence of the “age-friendly city”, a city which has physical and social environments that foster healthy behavior, can have a major impact on improving both the active participation and independence of older people.
Furthermore, as the ageing population rises, health costs rise along with it. This
pressure on the health care system has led governments and global institutions to seek solutions to maintain this population in a cost effective manner. Due to this, policy and discourse surrounding the elderly living independently in their homes as they age, has gained prominence.However, “to maintain older residents in noninstitutionalized settings, communities must recognize the needs of various older subpopulations and identify local resources to address those needs. These tasks are often complicated, requiring the consideration of such component issues as…the relationship between
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population density and resource availability or access” (Hirshorn and Stewart, 2003: 134-135)
Consequently, exploring the relationship between population density and resource access in this context would prove important information to governments and
organization in light of such demographic shifts. Thus, the following research will focus on accessibility to community resources for the elderly in Amsterdam, Netherlands. The Netherlands has one of the overall highest population densities in the world with almost 500 inhabitants per km2. As well, by the year 2040 there will be approximately 4.6 million people over 65 in the Netherlands, compared to 2.7 million in 2012. There has also been a 'double aging', within the over-65s increasing the proportion of people aged over 80 the most. With that said, health is becoming an increasingly important issue, “if only in terms of who is going to pay for all the new medical technology and treatment” (Statistics Netherlands, 2012: 43). However, more pertinently, as “growing old is accompanied by increasing infirmity, immaterial things like health, welfare and happiness will become more important” (Statistics Netherlands, 2012: 43).
Thus, the purpose of this study is to primarily consider the elderly ageing in place in a dense urban environment, and assess how accessible community resources are to this population. Traditionally, the use of institutional care has been prevalent in the
Netherlands, however the rise in elderly and subsequent costs (one of the highest
health care expenditures in Europe) has led to a shift towards a policy of ageing in place (Da Riot, 2012). This has created a spatial shift in the provision of care for the elderly to within the home and the surrounding community, as opposed to living in a facility with care bounded to the institution. Thus, it is important to consider those who are ageing in place and the services and resources available to them. Moreover, it is the spatial nature of care within the community which calls for a geography approach, more specifically a quantitative approach. A GIS approach provides insight into population characteristics, location of services and resources, and unmet need (Hirshorn and Stewart, 2003). As a result, this study can contribute to policy and planning as a support tool to ensure informed decisions on the need for increased resources or better
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and quantitative on outcomes of ageing in place, as a rather new strategy in health care initiatives for the ageing population in the West. Consequently, ageing in place will be considered from a relatively unexplored angel, the relation to community resources. More specifically the focus will be on community resources which serve the ageing population, including some aspects of the built environment which indirectly impact health and well-being of this population.
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THEORETICAL FRAMEWORK………..
CHAPTER 2
CONTEXTUALIZATION: THE POLITICS OF AGEING
This chapter provides the broader context of the research and begins with an overview of the neoliberal political shift as it pertains to ageing populations. With the global increase in ageing populations, policy approaches and initiatives geared towards older adults are enacted at the international level to promote individual responsibility and independence in later life. These approaches and initiatives will be expanded upon in this section. The subsequent sections consider the creation and implementation of policies for the ageing population in the Netherlands, as there is concern over new policies surrounding ageing in place.
2.1 Neoliberal Ageing Agenda
The various norms and values which pervade the lives of older adults in the western world are socially constructed and rooted in the political economy. Through economic mechanisms the situation of the elderly has been shaped from their expulsion from the workforce, to their marginalization in later life. This has been determined through the political economy and maintained as the norm. Therefore, during the period of the welfare state the onus was on the state to provide for the ageing population, which created an image of the elderly as a burden in terms of policy and planning (Biggs, 2001). In the advent of the rise in the elderly population there has been a “discursive re-shaping of retirement and ‘retirees,’” which has accompanied such demographic
changes (Rudman, 2006 182). There has been a marked departure away from the ‘retiree’ framed within a discourse of social isolation and ‘structured dependency’ to a new discourse of liberalization and positive retirement (Rudman, 2006). It has been largely “re-shaped as an individual responsibility that demands proactive planning and activity on several fronts” (Kemp and Denton 2003).
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As the welfare state has given way for neoliberalism in Western nations there is a link with the individualistic, active ageing discourse. Neoliberalism’s emphasis on self-reliance and market driven solutions is in line with the discursive re-shaping of the retiree. “We can decipher a neoliberal governmentality in which not only the individual body but also collective bodies and institutions (public administrations, universities, etc.), corporations, and states have to be “lean,” “fit,” “flexible,” and “autonomous.” (Lemke, 2002). The shift towards the promotion of active ageing produces a particular binary of positive ageing versus negative ageing, being dependency and poor health. Thus, “the production and celebration of an active body in old age is a disciplinary strategy of the greatest value” (Katz, 2000: 148).
Creating a political discourse which is geared toward ageing actively, therefore attempts to govern ageing bodies. The ideal of the young- old, or agelessness attempts to foster youth among the ageing while preventing seeking value in age (Andrews, 1999). This being the socially constructed value of eternal youth, which pervades society in the form of positive ageing through not ageing. Therefore, the role of older adults in society is governed by these norms and values which are shaped by social values and norms as well through politics and economics (Rozanova, 2009). Rozanova (2009) considers successful ageing discourse through an empirical analysis of articles in the Canadian Newspaper The Globe and Mail. As a result, there was an emphasis on older adults having a choice in how they age, the choice being to age successfully or
unsuccessfully. Ageing unsuccessfully in turn becomes a burden on the healthcare system, which these articles make evident through emphasizing responsibility of the individual to age successfully. One article states, “A new report from the Heart and Stroke foundation of Canada shows that baby boomers are becoming increasingly sedentary and obese, and the result is a shocking degradation of their heart health” (Rozanova, 2009: 219). Therefore, in relation to ageing actively there is also the interrelated discourse of ageing successfully. This also produces a binary which attempts to govern the individual choices of the older adults so they effectively self-police their ‘bad’ choices. The result of poor ageing practices would cause poor health resulting in burdening the health care system. This discourse evident in the media parallels the shift in western social policy. Similarly, Rudman (2006), analyzed texts
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from another Canadian newspaper, the Toronto Star, finding that ‘responsible’
retirement decisions and actions consistent with neoliberal goals and aims were being advocated. There is an emphasis on self-improvement with autonomy being the ultimate ideal. This however, is “regulated by a new set of social obligations bounded by neo-liberal rationality” (Rudman, 2006: 197).
A large component of ageing successfully or active ageing is maintaining health, which is encompassed in related social policy such as the promotion of exercise, healthy food programs and diet plans that focus on individual responsibility. This emphasis on
individual responsibility detracts from the physical environments where ageing populations reside and which is a determinant of health (Cardona, 2008). Thus, the neoliberal aim behind such policies is evident as the discourse of individual
responsibility over health, quality of life and longevity remains prevalent in Western society. This overarching discourse enforces individuality and independence in later life, deemphasizing, government support structures for the elderly as well as fostering
supportive communities. The specific policy initiatives and approaches which promote this discourse throughout the life course, especially focusing on later life will be outlined in the following sections.
2.2 The Active and Successful Ageing Approaches
It was in the 1990s when “the new identity for later life had emerged and had been recognized at the highest of international levels” such as the OECD, WHO and UN. Previously, within the social-gerontological literature and societal debate, the limitations of older adults was emphasized and early exit from the labor market was encouraged (Boudiny, 2013). It was in the 1990’s when the fear over the economic implications of the rise in the elderly population emerged and along with it the concepts of ‘active ageing,’ ‘successful ageing,’ and ‘healthy ageing’ came to light (Boudiny, 2013).
What exactly constitutes active ageing and how can this approach to ageing be realized at an international level are important considerations. This can begin to be considered with James Fries and his argument on the compression of morbidity. According to Fries,
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“chronic disease and physical decline originate early in life, develop insidiously and can be prevented.” This lies at the center of World Health Organization’s (WHO) approach to “Noncommunicable diseases, ageing and health with its focus on the life course, health promotion and ‘active ageing’” (WHO, 2002). As aforementioned ‘active ageing’ as a policy came into play in the 1990s, however since this period the term has yet to gain clarity through a concrete interpretation. It is used often interchangeably as it is interrelated with the notions of healthy ageing and productive ageing (Boudiny, 2013). According to the WHO active ageing is defined as “the process of optimizing
opportunities for health, participation and security in order to enhance quality of life as people age.” (WHO, 2002) This however, is a very broad definition which can also encompass the alternative notions of successful or productive ageing and healthy ageing. As well, various authors have defined it differently, creating varying approaches to ‘active ageing’ (Boudiny, 2013). The WHO also acknowledges determinates of active ageing, which affect the quality of life of the elderly: economic determinants, social determinants, physical environment, personal determinants, behavior determinants, and health and social services. These are determinants of health and well-being however, and not explicitly determinates of “active ageing” or the ability to age ‘actively’.
Walker (2002:124) considers ‘active ageing’ to be an umbrella term which is “used to cover anything that seems to fit under it.” In Walker’s ‘A strategy for active ageing’ he outlines seven key principles which are based on a “partnership between citizen and society.” The first is that ‘activity’ should encompass any pursuits which contribute to well-being and health; the second is ‘active ageing’ should encompass all older adults; thirdly, it should be a preventative concept, involving all age groups; forth, there should be fairness among the generations to develop activities which are intergenerational; fifth, ‘active ageing’ should emphasize rights and obligations; sixth, there should be both top-down and bottom-up action; finally, there should be respect for national and cultural diversity as participation can vary among regions and countries.
Furthermore, it is evident in through reviewing the literature that there is not a universal and straightforward approach to active ageing; it is a conception which can be defined
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in a variety of ways. That being said, it is a health and well-being centered concept which is meant to prioritize the prevention of poor health which comes with ageing.
2.3 The Ageing in Place Approach
Similar to active ageing, the concept of aging in place is not new, it has become more prevalent at an international level however in the late 1990’s and early 2000s. It is
considered a positive approach, which intends to meet the needs of older adults through supporting their independent living, or with some assistance, for as long as possible (Horner and Boldy, 2008). The Organization for Economic Co-operation and
Development’s (OECD) report ‘Ageing, housing and urban development’ states:
In response to the challenges posed by the unprecedented increase in elderly people, the OECD is investigating the broad policy implications of this major demographic trend to assist Member countries to introduce strategic frameworks in order to harmonize ageing reforms. Virtually all areas of public policy will be affected...policies for “ageing in place” and “active ageing” will be required; and solutions will have to be found for the long term care of the very elderly (OECD, 2003: 3).
The concept of ageing in pace is defined as:
A concept which favors giving older persons the opportunity to remain in their own homes rather than be cared for in an institutional setting. The improvement of housing conditions, design and associated services which enhance the mobility/accessibility of the elderly and which contribute to improving their physical condition is critical to sustaining their level of activity, reducing their dependency and improving their overall quality of life (OECD, 2003:128).
Further, it is imperative to “integrate older people’s housing into lively, diverse, engaging, and safe urban spaces.” As well, coordinated care such as combining
medical, social and cultural aspects should be prioritized to account for the changes that come with ageing, including loss of physical and mental capabilities (OECD, 2003: 24). That being said, “ageing in place can cause great harm if it becomes an excuse not to build and fund long-term care facilities” (Horner and Boldy, 2008: 358). There is also a need for services made available to meet the needs of the ageing population. However, with this necessary provision of services comes concern that governments do not fully
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understands the resources which ‘ageing in place’ requires (Horner and Boldy, 2008). As local authorities are now in charge of once centralized services this can put stress on municipal finances. “This situation affects the provision of housing and services for the elderly living in urban areas. It has led local authorities to work more in partnership with business and civil society to privatize housing and services, and to pursue policies for ‘ageing in place’ and ‘active ageing’” (OCED, 2003: 109).
Furthermore, there is the notion that older adults want to age in place, however this may not be the case for all, which can cause unfair judgement upon those who chose not to (Horner and Boldy, 2008). Additionally, as opportunistic as ageing in place can be for both the elderly and the government to be able to financially support the ageing
population, it can still pose a drain on government services. Many older adults cannot or do not want to rely on informal care and support, relying on private service providers or government support (Davies and James, 2011). Thus, ageing in place can provide older adults with further opportunities to maintain their independence through remaining in their homes, however there can be implications and challenges to the creation of ageing in place policy initiatives. Further, ageing in place can be a driver of spatial unevenness of elderly populations which will be discussed further in the following sections (Davies and James, 2011). Ageing in place occurs in physical space where it affects the lives of individuals therefore, it should not be only considered from a top-down public policy perspective as an initiative to reducing spending on old age care.
2.4 The Age Friendly City
Also similar to the concepts of ageing in place and active ageing the notion of ‘the age- friendly city’ emerged in the late 1990s. The age-friendly city came from policy initiatives launched by the World Health Organization (WHO) with the intent for “Age-friendly principles to provide cities and their older residents with an empowering and holistic framework within which to understand and address people’s experience of growing old” (UK Urban Ageing Consortium, 2014: 9). According to the WHO:
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An “age-friendly city” is an inclusive and accessible community environment that optimizes opportunities for health, participation and security, in order that quality of life and dignity are ensured as people age. More specifically, in an age-friendly city, policies, services, settings and structures support and enable people to age well by:
• recognizing the wide range of capacities and resources among older people; • anticipating and responding flexibly to ageing-related needs and preferences; • respecting older people’s decisions and lifestyle choices;
• protecting those who are most vulnerable; and
• promoting older people’s inclusion in, and contribution to, all areas of community life (WHO, 2007a)
However, the concept of an age friendly city is broad with many components which come together to produce positive outcomes for the elderly of today and tomorrow in urban environments. The following topic areas make up the WHO’s framework for the age-friendly city along with a checklist of action points based on the eight topic areas.
Figure 1. The eight domains to identify and address barriers to the well-being and participation of older people Source: World Health Organization, 2007
This notion of creating age-friendly environments stems from the ecological model of ageing, which puts forward that the interaction between older adults and their
environments produces outcomes in later life. The traditional long-term care focused system tends to discount the social and physical environmental influences on older
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adults, which are more recently being highlighted (Smith, Lehning and Dunkle, 2013). That being said, the reality of urban life is complex and “many groups within the older population feel largely excluded from the ambitious plans produced by cities competing in the global marketplace” (Buffel, Phillipson and Scharf, 2012). Within the next decade, most cities will contain one in four of their population aged 60 and over, within or around the urban core, creating a significant challenge for urban design and management (Buffel, Phillipson and Scharf, 2012).
Furthermore, the age-friendly city, like its counterparts active ageing and ageing in place policy initiatives, has identifiable identity issues. As Golant (2014) suggests, age-friendly cities cannot be straightforwardly distinguished from other community-based initiatives, such as Congress for New Urbanism, smart growth or sustainable
communities, universal design, walkable communities and complete streets. These initiatives promote more walkable, compact, safer and accessible neighborhoods as does the age-friendly city. However, resources such as museums, libraries, parks and communal spaces are associated with urban communities and can enhance several facets of later life. Also, the proximity of such resources and amenities creates
“opportunity structures”, or “features of the physical and social environment which may promote health either directly or indirectly through the possibilities they provide for people to live healthy lives” (Buffel, Phillipson and Scharf, 2012). Further, according to Buffel, Phillipson and Scharf’s (2012) critical social policy approach, there is a need for connections between the development of age-friendly cities and “the right to the city.” Harvey (2008: 31) refers to the way in which the quality of urban and city life has become: “a commodity … in a world where consumerism, tourism, cultural and knowledge-based industries have become major aspects of the urban political economy.” This is evident as a lot of urban development is dictated by private developers with pressure by the elderly among other groups to create urban
environments which reflect their demands. Thus, the notion of an age friendly city is an idealistic solution to creating positive ageing environments for older adults however, whether it is a functional solution is yet to be determined and needs to be approached critically.
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2.5 Political Background of Ageing and Elderly Care in the Netherlands
As aforementioned, most actors have recognized the population in the Netherlands will be ageing until 2040, when a new demographic balance will occur, this being a period of transition. It is this reality which has caused policy responses to shift former initiatives and values of the Dutch Long Term care System (van der Steen, 2008).
The long-term care (LTC) scheme was introduced in 1968 through a national
compulsory social insurance system created by the Exceptional Medical Expenses Act [Algemene Wet Bijzondere Ziektenkosten (AWBZ)]. However, up until the 1970s and early 1980s, the AWBZ mainly covered residential services. There has been a tradition of care home (verzorginghuizen) use since the Second World War as it helped lessen housing shortages for younger families, with the national social insurance system
funding the costs of residential care (Da Roit, 2012). With regard to other countries, The Netherlands care system for the elderly and the disabled is mostly arranged outside the family, as a result the Dutch system is considered ‘services-led welfare model’
(Grootegoed, 2013).
That being said, the economic crisis of the 1970s and 1980s prompted the “period of expansion, collectivization and solidarization of the Dutch welfare state” to come to an end (van Oorschot, 2006: 60). When the economic situation had improved from the mid-1980s, changes in the welfare system continued, with a wish to change its nature
entirely. The primary opposition to the model was that the national and collective nature of the system was perceived to undermine the spirit of responsibility (van Oorschot, 2006). Thus, there was an emphasis on personal responsibility being the first priority, resulting in shifting policy measures. As a result, in the late 1980s there was policy shift to de-institutionalization, which comprised two processes, the reduction of residential care beds available and the concentration of more needy older people in residential care (Da Roit, 2012).
Conversely, due to the reduction in residential beds and the ageing of the population, the late 1990s and early 2000s saw an increase in the needs of the population living at home (Da Roit, 2012). Therefore, the financial sustainability of home care was
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challenged, putting more of a strain on home care services. Measures were introduced in the 1990s to reduce the rising costs of homecare, which created problems such as waiting lists, job shortages and quality concerns. However, there was a subsequent period of expansion which led to these issues being reduced (Da Roit, 2012).
Consequently, there has been a marked departure from a system based on collective solidarity to a system based on individual responsibility, decreasing social spending and shifting the character of social support and social protection arrangements (van
Oorschot, 2006).
2.6 Changes in Policy – Ageing in Place
Encouraging ageing in place as opposed to institutionalization for the elderly is not typical to the Dutch welfare system, however it has become the norm on an
international level as well as in the Netherlands. There are fewer older people in
istitutional care in the Netherlands, despite the increase in the older population. This is due to restricted possibilities and the desire of the elderly to live independently. In 1996 over 36 percent of the 85 plus cohort resided in a nursing home or residential care, however in 2011, it dropped to 22 percent. Thus, increasingly the care needs have moved into the regular housing market, with the responsibility for the provision of housing, care and well-being shifting to the municipalities and citizens (PBL, 2013).
Table 1. Percentage of elderly people living independently and in care or nursing homes 1996 – 2011 Source: Centraal Bureau voor de Statistiek and Planbureau voor de Leefomgeving , 2013
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As table 1 shows there has been a decrease in elderly living in a care home, especially among the oldest age group, whom have been encouraged to live independently more so over the past ten years (PBL, 2013). Prior to this shift was a new discourse on cost containment in the 1990s, which produced “diverse normative views on responsibility and regulatory mechanisms that challenge the basis of the Dutch LTC system…based on redefinition of ‘who is in charge’ of deciding what is appropriate care” (Da Roit, 2012: 235). Thus, in the 1990s, ‘customary’ care and a consumer-directed (or cash-for-care) scheme known as the ‘Personal budget’ [Persoonsgebonden budget (PGB)] were introduced on an experimental basis (Grootegoed, 2013; Da Roit, 2012). ‘Customary’ care permitted boundaries to be set for care-giving within families, and in terms of what was considered to be beyond ‘customary’, families could request professional help. In terms of the ‘Personal budget’, it allowed care-dependent individuals to hire household members to provide ‘non-customary’ care for pay, providing choice in the services they receive (Grootegoed, 2013). By the early 2000s, those assessed for home care could chose either PGB or traditional services (Da Roit, 2012). Furthermore, there has been a separation between need assessment and service delivery, which was previously under the responsibility of the care providers. As of 2005 it has been assigned to a single national organisation with local branches, known as Centrum Indicatiestelling Zorg (CIZ; Centre for Care Assessment) (Da Roit, 2012).
Moreover, in 2004 more compeittion was allowed among home care service providers to create quasi-markets. Thirty-two regional purchasing agencies were allowed to contract suppliers selectively and negotiate prices and quality. That being said, there was continued debate on the healthcare reform law in the early 2000s but the Long Term Care (LTC) funding and provision system remained the same. However, the Social and Economic Council advised the government that the vast rage of risks covered under the AWBZ should be reduced to ensure financial feasibility (Da Roit, 2012). The primary narrative about ageing “presented the reforms as necessary
measures to avert dramatic consequences of ageing.” There was a shift in 2006, where a “new middle-ground narrative opened up the possibility of pursuing a more positive cultural and less worrisome economical political agenda” in response to the claim “that because the reforms are working, the future looks rather bright” (van der Steen, 2008:
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578-580). Further, in 2007, the new Social Support Act [Wet Maatschappelijk
Ondersteuning (WMO)], came into effect. This made municipalities largely responsible for various interventions and some AWBZ services as well (Da Roit, 2012). There was an emphasis on citizens arrainging their own support independently or through social networks (Da Roit, 2012). The shift to emphasizing independence and individual responsibility, and the movement away from a welfare system towards creating ‘quasi-markets’ is consitant with the overarching neoliberal agenda emphasized by
international organizations.
Moreover, in 2009, a reduction in access to publicly funded care was implemented for exisisting and future clients with mild ‘support’ needs for ‘independent living’
(Grootegoed, 2013). As well, there was an already established emphasis on the ‘active citizenship’ ideal, which “draws on a romantic vision of people’s intrinsic motivations to care for eachother without intrinsic reward” (Grootegoed, 2013: 210), which is meant to reduce state responsibility for LTC and foster informal and market care (Da Roit, 2012). The current state of Dutch long-term care policy which commenced January 2015, expects citizens to decrease their dependency on state provisions and become self-sufficient or depend on family and community support (Da Roit and de Klerk, 2014). As well many people in institutional care will be encouraged to live independently instead. Thus, there is a further shift to the Netherlands as a ‘participation society’ in its
reconfiguration of health-care arrangements for long term care (Da Roit and de Klerk, 2014).
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Figure 2. Moving balance of people 65 and over
Source: Centraal Bureau voor de Statistiek and Planbureau voor de Leefomgeving, 2013
Furthermore, as elderly care is largely being decentralized to municipalities it is important to consider where the elderly are residing and how these municipalities are planning for their needs. In the Netherlands, cities are seeing an increase in settled elderly as opposed to elderly leaving the cities (PBL, 2013). As figure 1 shows, it is evident that in the Netherlands largest city there are less elderly (65+) leaving and a rise in established elderly. Thus, the notion that the city is for young or working age
individuals is not necessarily the case. As a result, in urban areas such as Amsterdam, the elderly population, their demand for support and care, and the supply of support and care must be considered. As the provision of care is shifting towards more individual responsibility and independence, the opportunities and challenges posed by this shift calls for further consideration and analysis as the ageing population continues to rise.
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CHAPTER 3
THE SPATIALITY OF AGEING
The spatial context in which ageing takes place is elaborated upon in this section. The research highlights spatial accessibility as being a key determinant of the health care delivery system. Accordingly, as individuals grow older their spatial experience narrows, creating a need to maintain communities which can support such policy initiatives as ageing in place and active ageing.
3.1 Age, Space, and Place
As the concepts and political initiatives of active ageing, ageing in place and the age friendly city have been discussed, it is imperative to recognize how these concepts, as well as the concept of ageing are shaped and experienced differentially in space. The environment is significant, as “individuals do not grow old in a contextual or situational vacuum” (Golant, 2014). Consequently, it is the relationship between age, space and place that geographers have been interested in (Mowl, Pain and Talbot, 2000). Laws (1996) post-structuralism approach explores the relationship between space and age relations. According to Laws it is in “material Space” that people interact with others, thus it is in material space where elderly identities are simultaneously embodied or emplaced, space being a dimension in the construction of identities. Further,
The material spaces and places in which we live, work and engage in leisure activities are age-graded and, in turn, age is associated with particular places and spaces. Our metaphorical social position also varies with increasing age as old age is peripheralized (its immense disadvantage) into discrete locations, while ’youth is everywhere’” (Pain, Mowl and Talbot, 2000: 377)
Thus, older people are peripheralized in space, the home being largely perceived as the place where older people remain as they age. This has two facets, the home being the main space of older adults as well as their identifier. Also, the home being a space which should be avoided to ensure active and successful ageing, which includes
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engaging in the community (Mowl, Pain and Talbot, 2000). That being said, the home can also promote independence as older adults are not depending on institutional care, which promotes negative ideas of ageing such as less capabilities and isolation from society (Mowl, Pain and Talbot, 2000). Thus, through Laws approach, space and identity of the elderly are interrelated, the most important consideration being how space is produced and who it is produced for, as youth is considerably everywhere but aging bodies are not (Laws, 1996).
Figure 3. A model of residence Davies and James, 2011
As figure 3 illustrates there are several dimensions which influence place of residence as it pertains to the elderly ageing in place (Davies and James, 2011). It is not simply about the dwelling of residence itself, but also the location and the accessibility to
important infrastructure, such as health, transport, community and recreation, along with “the social networks provided by family, friends and links to the community also shape the character and experience of residence” (Davies and James, 2011:113).
That being said, there is a narrowing down of spatial experience in older age. Older adults are more limited in their experience of material space due to constraints on what they can access and perceived constraints on what they can access (Laws 1996; UK
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Urban Ageing Consortium, 2014 ). Therefore, “there is a need to ensure that the planning and design of the built environment both signals and enables an openness to its older citizens to make full and varied use of the rich and diverse resources that urban environments have to offer” (UK Urban Ageing Consortium, 2014: 37). As a result, “systems should thus work towards the optimum and most efficient spatial allocations of resources and initiatives for older people (i.e. where supply geographically meets
demand)”(UK Urban Ageing Consortium, 2014: 37). Thus, there is a varied and complex relationship between space, place and age, which structures how individuals and groups experience the urban environment, as well as how policy initiatives manifest in these environments. Moreover, how the urban environment is accessed by older populations will be considered further in the following sections.
3.2 Spatial Accessibility of Community Resources
“It is as if everyone is writing about ‘it’ [access] but no one is saying what ‘it’ is” (Norris and Aiken, 2006: 60)
As aforementioned, policy initiatives that target the growing ageing population stress older adults living independently in their homes as well as maintaining their health and well-being. That being said, “successful aging also depends on the quality of older people’s residential and community settings and care arrangements,” as there are various factors which impact health and well-being in later life (Golant, 2014).
Understanding factors and forces that contribute to the isolation and hardship faced by groups of people living in particular places is recognized as a major challenge for urban planning: exclusion from the customs, activities and relationships of an
ordinary social life can be improved or exacerbated by spatial planning” (Witten, Exeter and Field, 2003: 163).
Thus, the disparities found in the allocation of resources and care arrangements are geographic in nature, “the relationship between utilization, distance, and deprivation or need” being quite complex (Gatrell & Elliot, 2009). Further, the ability to access
resources which directly impact upon health and well-being, is vastly important. Access, however is an important concept for health policy, but it is a difficult concept to
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operationalize. According to Penchansky and Thomas (1981) “access is viewed as the general concept which summarizes a set of more specific areas of fit between the patient and the health care system.” The following dimensions of access are availability, accessibility, accommodation, affordability and acceptability. The most important
dimension to this topic being accessibility, “the relationship between the location of supply and the location of clients, taking account of client transportation resources and travel time, distance and cost” (Penchansky and Thomas, 1981). However, accessibility is a dynamic concept with interactions between spatial and aspatial factors (Ye and Kim, 2014). According to the International Encyclopedia of the Social & Behavioral Sciences, geographical access is:
Access in a geographical context is the quality of having interaction with, or passage to, a particular good, service, facility, or other phenomenon that exists in the
spatiotemporal world. For example, access may be based on measuring the distance or travel time between where residents live (housing units) and the facilities they need (e.g. medical facilities, shops, workplaces) (Health and places initiative, 2014).
In Ye and Kim’s (2014) approach to measuring spatial health disparity, they consider:
The concept of spatial accessibility to health care includes both dimensions of accessibility and availability. In general, accessibility refers to the ease to reach health services from the demand side while availability emphasizes choices of local service locations from the supply side. Spatial accessibility to health services is primarily dependent on the geographical locations of health care providers and population in need, as well as the travel distance/time between them (Ye and Kim, 2014: 5).
Furthermore, Guagliardo (2004) focuses on spatial accessibility in his work on access to primary care, considering spatial access as less understood measure of potential for health care delivery. Similar to Ye and Kim’s definition, Guagliardo considers spatial accessibility to include “the distinction between availability and accessibility” which “can be useful, in the context of urban areas, where multiple service locations are common, the two dimensions should be considered simultaneously. As well, “Spatial access emphasizes the importance of spatial separation between supply (i.e., health care providers) and demand (i.e., population) and how they are connected in space and thus is a classic issue for location analysis” (Joseph and Phillips 1984; Guagliardo 2004; Ye and Kim, 2014; Wang, 2012: 2).
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Moreover, the concept of spatial accessibility has been mainly applied to health care delivery, as access to healthcare is an important facilitator of public health (Guagliardo 2004; Ye and Kim, 2014; Wang, 2012; Luo and Qi, 2009; Luo and Wang, 2005)
However, less prominently spatial accessibility has been applied as an approach to measure community resources as, “the provision of public amenities such as parks, recreational facilities and social and cultural services, is a belief that they are beneficial to residents’ well-being” (Witten, Exeter and Field, 2003: 162). When considering urban environments, neighborhood spatial accessibility to amenities can be used, which “broadly refers to the ease with which residents of a given neighborhood can reach amenities” (Hewko, Smoyer-Tomic and Hodgson, 2002: 1187). Both neighborhood spatial accessibility and spatial accessibility measures have been used in a variety of situations, such as planning housing developments (Apparicio and Seguin, 2004). More recent studies have explored the notion of food deserts and spatial accessibility to healthy food options in urban areas (Apparicio, Cloutier and shearmur, 2007; Zenk et al., 2005; Pearce et al., 2007) As well, there have been studies on the spatial
accessibility of urban public facilities (Tsou, Hung and Chang, 2005) with a focus on specific facilities or resources such as public parks (Oh and Jeong, 2007; Chang and Liao, 2011). There are also a few studies on spatial accessibility to community
resources (Pearce et al., 2007; Pearce 2006; Witten, Exeter and Field, 2003), which considers spatial access to community services, facilities and amenities.
Thus, the concept of spatial accessibility has been applied to the study of population (supply) to resources (demand) in order to realize their relationship in space. Through considering spatial accessibility to community resources and public services at the neighborhood level, it is possible to understand the spatial relation between a segment(s) of the population and whether they can reach important and necessary services.
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3.3 Ageing and Accessing the Urban Built Environment
As urbanization and population ageing are two prominent demographic trends in the developed world, they are explicably related (Beard and Petitot, 2010; UK Urban Ageing Consortium, 2014; WHO, 2007). As older adults experience physical and mental
changes that come with the process of ageing, there is a higher likelihood that older age groups will be more sensitive to their physical environment. They do not travel as often as younger adults or teenagers who travel more for work or school, thus being exposed to more neighborhoods and neighborhood influences (Rosso, Auchincloss and Michael, 2011). As aforementioned, older adults spend more time closer to home as they age, narrowing their spatial experience, causing their residential neighborhood to have a greater impact than on other age groups (Day, 2007; Laws 1996; Davies and James, 2011). According to the UK Urban Ageing Consortium ‘A Research & Evaluation Framework for Age-friendly Cities’:
physical features (present or absent) that disable, obstruct or support people’s ability and right to move outdoors and access public spaces and buildings in older age. But the Age-friendliness of an urban environment can also be understood in terms of specific health-related benefits associated with getting and being
outdoors. Research in this area has, for instance, established the clear physical and mental health advantages linked with mobility outside of the home and being in outdoor spaces in particular.[29]
Therefore, it is clear that what older adults are able to access or not access within the urban environment, or more specifically their neighborhood, has an effect on their health and well-being. Further, Balfour and Kaplan’s (2002) study on the effect of the
neighborhood environment on functional health at an older age concluded that
Excessive noise, poor lighting, heavy traffic, and access to public transportation were predominantly important contributors to problems for older adults and could influence functional health as these factors impede on safety, self-care tasks physical activity, and community participation.
As well, in the Takano (2002) study of the importance of walkable green spaces in urban residential environments in a megacity, it was found that areas with walkable green spaces had a positive impact on the longevity of urban senior citizens regardless
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of other factors such as sex and marital status. Another consideration of urban dwelling elderly is mobility limitations. Clarke et al. (2008) focused on whether the urban built environment has a limiting role in the lives of older disabled adults. It was found that the build environment has a greater effect on mobility for those with more severe lower extremity physical impairment where streets are in poor or fair conditions while this result is lessened if streets are in good condition.
Moreover, Clarke and George (2005) consider “the role of the local built environment in the pathway between functional limitations and disability in a sample of older
Americans” (1933). It was concluded that older adults with declining physical function that live in an environment characterized by limited land-use mixtures, experience more dependency in conducting daily activities. It has also been realized that, “disability can be diminished swiftly and markedly if the physical and mental demands of a given task are reduced.” (Clarke and George, 2005: 1938) Therefore, the incorporation of diversity and accessibility in areas with a greater density of older adults, could reduce disability in later life (Clarke and George, 2005). Accordingly, it has been recognized in the literature and by international and governmental organizations that ensuring and maintaining well-planned, integrated communities can play in the lives of older adults. The common focus being on accessible and affordable health and wellness services as well as opportunities to stay active, participate in the community and remain secure(Beard and Petitot, 2010; UK Urban Ageing Consortium, 2014; WHO, 2007).
Moreover, in the previously mentioned accessibility literature there is a focus on urban areas in North America, Australia and New Zealand, the U.K and more recently, China (Cheng, Wang and Rosenburg, 2012). Continental Europe is generally excluded from accessibility literature as:
compact urban forms are more accessible in terms of number of jobs and travel
costs (defined as a function of travel time and traffic flow, e.g. congestion) than more sprawling, low density, single use land use patterns, even with low travel speed. However, most related research has been conducted in the U.S rather than the
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world’s highest density, most congested cities (HAPI, 2014:6).
Thus, as high density urban environments are perceived as more accessible than other urban forms, they are not considered in the literature in favor of less dense or sprawling urban areas. However, “other factors such as cost of transport, physical disabilities, cultural norms, and so on affect how accessible locations really are” (HAPI, 2014: 7). As a result, places should not be assumed to be inherently accessible or inaccessible without being studied further, as there are many contextual factors which contribute to the accessibility of an urban area.
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METHODOLOGY AND RESEARCH DESIGN………...
CHAPTER 4
RESEARCH INTEREST AND FRAMEWORK
The previous chapters have explained the overarching policy and planning initiatives surrounding ageing, as well as the consequent shift in the Netherlands to ageing in place initiatives. In this chapter, ageing and accessing the urban environment, or more specifically, community resources will be translated into a specific problem statement and research question, which was the guiding question surrounding this research.
4.1 Research Motivation
As presented in the context and literature review chapters, there is increasing
motivation to study ageing populations which are ageing in place, and their ability to access important health and well-being related resources in their communities. This specific topic is not prevalent in the literature as much of the accessibility research focuses on access to primary care, or access to the urban environment for vulnerable populations such as mentally disabled, racialized, or low income individuals. This will be discussed further in the subsequent chapter (Chapter 5). The intention behind this research is to consider all resources which impact health and overall well-being, not explicitly primary care or health care. That being said, ageing in place, or more
specifically, the accessibility of community resources for the elderly ageing in place, has yet to be considered from a geographic perspective. As realized by the Harvard health and place initiative (2012) “a lack of community resources has an indirect effect on health, through shaping the availability and convenience of health resources and habits that support healthy behaviors.” This research therefore seeks to bridge this gap,
merging accessibility to community resources with the population ageing in place, utilizing a quantitative approach. The application of Geographic Information Systems (GIS) for this purpose has been realized to be a useful tool. The journal of applied
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gerontology recognized the potential for the involvement of geography and GIS in the study of elderly populations and their health and wellbeing. This is evident as Hirshorn and Stewart (2003) argue for the use of GIS in service delivery for the elderly:
Ultimately, the impact of GIS technology on decision making and service delivery processes affecting older people may be observed not only at an applications level but also at a higher systems level. In particular, the development and use of a local
community GIS, requiring cooperative data sharing and information dissemination arrangements between multiple public, nonprofit, and even private sector organizations, may result in enhanced organizational communication and collaboration, greater
resource integration, and reductions in unmet need for community resources among older residents.
Further, the research is approached from an urban perspective, specifically a dense urban environment. The city is considered to allow for greater access to resources than rural or even suburban areas. Dense urban environments as aforementioned, are therefore considered to have optimal accessibility. “Evidence also suggests that the proximity of amenities and services often creates ‘opportunity structures’, i.e. ‘features of the physical and social environment which may promote health either directly or indirectly through the possibilities they provide for people to live healthy lives’” (Buffel, Phillipson and Scharf, 2012: 604). As a result, dense urban environments are virtually ignored in accessibility research with the assumption that these places have the most optimal ‘opportunity structures’. Conversely, this is not necessarily the case, although urban environments contain more opportunities, especially dense urban centers, this does not mean resources are distributed evenly in space (HARPI, 2012).
To address the lack of studies on dense urban environments in terms of accessibility, this research will focus on Amsterdam. It is an optimal city for this study as it is a dense urban environment with an ageing population remaining in the city. As brought up in the literature review, the notion of responsibility for the ageing populations is shifting from government to the individual and community based efforts. However, this elderly responsibility varies by place, as in certain countries such as Spain and Italy (WHO, 2011) the family assumes the responsibility for ageing parents or family members. Thus, the context is of place importance for this particular research. As a result, in choosing to focus on Amsterdam, the policy and planning initiatives of the Dutch
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government were addressed as part of the literature review in order to form a specific place-based research. One size does not fit all in terms of accessibility to community resources for aging populations. Thus, Amsterdam provides an appropriate case as it is the elderly population are increasingly encouraged to age in place, the responsibility for health and well-being shifting to the individual. As a result the elderly ageing in place are likely to be less mobile and active than younger individuals, limiting their range of travel and causing them to be mainly reliant on what is available to them within their communities. This is significant in the planning and policy implementation for urban environments to effectively allocate or reallocate resources (UK Urban Ageing
Consortium, 2014). As well, in order to increase health and well-being optimization for the elderly in their later life, ensuring that space isn’t only being produced for youth but for the elderly as well is vital. This can be made clear through the ability or inability of the elderly to access resources in their community which contribute to their overall health and well-being (Laws, 1996). Overall, this research can have implications for further quantitative studies in Amsterdam or other dense urban environments, and to support qualitative studies on this topic.
4.2 Problem Statement
Consequently, the motivations outlined in the above section has led to the formulation of the following problem statement:
The problem which this research seeks to contribute to is identifying the potential of the elderly population ageing in place to access community resources within walking and cycling distances in a high density urban environment. These community resources contribute to the health and overall well-being both of the elderly, directly and indirectly as they age, thus it is imperative they are accessible.
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4.3 Research Question and Sub-questions
The main research question is as follows:
Can the elderly ageing in place in Amsterdam access community resources within a walking and cycling distance?
The elderly population which is not residing in a care institution, instead looks to their community to provide them with information, support, care, social engagement and opportunities for physical activity (OECD, 2003;Davies and James, 2011;Rosso, Auchincloss and Michael, 2011; Buffel, Phillipson and Scharf, 2012). These resources are imperative to older adults as they grow old. It is known that accessibility to
community resources impacts health and well-being (HAPI, 2014; Witten, Exeter and Field, 2003). Thus, “designing communities in ways that supports the ability to walk or bike to destinations and provides access to recreational amenities can play a strong role in influencing physical activity for older adults” (Kerr, Rosenberg and Frank, 2012). As well, being able to walk or cycle to community resources, including recreational
amenities, support and enhances health and well-being. As a result, it is imperative to assess the ability for the elderly ageing in place to access community resources in a dense urban environment, which is often overlooked (HAPI, 2014).
The following sub questions were formulation as an addition to the main research question in order to further guide the research.
Sub-question: Are there geographic gaps between older populations and community
resources which reflect unmet need?
This first sub-questions addresses the potential for underserved areas where the supply of community resources does not meet the demand of the elderly population. Identifying the presence of underserved areas offers the potential for further analysis in creating new opportunities to improve the gaps between supply and demand which can have adverse effects on the population which reside there.
Sub- question: Does access vary based on the age and mobility patterns of the elderly? This sub-question reflects the variation in the ages which comprise the ‘elderly’ group. As this age group is not homogenous, there are differences in mobility and ability, in the
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elderly of younger ages and the elderly of older ages. Therefore, it is necessary to uncover these variations and reflect upon the results to address the needs of this population.
4.4 Hypothesis
The subsequent hypothesis is based on the literature review and collection of data and considers that more resources and opportunities are afforded to populations in urban environments. Thus, it is probable that accessibility to resources in general is sufficient across the city. However, do to the limitation in mobility of the elderly, community resources will not be accessible at shorter travel distances, thus areas of shortage will be evident. This entails the uneven dispersion of community resources for the elderly aging in place.
4.5 Conceptual Framework
Figure 4 represents the conceptualization of the research into a scheme. The elderly dwelling in urban environments, ageing in place are limited by mobility as they age. Both the distance to and availability of community resources lead to the spatial
accessibility of community resources which in turn contributes directly and indirectly, to the health and overall wellbeing of this population, which is demonstrated by linkages to all the other variables. The outcome of health and well-being is as a result of the elderly being able to access community resources, as opposed to being isolated in space. The purpose of this research is to determine the extent of this accessibility in Amsterdam for elderly people of the three age groups 55 to 65 years of age, 65 to 75 years of age and 75 and over (See Chapter 5).
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Figure 4. Conceptual Framework Source: Alexandra Ruina, 2015
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CHAPTER 5
METHODOLOGICAL BACKGROUND AND FRAMEWORK
The methodological framework, which is the basis for this research will be explained in this chapter. The background to spatial accessibility research will be introduced,
followed by the four parameters which allow for the successful measure of spatial accessibility. The first parameter is the use the neighborhood as the spatial unit of reference for the research results. Second, the aggregation method for the population will be discussed, as spatial clusters were used in the analysis to derive more accurate locations of the elderly population. Third, measures of spatial accessibility will be identified and evaluated, and the decision to use the 2SFCA as the measure of spatial accessibility for this research, will be explained. Finally, the use of network distance and the mobility patterns of the older adult population in the Netherlands will be discussed, as it was utilized in the computation of the accessibility measure.
5.1 Background to Spatial Accessibility and Geographic Information Systems
In the 1970s the distance to health care providers was realized as a substantial barrier to health care access in the United States. As a result, this realization prompted
attempts to measure spatial accessibility (Guagliardo, 2004). With more recent advances in Geographic information systems (GIS) and spatial analysis techniques, tools have been developed to be able to describe and understand the changing spatial organization of health care and wellbeing services and resources, “for examining its relationship to health outcomes and access, and for exploring how health care delivery can be improved” (McLafferty, 2003). An early, widely used conceptualization of spatial access by Khan (1992) is a “logically consistent basis for evaluating and monitoring the performance of a regional health care service system,” being an integrated approach which unifies availability and accessibility. As well, another early conceptualization of spatial access by Joseph and Phillips (1984) highlights the importance of spatial separation between supply, demand, and how they are connected in space.
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As a result of these prominent conceptualizations, researchers have drawn upon these approaches using GIS and spatial analysis to realize issues related to health and wellbeing of the population in specific community and urban settings (Hirshorn and Stewart, 2003; McLafferty, 2003). Further, a broad spectrum of techniques have emerged to solve these issues, some focusing on mathematical modeling or statistical analysis and others applying more of a qualitative approach. That being said there is a growing body of literature in which GIS contributes substantially to the understanding and further analysis of accessibility to health care services and resources (Ye and Kim, 2014). GIS, being used to ultimately “link diverse layers of population and environmental information to characterize the many dimensions of health care needs for small areas” (McLafferty, 2003).
Table 2, shows the dimensions and stages of access in health care studies. It is a matrix for understanding how to conduct an analysis based on geospatial that is data available (Guagliardo, 2004). There are both potential and realized measures of accessibility, which are dependent on the geospatial data available. With detailed patient-level utilization information, realized accessibility can be measured. However, many studies have used and developed potential measures of access based on distances between health services and demand points (Langford and Higgs, 2010).
Table 2. Taxonomy of healthcare access studies, combing dimensions and stages Source: Guagliardo, 2004
The operationalization of spatial accessibility measures in urban and health studies has become easier due to technological developments, the basis of these measures involve the specification of four parameters;
