Development of the Age-Friendly Environments

### **Chapter 3**

## Contemporary Geographical Gerontology: Reconciling Space and Place in Population Ageing

*Hamish Robertson*

### **Abstract**

Geographical gerontology can look like a niche subfield of geography or a tenuous overlap between that discipline and gerontology, which is itself a broadly interdisciplinary affair. However, in the context of progressive global population ageing, this intersectional field of study offers more than its current popularity might suggest. Many of the problems with contemporary aged care provision resolve around, I suggest, issues associated with concerns of space and place. These two key geographical concepts are highly dynamic at both the theoretical and applied levels. In this chapter, I consider them as a dualism that offers the field of gerontology and associated applications, a growing utility. Space can be seen as abstracted and instrumental, with which place can be seen as relational, generative and pluralistic. On their own, neither is necessarily likely to address the full scope of societal issues that population ageing presents. However, drawing on developments across these two conceptual domains offers opportunities for a contemporary geographical gerontology. We face a variety of interconnected global problems that demand a spatially informed perspective. Here, I propose how a developmental synthesis of these two concepts that might add utility and value for those within and beyond the current aged care sector.

**Keywords:** geographical gerontology, population ageing, space, place, space-place relations

### **1. Introduction**

Geographical gerontology may seem like a niche field in a discipline cluttered with many and varied interests but it's topicality and relevance are growing. Geography addresses the issues associated with population ageing from a variety of perspectives: demographic; medical/health; critical theory; economic; and at the interface of gerontology to name some of the more relevant. In addition, it is clearly and interdisciplinary undertaking given the conjunction of geography and gerontology which makes for an additional level of undertaking in terms of theory, methods, practices and synthesis [1]. While the geographic interest in ageing is a long-established one, global population ageing makes it an increasingly relevant and practical field of inquiry and analysis.

In this chapter I examine some of the key issues for a non-geographical audience in considering the relationship between population ageing and gerontological thinking using geography as the lens of inquiry. The implication being that social phenomena, social policy and societal responses all have geographic implications. As I have stated elsewhere [2], social policy is fundamentally geographic in nature because the, often, uneven nature of policy design and implementation will be exhibited in and through associated spatial effects. So, for example, access to healthcare services or aged care services will exhibit a spatial dimension because both the demand and supply sides of those 'equations' will vary across geographic space. This scenario exists even without the effects of gerrymandering and associated political impacts on policy and funding arrangements which, if anything, increase differential spatial effects.

My position here is intended for a broad audience and not an exclusively geographical one. It also is developed in the awareness that the United Nations Decade of Healthy Ageing Strategy (2021–2030) presents a number of the issues discussed here from a somewhat different but related perspective. This includes key concepts such as age-friendly environments discussed through the lens of space-place relations in this chapter; combatting ageism including sites of abuse and carcerality in ageing as a focus here; long-term care, both community and institutional in my analysis; integration, which I see as untenable without improved space-place management; and an overarching theme of enablement which I present as the process of negotiating the space-place relations and relationships of a 'reconciled' geographical gerontology. In addition, this chapter discusses the variability of ageing as an individual and collective experience through this space-place approach. My intention is that this contributes to the emerging discussion represented by the UN strategy.

In the Australian context, and elsewhere, we know that factors associated with ageing as an individual experience and population ageing as an aggregate phenomenon, vary significantly across urban areas, and between metro and non-metropolitan regions. The implications for service provision and access are considerable, with factors such as frailty a central focus of research [3]. This type of differential patterning is also leading to the phenomenon described as 'super ageing' in several countries including Japan and South Korea [4, 5]. While central governments make claims to providing universal systems of care that support health and ageing, in reality this is much more difficult to achieve than policy proclamations indicate. Indeed, we can observe that ageing well is often highly geographically patterned, as the research on centenarians and the so-called 'blue zones' all illustrate [6]. The 'blue zones', for example, are quite specific geographic places, often sub-national in character, that exhibit unique combinations of factors that appear to support socially engaged and healthy ageing including Okinawa, Sardinia, Ikaria and Costa Rica [7]. A question then arises in studying these if we can genuinely replicate them for urban environments or draw on them to reshape our spatial and place-based approaches to population ageing 'at large'?

Consequently, gerontology and the broader science of 'healthy ageing' can be seen to exhibit some key geographical characteristics including a differentiation between abstract ideas of space and those of a more embodied place production. From a geography of 'ultra-aged' communities, this is also likely to raise the ancient, even resurgent, concept of 'genius loci' in that we may seek to identify the unique characteristics of blue zones and other ageing 'hot spots' in order to research their replicability or, perhaps, replaceability, in the context of contemporary urban industrial societies [8]. Even the conventional concept of 'neighbourhoods' offers a place-based approach within major urban settings because it illustrates the idea that, as with scale

### *Contemporary Geographical Gerontology: Reconciling Space and Place in Population Ageing DOI: http://dx.doi.org/10.5772/intechopen.105863*

in spatial analysis, smaller units of analysis are both viable and useful for understanding individual and collective experiences, and the factors acting on them.

Making more 'places' that satisfy the needs, wants and capabilities of ageing communities means we can combine the utilitarian quantitative spatial techniques of technologies like geographic information systems (GIS) with the more qualitative and subjective or lived experiences of people within communities, to knit together these space-place aspects. Instead of divergence in both form and function, I suggest, designing our environments for an aging society may help us reconcile the abstracted spatial instrumentalities with the demands of place-based ageing where people can delay or avoid institutional aged care, and the loss of autonomy that experience often entails, while maintaining community support and care in ways that enhance the ageing-in-place experience.

### **2. Space and place for a broader audience**

Geography, architecture, philosophy, sociology and even psychology all concern themselves to varying degrees with the space-place duality. Quantitative geography followed quickly on from the emergence of computers in the post-war period and was informed by computer-based mapping technologies (now increasingly digital) of the kind pioneered by Roger Tomlinson and others. By the 1970's there was a resurgence in qualitative and critical theory in geography, including phenomenology and the work of Tuan [9], Buttimer [10] and Relph [11]. By the 1980's geographies of various aspects of ageing were emerging and associated categories of interest developed through the 1990's and onwards. These included the impact of feminist geography, health geography (as contrasted with more traditional medical geography) and even geographies of institutional and personal services 'care' [12]. While these are specific to geography as a discipline, geographers often travel in a disciplinary and practice sense and so the concept of geographical gerontology became more explicit with the work of a number of geographers including, for example, Andrews, Cutchin and Wiles [13] and several influential others. In effect, I suggest, the humanistic turn in geography produced new generations of researchers in addition to the ongoing work of the pioneers in this area and their students.

Amongst the relevant considerations is the integration of an expanding science of ageing and associated methods and technologies that may expand and extend our understanding of ageing across space and place. The risks are, as with many of the technological responses to ageing (service robots, surveillance systems etc.) the abstract, quantified and technical realm substitutes for the human dimension, including understanding and support that older people actually need. In this framework we continue to produce spaces of ageing, with some environmental modifications, that provide institutional forms of care and treatment for unwell older people. What happens out in the community, so much less surveilled, remains something of a mystery in that formal systems of care are often episodic and disconnected. Hence the recognition of case management as a paradigm for connecting the various systems-based silos in aged care and elsewhere [14].

### **3. Geographical gerontology in context**

The sub-field of geographical gerontology is close to 30 years old, depending on how the origin point is defined. While geographical gerontology gained visibility and, perhaps, momentum with the work of it can also be seen more broadly as a consequence of the interest of geographers in ageing as a process and population ageing as a demographic dynamic. Even these two factors alone might be sufficient to have produced the field of geographical gerontology, but it nonetheless goes beyond this including concepts such as the 'geography of care', disability geography and so on in which the geographical patterning and implications of specific social phenomena lend themselves to both theorization and analysis by geographers [12]. The converse is social scientists and others seeking some common ground with geography through concepts such as 'place making' on the one hand or the use of GIS on the other [15].

My position here is that much of what we take to be the development of demographic theory, more specifically concepts such as the demographic and epidemiological transitions, were a result of and deeply influenced by geographic comparisons and analysis. Omran, for example, developed his theory of epidemiological transition based on population planning research in Egypt [16] which was taken further by researchers in other locations [17, 18]. The demographic transition theory emerged from a number of shared observations in France and the United States (e.g. Thompson, Landry, Notestein), although earlier concerns about population decline and ageing had driven some racist, classist and more broadly eugenic thinking for several decades previously [19, 20].

These factors illustrate how the science of ageing has been deeply enmeshed in the politics of population change for decades. This also suggests why responses to population ageing are so variable since, at a social and political level, they have inherited many of these formative positions and ideas. This in turn has influenced responses to building for the prospect of an ageing society. Instrumentalist spatial views see the functional response as sufficient—the top-down view—while place-based perspectives assume a connection between the individual, their community and their location. Rather than taking an either-or view, my position here is that there is utility in combining them for an emergent geographical gerontology that can assist in meeting the material and relational needs of individual and population ageing. Neither the spatial nor the place-based perspective are sufficient on their own and neither guarantee satisfactory outcomes for older people more generally. But an informed and ongoing synthesis may yet offer potential improvements as population ageing progresses.

### **4. Abstraction and the view from nowhere**

Ageing as an individual experience and population-level ageing are two distinct phenomena. Individual ageing is heavily mediated through factors such as life experience, health status and even social and financial resources. Indeed, aged care policy in many countries is a fraught negotiation between established and emerging understandings of these complex factors. So, for example, the influence of the British Workhouse system on aged care policy is sometimes acknowledged but the values associated with that spatial formation (the aged care institution, in particular) have persisted well after the demise of the workhouse and thus influence political and associated attitudes towards older people, ageing and aged care. This can be seen, for example, in various inquiries into (ongoing) abuses of elderly patients and residents in such settings including the Midstaffordshire or Francis Inquiry [21].

Meanwhile, population ageing is an identified phenomena with specific features that make its study scientific. One of those features is a form of quantified abstraction

### *Contemporary Geographical Gerontology: Reconciling Space and Place in Population Ageing DOI: http://dx.doi.org/10.5772/intechopen.105863*

that aggregates the experiences of many people, indeed a growing proportion of the population, and then reduces those experiences to some 'key' phenomena and concepts. This is highly problematic because the complex nature of individual ageing makes for a lack of generalizability in my opinion. Instead, rising population ageing is generative of a growing diversity of individual and categorical forms of ageing. Olshansky and Ault [22], for example, proposed a fourth stage to Omran's three-stage epidemiological transition, one of delayed degenerative diseases. Others have proposed yet a fifth stage or even a second phase, and so on [18]. The intersectionality of physical and cognitive ageing, for example, make for many highly unique scenarios which current health systems struggle to diagnose and treat effectively including the dementias for which there are currently no cures and limited treatments.

When we add the environments, both physical and social, within these people age this diversity grows yet again. We can add the highly female aspect of advanced ageing to this mix to suggest that policy made by male-dominated societies or with a lack of a relational place-based approach to ageing, bode poorly for the care and treatment of older women [23]. The exaggerated abstraction of the very human experience of ageing likewise makes for a limited response to the full scope of the ageing experience and the needs of older people. Seeing these factors through a 'spatial' lens has some benefits but the addition of a place-based one could, I propose, inform the more instrumental spatial formations we commonly see. Again, in the Australian context, the 'big box' approach to residential aged care is driven not by the needs of older people but by funding and regulatory requirements that make a minimum institutional size necessary, rather than desirable.

Taking comments from the previous section a little further here, we can see that at a systemic level, this spatialized view and its intersection with the 'view from nowhere' presents a number of concerns and problems for successful and supported ageing, in both community and institutional care contexts. The exaggerated topdown view tends to assume a uniformity of service provision and accessibility that rarely exist and, even if it does in principle, it is rarely accessible to all social groups in the same way. So, for example, different social groups based on factor such as ethnicity, indigeneity, migration status, or disability category may find the same 'system' a very different entity in their particular encounters with it.

Indeed, the diversity of the ageing population here in Australia, and elsewhere, suggests yet another reason why spatial representations are insufficient and even the place-making concept needs to be seen as multiple and not, simply, a relational form of replacement for the spatial perspective. Instead, we may need to be seeing place-making as polymorphic and polysemic in that I suggest place-making runs counter to an abstracted universal and instead represents localized responses to both shared, in a general sense, and unique conditions. So, for example, responses to population ageing and its associated challenges may be quite different in Japan, Australia and China even though all three countries are experiencing the phenomenon of population ageing [24].

### **5. Place-making in an ageing world**

Given that a variety of spatial formations and practices already exist which regulate much of the ageing process and experience, ranging from acute care geriatric wards in hospitals to residential aged care facilities and even dementia-specific locked wards, the issue in this discussion is how we improve place-making for ageing. The clinical

view is effectively a view from nowhere unless mediated by genuine interaction with and understanding of the ageing individual. And many acute environments do not lend themselves to this kind of qualitative experience because they are designed and delivered on a 'factory' style model which emphasizes numbers and throughout, including a variety of metrics that tend to reinforce such models (e.g. length of stay). Thus, the ageing society requires a shift to a more qualitative approach that acknowledges these various complexities and their implications for the unwell older person, their careers and allied social supports. In effect, I am suggesting places within spaces as a form of not just redesign but reinvention.

This requires a shift to aged care as a process of place-making, one which seeks to humanize the experience of older people and the care provided to them. Many spatial formations either distort or minimize the inherent relationality in 'care', and as such create or exacerbate problems inherent in many institutional forms designed through a lens of spatial logic (schools, prisons, hospitals, asylums etc.). Yet, as many feminist theorists and others have identified, 'care' needs to be in relational terms [25, 26]. My position here is that so too does place-making in that it represents a form of relational creation, including that cognitive and affective attachments that individuals and groups bring to 'places'. And, as some observers have noted, this does not always ensure a positive outcome—place-making can also be negative and research domains associated with the Glasgow Effect (morbidity and mortality effects) or environmental racism illustrate all too readily [27, 28].

Closely linked to geographies of ageing, of mental health and feminist geographies is that of geographies of care [29]. Discussions in these fields have emphasised the interactional, relation al and even co-productive nature of spaces and places. This would seem to support the ideas discussed here and reinforce the concept of geographical gerontology as a relational, pluralistic engagement of space, place and time. Indeed, my own position is that demographic change sits at the intersection of space, place and temporality [2]. Given that these can be seen as framing both individual and collective experiences, I suggest this enhances the role and value of a contemporary and emergent geographical gerontology.

### **6. Future space-place relations**

Not only is population ageing a dynamic process but so too is the wider environment(s) within which people age. Structured and funded health, aged and disability care services not only intersect with the ageing process but also they are themselves dynamic, as they respond to new knowledge but also shifts in policy, funding, politics and so on. Ageing in place, for example, became a popular policy framework based on the idea of keeping people in their own homes (where they had them) for as long as possible [30]. This usually focused on some structural adjustments to the home often with a focus on the home as a modifiable space and some social supports, rather than an approach informed by 'place' thinking.

It also intersects with James Fries' [31, 32] ideas around the compression of morbidity, because the home and the local environment are and tend to remain very familiar to older people even as physical impairments and dementing illnesses progress. Certainly, much more familiar than their potential relocation to aged care facilities that may be physically far from their own 'place', including familiar friends, neighbours and families. In the broader context of rising chronic disease levels at a population level, these ideas of adjustment and compression could be seen as going

### *Contemporary Geographical Gerontology: Reconciling Space and Place in Population Ageing DOI: http://dx.doi.org/10.5772/intechopen.105863*

well beyond the 'aged' in terms of their utility. Whether they are really about placemaking is another issue and hence unpacking such policy perspectives through a space-place lens is helpful here too.

Institutional aged care has become increasingly about caring for medically unwell older people and the definitions of such institutions are shifting in response to population ageing [33]. The common framing of aged care facilities as more 'welfare' oriented that health and illness oriented is at once both suspect and problematic. In the Australian context, for example, residential aged care is primarily about caring for these medically unwell older people, frailty and dementia being contributing factors, who in many cases cannot remain safely in the community [34]. And this has been the situation for many years now. The scope of that 'unwellness' includes physical disease impairments, cognitive disorders including the dementias, and a variety of, often multiple, sensory impairments including especially hearing and sight.

Additional complexity arises as the health problems associated with these various sub-domains intersect and overlap, making for an increasing variety of often quite specific symptoms and disease states in individual older people. How these individuals respond to space and place factors needs to be seen through this complex array of mediating factors which make generalisations both difficult and perhaps even inappropriate. We may still seek universals in knowledge production but ageing has a way of reinforcing the individual and the local. Consequently, I suggest, geographical gerontology will of necessity be pluralistic in the way it addresses both ageing in place and place-making (and place maintenance) for ageing.

The growth of clinical and research knowledge in this field also adds to the nature of these complexities. We know that, as with the neurosciences, our knowledge base is growing rapidly but there is a great deal yet to learn. Consequently, the assumption of certainties in this area is problematic. If our rate of knowledge doubles or quadruples in the coming decade, for example, then much of what we assume to be solid now is unlikely to be so in another decade. New knowledge will shift our thinking and the diversity of the ageing experience, and its growing documentation will greatly expand what is, currently, known. We will know more about more diverse spaces and places of ageing as time passes and, consequently, develop a greatly enlarged geographical gerontology.

Critical theory approaches add another layer to this scenario in that we can geographically examine the *sites* of aged care through a variety of theoretical and applied perspectives. To what extent does relational theory [35] in geography address ageing in the community compared to ageing in some form of institutional care? Does the production of aged care places vary between, say, low care environments where people generally need (or perhaps receive is the better emphasis) fewer supports, versus high-care ones where illness, dementia and sensory impairments are usually major factors? How do space and place function for unwell older people compared to those who age 'well'? To what extent do we see institutional forms of aged care as exhibiting carceral aspects, as in secure dementia units, for example [36, 37] and what can we do about this through an expanding geographical gerontology?

The potential scope of questions in this area is therefore an evolving one. Peak population ageing is occurring at different times in different countries, and can also vary within countries, for example in younger urban settings compared to aged rural contexts, or across provinces and regions. Growing data illustrates how even at the national level, the progressive geographies of population ageing vary considerably even across the richer countries [38]. Thus, we face a multiplicity of geographies of ageing and associated formations of geographical gerontology at the level of official

geographies (nation, province, region etc.) due to these spatial and temporal variabilities. We are engaged in an unequivocally pluralistic undertaking in both trying to reconcile space and place, as well as in place-making for ageing societies. If we then turn our attention to the 'place' concept, this variability must be seen as having an existing and developmental scope because local environments, cultures and responses will vary, as will individual responses mediated by these, and the health-related factors identified above.

The implications of this interpretation include the need and desirability of a pluralistic approach to the domains of theory, policy and practice in this 'emergent' geographical gerontology. Perhaps obviously, progressive population ageing in different countries and cultures (and within multicultural societies) requires a capacity for theory that does not homogenize the ageing experience and associated knowledge. In the policy domain, this demands a commitment to and capacity for negotiated space-place relations that are adaptive since, for example, the needs of younger old communities will differ from those marked by advanced population ageing. While we still tend to 'consolidate' those aged 65 and over, their trajectories and experiences differ significantly at the individual and cohort level, as discussed earlier. And, lastly, at the practice level we need to build the skills across disciplines and within communities to negotiate space-place relations and relationships for successful population ageing.

Place-making implies a set of negotiated outcomes and yet it remains that much of what we see in ageing theory, policy and practice maintains the top-down perspective. So planning for sites of ageing services and aged care could be improved by better engagement with older people, their advocates and the knowledge base we currently possess. The lived realities of ageing in the community and/or in institutional care demand an improved synthesis and not the disciplinary silos that persist in many contexts. We know, for example, that nutritional support is extremely important for people to 'age in place' successfully and yet supportive meal services in countries like Australia were and remain largely based on charity models from a bygone era (e.g. meals on wheels). A consequence of this is that many community-dwelling older people present to acute care services with malnutrition already present [39, 40]. Despite considerable evidence-based research on this issue, and its consequences for individuals and healthcare services, little has changed in the past few decades. And, at the policy level, a marketized approach to social care services has done nothing, I suggest, to improve this situation. Here too, an improved space-place synthesis offers a pathway to improved management of health and social care concerns that have wider systemic impacts.

### **7. Limitations**

The chapter draws of a variety of literatures and, as such, is a conceptual piece. As noted earlier, the intended audience is not a strictly geographical one but rather a broadly gerontological audience for whom some geographical ideas may be of interest. In addition, attempts at the synthesis of ideas from different fields carry some innate risk in a piece of this length. The proposed benefit in doing this is that the result informs thinking and practice across those academic and professional disciplines. As mentioned earlier, my hope is that this can inform local through to international discussions about the issues identified in the UN strategy and their implications for population ageing as an increasingly global phenomenon.

*Contemporary Geographical Gerontology: Reconciling Space and Place in Population Ageing DOI: http://dx.doi.org/10.5772/intechopen.105863*

### **8. Conclusions**

It is the contention of this chapter that geographical gerontology offers an opportunity to explore and, perhaps, even reconcile the key concepts of space and place in ways that avoid the problems associated with 'the view from nowhere' and the excessive abstraction often associated with quantification as a tool for understanding complex social phenomena. A key point explored here is that variation is normal at the individual level of ageing and, therefore, it is magnified when inquiring on population-level ageing and its associated complexities over space and time. By this I mean that the uniqueness of individual and aggregate level ageing is growing and will continue to do so as the ageing experience develops, as aged care models develop, and as new knowledge adds to what is already known or assumed to be known about ageing.

The conventional understandings of space and place, especially outside of disciplines that directly inquire on them, must change too. Geography's intersection with gerontology has a key role to play in this process because adapting to population-level ageing requires an ongoing synthesis of new knowledge from the various research and clinical practice fields which engage with ageing. That makes ageing, to borrow from the philosopher of biology John Dupré [41], a process phenomenon rather than a categorical one given its pluralism and fluidity. In addition, the personal and community experience(s) of ageing will only grow in their diversity in coming years as the phenomenon progresses globally. It is in this sense that geographical gerontology may also become a way of linking the abstract and the personal as well as the spatial and the place-based experiences of ageing.

### **Conflict of interest**

"The author declares no conflict of interest."

### **Author details**

Hamish Robertson University of Technology Sydney, Ultimo, Australia

\*Address all correspondence to: hamish.robertson@uts.edu.au

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Golant S. The Residential Location and Spatial Behaviour of the Elderly, Department of Geography, University of Chicago, Chicago. 1972

[2] Robertson H. Space, time and demographic change: A geographical approach to integrating health and social care. Journal of Integrated Care. 2017;**25**(1):39-48

[3] Taylor D, Barrie H, Lange J, Thompson MQ, Theou O, Visvanathan R. Geospatial modelling of the prevalence and changing distribution of frailty in Australia–2011 to 2027. Experimental Gerontology. 2019;**123**:57-65

[4] Kim KW, Kim OS. Super aging in South Korea unstoppable but mitigatable: A sub-national scale population projection for best policy planning. Spatial Demography. 2020;**8**(2):155-173

[5] McCurry J. Japan will be model for future super-ageing societies. The Lancet. 2015;**386**(10003):1523

[6] Buettner D. The Blue Zones: 9 Lessons for Living Longer from the People Who've Lived the Longest. Washington DC. National Geographic Books; 2012

[7] Poulain M, Herm A, Pes G. The Blue Zones: Areas of exceptional longevity around the world. Vienna Yearbook of Population Research. Special issue on Determinants of unusual and differential longevity. 2013;**11**:87-108

[8] Vecco M. Genius Loci as a Meta Concept, Journal of Cultural Heritage, Jan/Feb, 2020;**41**:225-231

[9] Tuan YF. Humanistic geography. Annals of the Association of American Geographers. 1976;**66**(2):266-276

[10] Buttimer A. Grasping the dynamism of lifeworld. Annals of the Association of American Geographers. 1976;**66**(2):277-292

[11] Relph E. Place and Placelessness. London: Pion; 1976

[12] Milligan C, Power A. The changing geography of care. In: Brown T, McLafferty S, Moon G, editors. A Companion to Health and Medical Geography. Wiley-Blackwell; 2009. pp. 567-586

[13] Andrews GJ, Cutchin M, McCracken K, Phillips DR, Wiles J. Geographical gerontology: The constitution of a discipline. Social Science & Medicine. 2007;**65**(1):151-168

[14] You E, Dunt D, Doyle C. What is the role of a case manager in community aged care? A qualitative study in Australia. Health & Social Care in the Community. 2016;**24**(4):495-506

[15] Lechner AM, Owen J, Ang M, Kemp D. Spatially integrated social sciences with qualitative GIS to support impact assessment in mining communities. Resources. 2019;**8**(1):47

[16] Omran A. The epidemiologic transition: a theory of the epidemiology of population change, Milbank Memorial Fund Quarterly. 1971;**49**(4):81-95

[17] Mackenbach JP. The epidemiologic transition theory. Journal of Epidemiology and Community Health. 1994;**48**(4):329

[18] Mercer AJ. Updating the epidemiological transition model. Epidemiology & Infection. 2018;**146**(6):680-687

*Contemporary Geographical Gerontology: Reconciling Space and Place in Population Ageing DOI: http://dx.doi.org/10.5772/intechopen.105863*

[19] Soloway RA. Demography and Degeneration: Eugenics and the Declining Birthrate in Twentieth-century Britain. UNC Press Books; 2014

[20] Thane P. Old age in English History: Past Experiences, Present Issues. Oxford: OUP; 2000

[21] Jones A, Kelly D. Whistle-blowing and workplace culture in older peoples' care: Qualitative insights from the healthcare and social care workforce. Sociology of Health & Illness. 2014;**36**(7):986-1002

[22] Olshansky SJ, Ault AB. The fourth stage of the epidemiologic transition: The age of delayed degenerative diseases. The Milbank Quarterly. 1986:355-391

[23] Jones RL. Imagining feminist old age: Moving beyond 'successful' ageing? Journal of Aging Studies. 2021;**2021**:100950

[24] Chomik R, McDonald P, Piggott J. Population ageing in Asia and the Pacific: Dependency metrics for policy. The Journal of the Economics of Ageing. 2016;**8**:5-18

[25] Gilligan C. In a Different Voice: Psychological Theory and Women's Development. Harvard University Press; 1993

[26] Lanoix M. The citizen in question. Hypatia. 2007;**22**(4):113-129

[27] Hanlon P. Unhealthy Glasgow: A case for ecological public health? Public Health. 2015;**129**(10):1353-1360

[28] Seamster L, Purifoy D. What is environmental racism for? Place-based harm and relational development. Environmental Sociology. 2021;**7**(2):110-121

[29] Sherwin S, Stockdale K. Whither bioethics now? The promise of relational theory. International Journal of Feminist Approaches to Bioethics. 2017;**10**(1):7-29

[30] Dalmer NK. A logic of choice: Problematizing the documentary reality of Canadian aging in place policies. Journal of Aging Studies. 2019;**48**:40-49

[31] Fries JF. The compression of morbidity. Health and Society. 1983;**61**(3):397-419

[32] Stallard E. Compression of morbidity and mortality: New perspectives. North American Actuarial Journal. 2016;**20**(4):341-354

[33] Sanford AM, Orrell M, Tolson D, Abbatecola AM, Arai H, Bauer JM, et al. An international definition for "nursing home". Journal of the American Medical Directors Association. 2015;**16**(3):181-184

[34] Cations M, Lang CE, Ward SA, Crotty M, Whitehead C, Maddison J, et al. Cohort profile: Dementia in the registry of senior Australians. BMJ Open. 2021;**11**(2):e039907

[35] Hopkins P, Pain R. Geographies of age: Thinking relationally. Area. 2007;**39**(3):287-294

[36] Moran D. "doing time" in carceral space: Timespace and carceral geography. Geografiska Annaler: Series B, Human Geography. 2012;**94**(4):305-316

[37] Repo V. Spatial control and care in Finnish nursing homes. Area. 2019;**51**(2):233-240

[38] Bloom DE, Canning D, Lubet A. Global population aging: Facts, challenges, solutions & perspectives. Daedalus. 2015;**144**(2):80-92

[39] Lackoff AS, Hickling D, Collins PF, Stevenson KJ, Nowicki TA, Bell JJ.

The association of malnutrition with falls and harm from falls in hospital inpatients: Findings from a 5-year observational study. Journal of Clinical Nursing. 2020;**29**(3-4):429-436

[40] Vivanti AP, McDonald CK, Palmer MA, Sinnott M. Malnutrition associated with increased risk of frail mechanical falls among older people presenting to an emergency department. Emergency Medicine Australasia. 2009;**21**(5):386-394

[41] Dupré J. A process ontology for biology. The Philosopher' Magazine. 2014;**67**:81-88

### **Chapter 4**

## Walking Accessibility to Primary Healthcare Services: An Inequity Factor for Olders in the Lisbon Metropolitan Area (Portugal)

*Eduarda Marques da Costa, Ana Louro, Nuno Marques da Costa, Mariana Dias and Marcela Barata*

### **Abstract**

This chapter discusses the walking accessibility to primary healthcare by the olders in Lisbon Metropolitan Area (LMA), Portugal, and its contribution for age-friendly environments as a factor of inequity. Constrains emerged from the collation of the supply approach, represented by service catchment areas based on walking distance time, and the demand approach, through a survey. The location and density of primary health network are a major factor, as it is related to distinct land use patterns within the LMA. The settlement structure influences the potential walkability to primary healthcare. The discrepancy between the potential walking accessibility and the real options is notorious, as olders' choices are diversified in terms of transportation modes and destinations, but mostly keeping relatively short time distances. This phenomenon is also influenced by factors such as personal preference, difficulty to walk, negative perceptions about the surroundings, and insufficient care support. This debate is already an effective concern of local authorities with spatial planning, social and health competences, insofar as solutions in terms of service flexibility and new travel solutions adapted to the specific needs of the olders are a growing reality in the LMA, promoting more age-friendly, health, and inclusive environments, and hence an equitable metropolis.

**Keywords:** older people, walking accessibility, primary health services, service catchment area, inequity, healthy cities, age-friendly environment, Lisbon Metropolitan Area

### **1. Introduction**

Population aging is one of the most evident demographic phenomena around the world. The United Nations (UN) estimates that the number of people aged 60 and over will double by 2050 and triple by 2100 (corresponding to 3.1 billion people) [1]. This age group is considered one of the most vulnerable in society, particularly affected by poverty, illness, and social isolation [2], and it is often studied as a

homogeneous group when there are several factors that distinguish older individuals (age, education level, family context, income, physical and mental health conditions, mobility level, technological capacity, etc.) [3].

In this sense, spatial planning and service networks must be adapted in advance according to the long-term demographic projection and based on a deep knowledge of the current reality, being extremely important to confront the needs of the population and the response capacities of the territories and services [4].

This study focuses on the debate about the walking accessibility to primary health services by the older in the Lisbon Metropolitan Area (LMA), in Portugal, for healthy and age-friendly environments since the level of proximity to services and the ability to reach them are fundamental to promote a healthier aging and greater equity in and among communities. The study presents three research questions (RQs):

RQ1) Is the location within the LMA a differentiating element of walking accessibility to primary health services (PHS) and hence an inequity factor? RQ2) Do the olders demand for PHS consistent with what is expected to have in age-friendly environments?

RQ3) What kind of solutions are implemented in LMA to promote a more equitable access to PHS by the olders?

The study combines several approaches. We seek to identify possible constraints to equity based on the accessibility to health services: (i) the potential of walking accessibility generated by network analysis recurring to geographic information systems and using adapted criteria to the older community; (ii) the actual demand patterns of the olders gathered from an applied survey in LMA; and (iii) the identification of solutions at local, municipal, and metropolitan levels in the LMA and energized by local authorities, health services, nongovernmental organizations, or social institutions to minimize inequity situations.

The chapter is organized into six parts: Section 1 respects to the introduction and is followed by a theoretical rationale centered on walking accessibility to primary healthcare by the older people in Section 2, and the presentation of the methodology and case of study in Section 3. The discussion of the results based on the confrontation between the supply and demand approaches of primary health services by the olders in LMA is presented in Section 4, and some initiatives that minimize the identified constraints in LMA are addressed in Section 5. The chapter ends with the main conclusions (Section 6).

### **2. Accessibility to healthcare services for age-friendly environments**

The rapid aging of the world population is considered one of the major global challenges. On the one hand, it is seen as a positive phenomenon insofar as it represents social, economic, and biomedical progress due to generalized better feeding, personal hygiene, healthcare, and housing conditions, among many other aspects. On the other hand, it reflects a demographic trend that combines increasing life expectancy and falling fertility rates [5]. In the long term, and related to a time of growing urban population, this phenomenon will bring an overload of the social and health systems, among other services and infrastructures, and the need to readjust them [4, 6]. In a larger level, this will affect the regional competitiveness and make the social and territorial cohesion difficult. This is based on the perspective that

### *Walking Accessibility to Primary Healthcare Services: An Inequity Factor for Olders… DOI: http://dx.doi.org/10.5772/intechopen.106265*

the older population will, at some point, become more dependent on society and greater demanders in terms of physical and/or mental healthcare and supportive care [7]. On the other hand, their moving limitations could promote social isolation and a strong feeling of loneliness, considered by the Joint Research Center as a public health issue with negative impacts on community trust, social cohesion, and economic growth [8, 9].

However, it is a mistake if we consider that all people over the age of 65 have the same characteristics and needs, and that remains the same over time. Given the conditions of the modern world, in Europe, as in other World regions, we are witnessing the existence of a group of older people who are more active, qualified, informed, socially participatory, mobile, technological, and demanding in the cultural and recreational domain [10, 11]. To respond to these demands, their living spaces have expanded from the local to the regional/metropolitan level [12]. On the other hand, the increase in average life expectancy is reflected in the existence of individuals with diversified health conditions, namely about disease prevalence and different physical and mental conditions, influenced by the natural aging process, genetics, lifestyle, and the surrounding environment [13].

In the quest to keep the olders as an active part of society, with good health and well-being levels until as late as possible, adaptations in the urban environment of communities and cities must compensate the physical, mental, and social changes associated with aging. Operationally, this is observed in the guidelines promoted by institutions such as the United Nations and the World Health Organization (WHO) and reflected in the naming of this decade as "The United Nations Decade of Healthy Aging (2021-2030)" [14], with a view to improve the lives of older people, their families, and the communities in which they live.

In urban planning, the "Age-friendly Cities and Communities," that is, "(…) places that actively involve, value, and support older adults, both active and frail, with infrastructure and services that effectively accommodate their changing needs," is one of the most widespread urban models ([15], p. 1). Simultaneously, Age-friendly Cities and Communities is an initiative of the WHO, started in 2006, to support active and healthy aging at local level. "Housing," "Social participation," "Outdoor spaces and buildings," "Transportation," and "Community support and health services" are some of the focused topics [4].

In this model, as in others as "sustainable communities," "healthy cities," or the "15-minute city," the principle of proximity is fundamental [16, 17]. Proximity refers to the distance (physical or not) and/or distance time to the different destinations where individuals live: workplace, various services, goods and equipment, public spaces, green spaces, commercial areas, cultural spaces and leisure; but also to the network of contacts: family, friends, or other social networks. The proximity to people and living areas as a way of satisfying individual needs are enhancers of a greater quality of life and well-being, active participation in society, maintenance of the practice of physical and mental activity, and greater autonomy [18]. Despite the studies regarding the concept of proximity (e.g., 15-minute walking, radius distance of 500 meters, etc.), this is conditioned by the ability and perception of individuals, especially when we refer to the older community, where part of it has age natural mobility constraints.

The principle of proximity as a factor of an age-friendly, healthy, inclusive, and sustainable environment leads us to the promotion of a walkable environment, and this is an environment based on active transport modes, namely the walking in and around the community, to enhance, simultaneously, an equitable accessibility

to all destinations and a positive physical activity engagement [19]. This discussion requires a double understanding about (1) the relationship between urban mobility, particularly in the older people context, and the built environment; and (2) the characteristics and specificities of each community [20].

Hence, recent research promotes an holistic perspective that relates the social and physical environments, recurring to digital tools and services, to promote better health, independent living, active participation, and more equity. See, for example, the SHAFE project results [21, 22] that present the community level as the physical, social, and cultural ecosystem closest to the people and their daily lives.

The mobility of all, as the ability to meet the needs to move freely [23], is one of the challenges that cities have for pursuing social and civic life, participation in community activities, the development of a sense of belonging, and to promote health and well-being through the possibility of accessing health services, green spaces, commercial areas, leisure and cultural spaces, etc. [24]. Hence, it is utmost important to consider that the cognitive and motor skills of olders deteriorate over time, affecting their mobility [25]. This is reflected in constraints on walking speed, the ability to freely drive or use public transport, the increase in falls and the feeling of insecurity when walking on the street, and constraints that, at the limit, avoid carrying out their daily lives autonomously [26].

Mobility is also a reflection of a mutual interaction between the built environment and olders' behavior, insofar the organization of the physical and functional components of urban system generates the opportunities for movement in the context of urban life. Thus, the configuration of the urban system must be adapted to the needs of the elderly [27]. This interaction raises the importance of thinking about improving urban accessibility, that is, the ability of an individual to reach a certain place, through a certain transport mode and in a certain time. This requires a relational reading between the conditions of transport infrastructure networks (and the ease of travel in terms of distance and time), the location of activities and services of general interest proximity between services and users), and the characteristics and needs of users [27–29].

As health is a universal right, the planning of public health services must consider three fundamental principles [30], which sometimes collide. The first concerns the "Equity in service provision," represented by the equal access to healthcare for people in equal need. This premise is related to the notions of spatial fairness and spatial justice that considers the geographical context as an influencing factor. The second is the "Effectivity of health services," balancing the real health benefits and the resources management. The last is the "Efficiency of health services" maximizing the health benefits and minimizing the costs of provision.

Focusing on the health services at the local level, Primary Health Care (PHC) is the first contact between the individual and the health system, as it "provide complete care to people, according to their health needs throughout their lives and not only for a set of specific diseases. (…) ensure that people receive comprehensive care, from promotion and prevention to treatment, rehabilitation and palliative care, as close as possible to their daily environment" [31, n.p.]. It is stated that a PHC-based health system allows for greater efficiency of more specialized care (e.g., hospital care), lower hospitalization rates, and reduced individual and government health expenditures [31].

A primary health service with positive impact on health, quality of life, and wellbeing should present good levels of access [4], considering several demand factors: availability and diversity of health services, frequency of use, individual and family

*Walking Accessibility to Primary Healthcare Services: An Inequity Factor for Olders… DOI: http://dx.doi.org/10.5772/intechopen.106265*

factors, physical and social environment, among others [32, 33]. Over time, several studies addressed this topic [28, 29, 33–36], combining the approaches of health service providers and users, reflected in the following principles:


Accessibility to health services arises the need of a multisectoral and multilevel approach, in this case related, for example, to the healthcare network, mobility and accessibility, and demographic characteristics in each territory as they are influencing factors of healthcare inequalities [36]. Among other methodologies, the levels of physical accessibility of each service could be evaluated recurring to geographic information system (GIS) [17, 23, 32, 33, 36]. Here, it is possible to model the respective service catchment area in a certain distance and/or distance time, based on the various transport modes or their combination. Service catchment areas allow to quantify the total area and served population within the proposed thresholds (e.g., within 15-minute walking in a determined speed); to identify worse served communities, and hence more vulnerable; and to relate it to context indicators in the social, economic, and territorial domains [29, 36, 37]. This analysis is also a potential support element for the restructuring of the service networks through the identification of new service positioning for better population and territorial coverage rates [38], to adapt the transport system in order to promote better accessibility level, or even to support the design of innovative, flexible, and informal solutions promoted by various stakeholders [22].

### **3. Methodological steps and case study framework**

The methodology of this study followed three steps (**Figure 1**), in order to answer the research questions.

Step 1 involved a literature review, not only for thematic framing of the mobility conditions of the older people and their specific constraints (e.g., pedestrian speed), but also for the identification of the main methodologies and accessibility indicators, specifically adapted to the olders.

Step 2 refers to the application of the assessment of walking accessibility to primary healthcare from the perspective of the older people in the case of the Lisbon

#### **Figure 1.**

*Methodological steps of the research.*

**Figure 2.**

*(a) Population density of older people (65+ years old); (b) land use in LMA—urban fabric. Source: [40, 41].*

Metropolitan Area, Portugal. LMA is spread over by 18 municipalities, totaling 3015km2 , and has a total population of 2,870,770 inhabitants, in 2021, and a population density of 952 inhab./km2 . About 22% of LMA's people are aged 65 or over (proportionally to the national figure of 23%) [39], unevenly distributed among the LMA, emerging a radioconcentric pattern, with higher older population densities in the parishes of the central areas (Lisbon & Ring 1 and Ring 2) and decreasing toward the peripheral areas (Ring 3 and Ring 4).

The population distribution is consistent with the urban occupation that presents the same radioconcentric pattern. The central metropolitan areas present a higher proportion of occupation, reflecting their urban/suburban and dense profile, while the peripheral areas present more dispersed urban occupations, reflecting the periurban occupation, except some urban continuum axes that grew along major road and rail axes (**Figure 2**).

In Step 2.1., network analyses based on geographic information systems (GIS) allowed to visualize the service catchment areas of primary healthcare facilities and to quantify the served resident population, considering the geographic location of

*Walking Accessibility to Primary Healthcare Services: An Inequity Factor for Olders… DOI: http://dx.doi.org/10.5772/intechopen.106265*

the equipment, the constraints of the transport network, and the characteristics of pedestrian mobility. The service areas were modeled, and the served population was calculated based on time-distance cutoffs of (i) until 15 minutes; (ii) 16–30 minutes; (iii) 31–60 minutes; and (iv) more than 60 minutes [32, 33, 36]. This approach considers two walking criteria: (a) average speed of the older people of 3.5 km/; and (b) average speed of disabled older people of 1.6 km/h [25, 36]. This step will answer to RQ1.

Step 2.2., related to demand, presents the results of a survey applied to the LMA population in 2017, including the older people. Based on the total sample of 403 families, with respect to 1004 individuals surveyed (for a Significance Level of 95% and a Margin of Error of 5%), we extracted the responses of 131 older adults from 111 families for this study. The total sample took into account the demographic distribution of the metropolitan population (age, sex, and family typology) and its geographic distribution considering the central area of Lisbon and its sequential four rings based on the distance to the Lisbon city (**Figure 3**). Such rings represent territories with urban land use profiles and, consequently, very different population densities, housing and services location, health services, and transport networks. This step will provide the answer to RQ2.

This survey collected information as: (i) the characterization of the respondents (age, income, family background, area of residence); (ii) the demand for primary healthcare services (location, frequency, travel mode, and time spent in the travel); and (iii) individual perceptions about personal health, safety, traffic, noise, and air pollution caused by transport in the residential area (as environmental factors). Hence, it was possible to discuss the results obtained in Steps 2.1. and 2.2., confronting the potential accessibility to primary healthcare services and the actual behavior of the surveyed older people.

Finally, Step 3 addresses some strategies to minimize older's constraints to health accessibility in LMA, giving already implemented examples in three lines of action: (i) strategic plans oriented toward an healthy and inclusive aging; (ii) health services at home or in the proximity; and (iii) promotion of flexible transport to reach health services. This step answers to the RQ3.

### **4. Supply and demand of primary healthcare services of LMA's older people**

### **4.1 Supply approach to primary healthcare system in LMA**

The last restructuring of the Portuguese health system dates from 2008, when the Constitutional Government recognized primary healthcare as a central pillar of the health system, published in the Decree-Law n° 28/2008, of February 22 [42]. One of the novelties was the creation of "groups of health centers" (ACES, in Portuguese Agrupamento de Centros de Saúde), with the function of providing primary healthcare to the population of a certain geographic area. Such geographic delimitation is related to geodemographic criteria (e.g., population structure, aging index, accessibility to the referral hospital), and with a population range between 50,000 and 200,000 residents.

The ACES have several functional units [42], namely:


In January 2022, the network of Family Health Units (USF) and Personalized Health Care Units (UCSP), the most relevant functional units in the provision of healthcare, was widespread and complementarily distributed in the LMA, totalizing 225 units (153 USF and 72 UCSP) (**Figure 4**). Only 1.5% of the LMA surface and 0.5% of the population are not allocated to any of the USF/UCSP facilities.

Given their valences and functions, the studied health services have a limited schedule, but consistent with the law. The vast majority of services start at 8:00 am (94%), and the rest at 9:00 am, while the closing time is more diverse, between 4:00 pm and 8:00 pm, with a higher incidence at 8:00 pm (63%) and at 6:00 pm (22%).

Considering the proximity logic of primary healthcare services, it is desirable that the entire population has access to the equipment in which they are enrolled in a relatively short distance time, not forgetting that this indicator depends not only on the locations of the residence and equipment, but also by the selected transport mode. In the case of older people, it is important to approach car use based on the legal allowed speeds, but also the license possession and driving skills (factors influenced by the

*Walking Accessibility to Primary Healthcare Services: An Inequity Factor for Olders… DOI: http://dx.doi.org/10.5772/intechopen.106265*

### **Figure 4.**

*Location of USF and UCSP equipment by LMA ring, 2022: (a) family health units; (b) personalized health care units. Source: Based on [43].*

#### **Figure 5.**

*Service catchment area of primary healthcare services (USF and UCSP) according to different time-distance cutoffs in all LMA (a) and (b) and zoomed in to the LMA Center (b) and (d); and different walking speeds: 3.5 km/h (a) and (b), and 1.6 km/h (c) and (d).*

individual conditions of the users) [24]. Regarding walking mode is fundamental to consider the diversity of realities within the age group over 65 years old in terms of individual mobility ability, as this influences the walking speed (e.g., 3.5 km/h of regular pedestrian speed of an older person, 1.6 km/h on conditioned pedestrian speed cases) [32, 36].

**Figure 5** demonstrates the accessibility level to healthcare services in the LMA, based on the representation of the service catchment areas of all equipment (USF and UCSP) by pedestrian mode conditioned to the aforementioned speeds, while



### **Table 1.**

*Inhabitants with 65 or more years old (%) and surface (%) covered by service catchment areas of primary healthcare services (USF and UCSP) according to different time–distance cutoffs (until 15 min., 30 min., and 60 min.) by LMA ring (absolute values available on Appendix 1). Source: own calculations based on BGRI [40] and service catchment areas calculated on network analysis function of ArcGis.*

the proportion of the surface and population covered by these service areas by ring is quantified in **Table 1**; and **Appendix 1**. In a scenario where the entire population of LMA travels in a walking speed of 4.5 km/h, then 65% of the population would reside within 15 minutes nearby health service. This proportion reduces to 57% if we consider only the olderly population, assuming a walking speed of 3.5 km/h, drastically reducing to 26% if we assume a walking speed of 1.6 km/h. A detailed analysis highlights three evidences (**Table 1**).

Firstly, the distribution of primary healthcare services (USF and UCSP) is in line with the urban system of the LMA, insofar as they are essentially located in the most densely populated areas [41]. This evidence comes from the higher percentage of population served at any time–distance limit in any ring compared with the percentage of covered area. For example, the served population at a distance time of 15 minutes at a walking speed of 3.5 km/h attends 69% in Lisbon & Ring 1 for only 31% of the covered territory. Keeping the criteria, in Ring 3 this situation is even more evident: 43% of the population served for only 5% of the ring surface. In LMA case, in the more peripheral Ring 3 and Ring 4 there are large unpopulated areas or with a very low population density, with land allocated to agricultural or forestry uses, for example.

This high complementarity between the urban system and the primary healthcare service system in the LMA could not happen in other metropolitan areas, highlighting the priority to study the served population by levels of distance time. Thus, the approach for urban planning should seek to increase the proportion of

*Walking Accessibility to Primary Healthcare Services: An Inequity Factor for Olders… DOI: http://dx.doi.org/10.5772/intechopen.106265*

served population and respective conditions, rather than only focus to increase the served territory [33, 36].

Secondly, in the context of the LMA, is clear a ring differentiation in terms of walking accessibility to primary healthcare services. The central rings, closer to Lisbon, have better accessibility levels, which means that a greater proportion of older people lives close to the services. For example, 69% of the olders in Lisbon & Ring 1 and 54% in Ring 2 live within a 15-minute walking distance from the equipment (speed of 3.5 km/h), compared with 43% in Ring 3 and 44% in Ring 4. The same pattern is found in the constrained walking speed simulation (1.6 km/h): 33% in Lisbon and Ring 1, compared with 18% in Ring 3 and 23% in Ring 4.

This pattern is related to the socio-urban characteristics of each ring. In Lisbon and in the two following rings, there is a combination between a more concentrated urban occupation and a greater population density, thus generating a more numerous and spatially closer health facilities network, serving a larger number of residents in a short dispersed area. Thus, the proportion of residents and area served within 15-minute walking are higher than in the more peripheral areas (rings 3 and 4). These last rings present a more dispersed and mostly peri-urban occupation profile, although there is existence of some relevant urban areas especially nearby the major road and rail axes. In these areas, population is distributed between small urban concentrations where the main services are located and very low dense areas further away from small urban centers [28, 40, 41]. This increase the official service area allocated to each equipment to maintain criteria of resources' efficiency and the number of users according to the law [42].

Lastly, the differences in walking speeds are highly penalizing the relationship of proximity between health facilities and users, in particular for users who have mobility constraints such as the older people [19, 24]. We can observe this situation by comparing the served LMA's older people up to 15-minute walking from a primary healthcare service: 57% when the walking speed is 3.5 km/h and 26% when the walking speed is 1.6 km/h.

Answering to RQ1, the results obtained raise a clear situation of inequity in the walking accessibility to the primary health services, penalizing the communities located in the most peripheral rings of the LMA, and particularly the age group of the olders, considering their pedestrian speed limitation (according to with the bibliography). This situation of inequity is further reinforced when the response of the public transport system in peripheral (and hence, more vulnerable) communities is also more limited in terms of network and service (fewer routes and less frequent service), when compared with the central areas of the LMA [12, 28].

This reading also highlights two aspects. Firstly, the importance of an analysis of accessibility indicators to health services considering the urban context [44], the settlement distribution, and the transport network, since a global analysis at the regional or metropolitan scale creates generalized ideas, insufficiently adequate to support the health service network planning in complementarity to the urban and transport systems, especially at the local level. This approach allows the discussion about inequity in a determined territory. Secondly, the need to compare the quantification of accessibility levels previously calculated using geographical modeling and the actual behavior of individuals, in this case those over 65 years of age, to validate whether better or worse walking accessibility to health services reflect real pedestrian displacements by these communities. Large discrepancies between potential and real walking accessibility must be studied in order to identify influencing factors (Section 4.2), as well as to support the design of flexible and/or informal solutions to minimize accessibility and access difficulties to health services (Section 5).

### **4.2 The demand for primary healthcare services in the perspective of older people in LMA**

In addition to the analysis of primary healthcare service supply and its potential walking accessibility, we analyzed the real demand in the LMA through a survey applied to the metropolitan residents in 2017. The results give the real mobility patterns of residents to various activities, namely health services (in a pre-pandemic period). The search questioned the following: (i) the place where people seek such service (in the parish of residence, in the municipality of residence or in another municipality); (ii) the travel time to the destination; and (iii) the preferred transport mode(s).

The sample attends 111 families with older people that corresponds to 131 individuals over 65 years old. Single-person families (43%) are the most representative type of family, followed by couples of aged (26%), and other family types (18%), namely the coexistence of three generations or grandparents living with grandchildren. Around 63% of these aged families have an average monthly income of up to 1000 euro, 21% between 1000 and 1500 euro, and 17% of more than 1500 euro per month. About half of the older respondents affirmed to spend less than 30 euros a month on transport (48%), followed by families with costs between 30 and 60 euros (30%) and 60–150 euros (17%). It is also worth noting that half of the families with older people do not own any vehicle, 34% have one vehicle, and 15% have two vehicles (although the possession of vehicles in the family does not necessarily mean that the older individuals are their users as drivers, but could promote their use as passengers) [24].

Considering only individuals aged 65 or over (**Table 2**), it was observed that the demand for primary healthcare service is mainly based on short-term trips up to 15 minutes (60%), with a still relevant proportion of individuals who take 16–30 minutes (25%). The short duration of each trip also reflects the proximity to the desired destination, mostly in the residence parish (50%) or in another parish in the residence municipality (20%). A fifth of individuals travel to other municipalities, a phenomenon related to the proximity of health services to other moments of daily life (e.g., proximity to the workplace, family housing) or personal motivations and taste (e.g., preference for private services or for a specific doctor). Lastly, the use of individual motorized transport stands out (43%), followed by active modes (walking or cycling) (21%) and public transport (17%). In the LMA, carrying out short-term trips supported by the use of the car is observed not only to reach health services, but also to other goods and services and to school/employment, not only by the olders but also by all communities [23, 28].

Various realities relate the used transport mode to distance-time traveled emerged (**Table 3**). More than 4/5 of who use soft modes make short-term trips (up to 15 minutes) (87%). On the other hand, individual transport is the choice for short-term (74%) and medium-term trips duration (20%), that is, between 16 and 30 minutes. It should be underlined that the higher speed of this mode allows traveling a greater physical distance in the same period. In turn, those who use public transport are essentially to carry out medium-term trips (68%), while those who use various modes of transport are not strongly correlated with one specific time range, except the emphasis on trips of longer duration (more than 31 min.) (15%), compared with the other modes. These results are consistent with the general evolution of urban mobility from the community to metropolis level, increasing the diversity of living areas of individuals in their daily lives and the distance between the area of residence and such destinations, and hence arising new challenges related to the services and transportation planning [12]. An in-depth study differentiating the age of older people could be necessary to differentiate their needs.


*Walking Accessibility to Primary Healthcare Services: An Inequity Factor for Olders… DOI: http://dx.doi.org/10.5772/intechopen.106265*

#### **Table 2.**

*Accessibility patterns to primary healthcare services (USF and UCSP) by older people by LMA ring.*

Different dynamics are observed in the demand for primary healthcare service by LMA's ring, with a greater similarity between Lisbon & Ring 1 and Ring 4 compared with what is observed in Ring 2 and Ring 3 (**Figure 6**). In Lisbon & Ring 1 and Ring 4, there is a predominance of short-term trips/up to 15 minutes and a geographical proximity between the individuals and the destination (mainly in the parish of residence), and in the case of Lisbon & Ring 1 to the residence municipality. It is evident that geographical proximity is not particularly conducive to travel by soft/active modes, since it predominates the car use and public transport in the central area. This situation may result from several factors, namely the physical condition of the older person, the conditions of family support or related with perceptions about themselves and about the surrounding environment [4, 7, 15]. As a note, within this older people's sample, 32% feel healthy, while 38% do not feel healthy (at different levels, but not discussed in depth in this work). About 48% of the older individuals do not feel safe to walk or cycle in the residence area (against 25% who assume the opposite), 41% consider that there is a lot of traffic, and 53% consider that there are high levels of noise and air pollution in the residence area.


### **Table 3.**

*Time spent vs. transport mode to primary healthcare services by older people in LMA.*

#### **Figure 6.**

*Synthesis of accessibility patterns to primary healthcare services by older people by LMA ring.*

In turn, a greater diversity in the travel tie can be found in Ring 2 and Ring 3, with considerable proportion of respondents who spend more than 30 minutes looking for primary healthcare services. This situation is associated with the destinations of the trip, given the diversity of relevant destinations (parish, municipality, and other municipalities). Private transport maintains its predominance, complemented by the use of public transport in Ring 2 and by soft modes in Ring 3.

In this way, focusing on the RQ2, the expectation for an age-friendly environment related to walking accessibility to primary health services [4, 15, 18–22, 26] is not fully observed in the behavior of the surveyed population, that is, not everyone seeks to access the services under study on foot and in a short time. This situation is due to the combination of several factors, namely the organization of the health system itself (as some equipment is shared between communities and/or municipalities); to personal motivations and perceptions (e.g., insecurity feelings in public space); the physical and mental conditions and level of autonomy of individuals; or the use of complementary services provided by private or other entities (e.g., social institutions or local authorities). The differences between rings arise the importance to relate the results with context indicators of the urban environment in order to identify the main influencing factors of the emerged results [29].

### **5. Promoting equity minimizing older's constraints to health accessibility in LMA**

As it is not efficient to multiply the number of health services and associated physical and human resources in order to increase proximity to all users, it is essential *Walking Accessibility to Primary Healthcare Services: An Inequity Factor for Olders… DOI: http://dx.doi.org/10.5772/intechopen.106265*

to create complementary responses, prioritizing the most vulnerable users, and attracting several community stakeholders to the action [21, 22, 23, 45]. This will minimize risk situations caused by the retraction in the demand for health services and promote a better health for all.

The constraints to health accessibility by the olders are not a recent concern in the policy orientations of WHO for Age-friendly Cities [4]. Considering the proposed checklist for cities in the report "Global Age-friendly Cities: A Guide," some premises in the domains of health services and transportation should be implemented. SHAFE project synthetized similar orientations, highlighting as well the main policy documents and possible stakeholders at several levels, to promote smart healthy agefriendly environments [21, 22].

Based on **Table 4**, it is highlighted the need of a health system with a varied offer of services, well distributed territorially and that answers to the community's needs in the domain of health services. Complementarily, the existence of community support services is proposed, namely home services, which alleviates the strain on the service network and promotes better levels of health and well-being for the beneficiaries. On the other hand, and to promote a high quality transportation and a better accessibility level to health services, it is proposed the existence of a good public transport system in terms of affordability, frequency, quality, and comfort of vehicles, territorially spread and that responds to the major origin-destination needs. Quality of transport stops and stations is referred as well as they could be the first barrier to use public transports. As well, community transports are highly pointed to be complementary to the regular public transport system.

In the Portuguese case, municipalities and local organizations that have more proximity to the needs of each community have limited intervention to define policies and get funding to the healthcare model. While the local government involvement in the health domain is residual, other entities as social institutions and nongovernmental organizations present a high degree of organization and power, complementing the public health service [22]. This proves that external stakeholders to the Ministry of Health with health, social and transportation competences (e.g., local authorities, nongovernmental organizations, private institutions of social solidarity, transport operators) are more and more aware of their complementary role in supporting the proximity health service network and especially the older people as a vulnerable group with specific needs [21–23, 45]. In this sense, the provision of community support services has proved to be an asset as a way of bringing services that promote health and well-being closer to them.

In the Portuguese case, some actions are already in operation, namely tele-consultation, transport adapted to citizens, home deliveries of pharmaceutical or food products, home support, or even the adaptation of housing infrastructure (first factor of accessibility limitation) [22]. Specifically to LMA, some examples of recent strategies and/or actions that already exist in the municipalities of the LMA considered as good practices that complement the primary healthcare service formal structure should be highlighted.

### **5.1 Strategic plans oriented toward an healthy and inclusive aging**

Assuming that aging is everyone's business and that the community is the central place for aging policies, this issue begins to be evident in the design of strategic plans and measures that promote a more active, healthy, and sustainable aging process. Measures


Transport stops and stations

• Location of stops and stations suitable for the settlement system, especially considering the older people, with good safety, cleanliness, and easy access conditions;

Community transport

• Existence of community transport services as a complement to public transport services, resorting to voluntary work and adapted vehicles.

#### **Table 4.**

*Checklist for Age-friendly Cities in the domains of Community Services, Health Services, and Transportation. Source: own elaboration based on [4].*

that promote better and easier accessibility of the older people to health services, applying not only the adaptation of infrastructures, but partnerships with local transport operators or the creation of innovative and informal responses are already a reality.

One of the examples is the Strategic Plan for Sustainable Aging 2016–2025 (PEES) of the municipal council of Amadora, which promotes a set of measures in favor of access and accessibility to health by the older [46]. As part of strategic objective 1 – Promoting safety and physical, psychological, social, and economic integrity of the older people, measures such as "Ensuring increased accessibility to health care for people aged 65+ classified with functional limitation/disability" or "Ensure increased accessibility to healthcare for people aged 65+ enrolled in ACES" stand out. In strategic objective 4 – Promoting mobility, transport and accessibility with better personal comfort and safety condition, we underlined measures such as: "Identify by 2023 public services without accessibility for people with reduced mobility"; "Put into operation in 6 parishes a door-to-door transport service for citizens with reduced mobility to travel to public services, health centers and hospitals"; and "Raise public transport operators' awareness of the need to create or improve internal circuits in the county by 2025".

*Walking Accessibility to Primary Healthcare Services: An Inequity Factor for Olders… DOI: http://dx.doi.org/10.5772/intechopen.106265*

### **5.2 Home-based healthcare or in the proximities**

There are several solutions that have brought health services closer to their users. For example, several health services are carried out through the displacement of health teams or in which the need for physical displacement is replaced by telehealth services using several technologies (internet, telephone). Delegation of health services competences to other health service providers or partners in the health network (e.g., vaccination in pharmacies; medical care in municipal facilities or institutions of social support; home medication delivery) is already a reality in Portugal. Lastly, local autarchies or institutions of social support also provide health services.

In the period of the Covid-19 pandemic, since 2020, the Lisbon municipal council, in partnership with the Ministry of Health, has promoted an annual flu vaccination strategy benefiting around 165,000 olderly people [47]. This initiative is carried out recurring to mobile health units that travel to the neighborhoods (and, in case of need, to home), and counts on with the collaboration of other municipal entities, such as the parish councils and the fire brigades. The objective is to promote vaccination as a proximity service, preventing people from having to travel to health centers or other health facilities.

Articulated with ACES Oeiras and Lisboa Ocidental, since 2018, the municipal council of Oeiras makes available a home medical service—"Doctor at Home" for people over 65 years old who are beneficiaries of the Special Scheme for Participation in Medicines, identified according to the average income of households (currently meets the need of 2316 citizens) [48]. This service includes a specialized assistance service for triage, medical assistance available 24 hours a day by telephone, and medical consultations at home.

### **5.3 Promotion of flexible transport to reach health services**

It is not only health services that are becoming increasingly flexible, but also transport responses have seen adapted to needs, especially to serve the most vulnerable populations and/or territories. In this way, the different levels of accessibility to health services are no longer such an evident exclusion criterion for the vulnerable fringes of the population. Improvements on the transport system responding to the older's needs in terms of origin-destination, service schedules, adaptation of transport conditions (e.g., lowered entrances, space for wheelchair) are more and more considered, as the existence of flexible transport solutions (door-to-door transport, transport on demand), provided by local authorities, social entities, and transport operators.

In several LMA municipalities, stands out the "Solidarity Transport for the Olderly" initiative as a way to overcome the difficulties that the older people face in transport, minimizing situations of isolation, loneliness, and insecurity [49]. One of the areas where the project is being carried out is in the parish of Carnide, municipality of Lisbon, where the Parish Council has allied with the Association of Retired, Pensioners and Olders of Carnide to create a service for residents over 55 years of age. The destinations are not exclusive to health facilities, but also include commercial areas, green spaces, or any other destination (free of charge within the parish, scheduled by telephone).

In the municipality of Almada exists the inclusive mobility service "Almada BUS Saúde". Operating since 2017, it has reached 500,000 users in early 2020, demonstrating its great utility [50]. With a circular route and without fixed stops, it aims to travel around the main health facilities in the city of Almada (hospital and health centers)

and other public services. Beyond that, the vehicles are specially adapted to transport olderly people and people with reduced mobility.

Lastly, we highlight an equity measure implemented since April 2022 by the TML – Transportes Metropolitanos de Lisboa (Lisbon Metropolitan Transports), as the metropolitan transport authority. The TML decided to create a monthly metropolitan public transport pass with equal cost for all individuals (40 euros), independently of their origin destinations or the transportation modes, with particular adding benefits for specific groups as olders and students, giving a discount of 50% of the monthly cost to these groups [51].

Responding to RQ3, with this small set of examples (among many others already systematized), it is possible to observe the existence of a great diversity of solutions that promote equity in access to PHS in the LMA. The vast majority of the solutions observed are dynamized at the local/community level by different stakeholders. The solutions identified are at the level of policy instruments that frame the studied challenge, but also in the areas of health services and transport. This verification is in line with the theory principles promoting an age-friendly, healthy, inclusive, and sustainable environment considering multisectoral and multilevel approaches and calling on the various community stakeholders to actively participate in the solutions for more equitable communities and metropolises.

### **6. Final conclusions**

This chapter discussed the walking accessibility to primary healthcare by the olders in Lisbon Metropolitan Area (LMA), Portugal, and its contribution for agefriendly environments as a factor of inequity, based on three research questions to which an answer is now given.

Since the health and transport networks are directly related to the LMA's radioconcentric urbanization pattern, metropolitan rings also differentiate the levels of walking accessibility to primary health services. The management of services is essentially anchored in the criterion of the population served by equipment (as a way of maintaining its efficiency in terms of human and financial resources). Thus, denser areas register a network of health facilities with a greater number of equipment and proximity to each other (improving the walking accessibility level), while less dense areas and more dispersed occupation generate greater service catchment area, and hence greater distance between the user and the equipment by part of the population, affecting distance and distance–time measures. Hence, this relation between the health, settlement, and transport networks generates differentiated accessibility levels to healthcare, creating a situation of inequity within the metropolis.

As expected for age-friendly territories, generally, the demand for primary health services takes place through short-term travel. However, such distance time is partially solved through individual motorized modes, in contrast to the proposed modes (walking and public transport). This phenomenon may result from the combination of several factors that require in-depth study (inexistence of public transport? fear of walking? the service is too far? resorting to the family for travel?). Here, there were also different behaviors between the metropolitan rings, highlighting the influence of the characteristics of the health and transport networks in the individuals choices.

Finally, consistently with the guidelines of UN and WHO for age-friendly environments, it is possible to see in LMA the existence of some strategies, from local

*Walking Accessibility to Primary Healthcare Services: An Inequity Factor for Olders… DOI: http://dx.doi.org/10.5772/intechopen.106265*

to metropolitan level, which complement the limitations of primary health services access by older. Such guidelines are evident (i) in strategic plans (in a top-down orientation); (ii) in the provision of health services at home or in areas closer to users promoted by local authorities, social partners, or other health service providers; and (iii) in flexible, affordable, and adapted transport strategies (both in a bottom-up orientation). These types of initiatives are minimizing inequity situations within and among the LMA's communities.

The usefulness of this work is centered on three aspects: (1) effectiveness of the relationship between the theory relating to the construction of age-friendly environments and a methodology for evaluating situations of inequity in the metropolitan context centered on the principle of accessibility to primary health services; (2) possibility of methodological replication over time for this case study and/or for other territories and services; and (3) production of knowledge to support policy decision in the area of urban planning, and in particular in the fields of health and transportation, with utility at local, municipal, and metropolitan/regional levels, promoting a multisectoral and multilevel approaches. However, some limitations should be acknowledge, as the results are very dependent on the quality and timeliness of the data. For example, in this case, demographic data on the statistical subsection (the Portuguese smallest territorial unit possible) date from 2011, due to the unavailability of data from the 2021 Census until now. This generates possible discrepancies between what was elaborated and the reality, especially in areas of intense new urbanization or areas that are facing population losses. The same applies to the high variability of the organization of health services, with constant restructuring in terms of the equipment physical location and provided services, which can also generate outdated readings. Finally, in order to bring the analysis even closer to reality, the service areas in terms of served parishes of each equipment defined by law should be taken into account, implying an equipment-toequipment methodological replication.

Hence, the multisectoral reading relating health services and transportation; the combination between the potential accessibility levels to primary health services based on modeling (representing the network supply) and the real behaviors of the older people (as the demand); and the identification of complementary solutions allow us to discuss the accessibility level to primary health services in a more complemented approach. This will better support the urban planning strategies and instruments toward more age-friendly, healthy, and inclusive environments; to a more competitive, social and territorial cohesive territories, and lastly, to more equitable communities and metropolitan areas.

### **Acknowledgements**

This article was financed by national funds through FCT–Portuguese Foundation for Science and Technology, I.P., under the framework of the Project GRAMPCITY – Moving smartly toward accessible and inclusive urban environments for our elders (PTDC/GES-TRA/32121/2017), of the Master Scholarship "For more age-friendly mobility and accessibility in urban areas" (PTDC/ GES-TRA/32121/2017-BI-LIC); of the PhD Scholarship "Planning the urban environment for healthy aging" (UI/BD/152227/2021), and the Research Unit (UIDB/00295/2020 and UIDP/00295/2020).


**80**

**A. Appendix 1**

*Walking Accessibility to Primary Healthcare Services: An Inequity Factor for Olders… DOI: http://dx.doi.org/10.5772/intechopen.106265*

### **Author details**

Eduarda Marques da Costa, Ana Louro\*, Nuno Marques da Costa, Mariana Dias and Marcela Barata Centre for Geographical Studies, Institute of Geography and Spatial Planning, University of Lisbon, Lisbon, Portugal

\*Address all correspondence to: analouro@campus.ul.pt

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Envelhecimento [Internet]. 2022. Available from: https://unric.org/pt/ envelhecimento/ [Accessed: May 25, 2022]

[2] 4 ways to improve the lives of older people – World Economic Forum [Internet]. 2021. Available from: https:// www.weforum.org/agenda/2021/10/ healthy-ageing-older-people/. [Accessed: May 19, 2022]

[3] Fitzgerald KG, Caro FG. An overview of age-friendly cities and communities around the world. Journal of Aging & Social Policy. 2014;**26**:1-18. DOI: 10.1080/08959420.2014.860786

[4] World Health Organization. Global Age-Friendly Cities: A Guide. Geneva: WHO; 2007. p. 82

[5] Villaverde Cabral M, Moura Ferreira P, Alcântara da Silva P, Jerónimo P, Marques T. Processos de envelhecimento em Portugal. Lisboa: Fundação Francisco Manuel dos Santos; 2013. p. 381

[6] Louro A, Franco P, Marques da Costa E. Determinants of physical activity practices in metropolitan context: The case of Lisbon metropolitan area, Portugal. Sustainability. 2021;**13**:10104. DOI: 10.3390/su131810104

[7] Coelho C. Envelhecimento e saúde em Portugal: práticas e desafios num cenário de aumento da população idosa (1974-2031). Lisboa: Universidade Nova de Lisboa; 2016

[8] Casabianca E, Kovacic M. Loneliness among Older Adults – A European Perspective. Ispra: JRC; 2022. p. 9

[9] van den Berg P, Kemperman A, de Kleijn B, Borgers A. Ageing and loneliness: The role of mobility and the built environment. Travel Behaviour and Society. 2016;**5**:48-55. DOI: 10.1016/j. tbs.2015.03.001

[10] Aroogh MD, Shahboulaghi FM. Social participation of older adults: A concept analysis. International Journal of Community Based Nursing and Midwifery. 2020;**8**:55-72. DOI: 10.30476/ IJCBNM.2019.82222.1055

[11] Wen C, Albert C, Von Haaren C. The elderly in green spaces: Exploring requirements and preferences concerning nature-based recreation. Sustainable Cities and Society. 2018;**38**:582-593. DOI: 10.30476/ijcbnm.2019.82222.1055

[12] Louro A, Marques da Costa N, Marques da Costa E. From Livable communities to Livable Metropolis: Challenges for urban mobility in Lisbon metropolitan area (Portugal). International Journal of Environmental Research and Public Healh. 2021;**18**:3525. DOI: 10.3390/ ijerph18073525

[13] Oliveira M. Diversidade: um olhar sobre o idoso. In: Proceedings of the II Congresso de Ensino, Pesquisa e Extensão da UEG. Pirenópolis; 2015

[14] Ageing – United Nations [Internet]. 1999. Available from: https://www. un.org/en/UN-system/ageing [Accessed: May 19, 2022]

[15] Alley D, Liebig P, Pynoos J, Banerjee T, Choi IH. Creating elderfriendly communities: Preparations for an aging society. Journal of Gerontological Social Work. 2007;**49**:1-18

[16] Marques da Costa E, Fumega J, Louro A. Defining sustainable

*Walking Accessibility to Primary Healthcare Services: An Inequity Factor for Olders… DOI: http://dx.doi.org/10.5772/intechopen.106265*

communities: Development of a toolkit for policy orientation. Journal of Urban Regeneration and Renewal. 2013;**6**:278-292

[17] Di Marino M, Tomaz E, Henriques C, Chavoshi SH. The 15-minute city concept and new working spaces: A planning perspective from Oslo and Lisbon. European Planning Studies. 2022:1-24. DOI: 10.1080/09654313.2022.2082837

[18] van Hoof J, Kazak JK, Perek-Białas JM, Peek ST. The challenges of urban ageing: Making cities agefriendly in Europe. International Journal of Environmental Research and Public Health. 2018;**15**:1-17. DOI: 10.3390/ ijerph15112473

[19] Lakshmanan CT, Ramachandraiah A, Sivakumar R. Walkability analysis for age friendly neighborhood. Journal of Critical Reviews. 2020;**7**:842-844. DOI: 10.31838/jcr.07.04.158

[20] Banister D, Bowling A. Quality of life for the elderly: The transport dimension. Transport Policy. 2004;**11**(2):105-115. DOI: 10.1016/S0967-070X(03)00052-0

[21] van Staalduinen W, Spiru L, Illario M, Dantas C, Paul C. D4 report on SHAFE policies, strategies and funding. International interdisciplinary network on smart healthy age-friendly environments, COST Action 19136 (2020-2024). NET4Age-Friendly. 2021. pp. 1-153

[22] van Staalduinen W, Dantas C, van Hoof J, Klimczuk A. Building smart healthy inclusive environments for all ages with citizens. In: Pires IM, Spinsante S, Zdravevski E, Lameski P, editors. Smart Objects and Technologies for Social Good: 7th EAI International Conference. Cham: Springer International Publishing; 2021. pp. 255-263

[23] Louro A, Marques da Costa N, Marques da Costa E. Sustainable urban mobility policies as a path to healthy cities—The case study of LMA, Portugal. Sustainability. 2019;**11**:2929. DOI: 10.3390/su11102929

[24] Dickerson AE, Molnar LJ, Eby DW, Adler G, Bedard M, Berg-Weger M, et al. Transportation and aging: A research agenda for advancing safe mobility. The Gerontologist. 2007;**47**:578-590. DOI: 10.1093/geront/47.5.578

[25] Falcão SRA. Autonomia e movimento do corpo idoso: estudo de caso. Lisboa: Universidade Técnica de Lisboa; 2011

[26] van Schooten KS, Pijnappels M, Rispens SM, Elders PJM, Lips P, Daffertshofer A. Daily-life gait quality as predictor of falls in older people: A 1-year prospective cohort study. PLoS One. 2016;**11**:e0158623

[27] Gargiulo C, Zucaro F, Gaglione F. A set of variables for elderly accessibility in urban areas. Journal of Land Use, Mobility and Environment. 2018;(2): 53-66. DOI: 10.6092/1970-9870/5738

[28] Louro A, Marques da Costa N. Mobilidade urbana e municípios saudáveis na AML. Tendências entre as últimas duas décadas (2000 e 2010). Finisterra. 2019;**LIV**:71-95

[29] Marques da Costa E, Palma P, Marques da Costa N. Regional Disparities of SGI Provision. In: Fassmann H. Rauhut D. Marques da Costa, E. Humer, editors. Services of General Interest and Territorial Cohesion: European Perspectives and National Insights Viena: Vienna University Press; 2015. pp. 91-121

[30] Amer S. Towards Spatial Justice in Urban Health Services Planning. A Spatial-Analytic GIS-Based Approach Using Dar es Salaam, Tanzania as a Case Study. Enschede: International Institute for Geo-Information Science and Earth Observation; 2007

[31] Cuidados de saúde primários [Internet]. 2021. Available from: https:// www.who.int/world-health-day/worldhealth-day-2019/fact-sheets/details/ primary-health-care. [Accessed: May 19, 2022]

[32] Marques da Costa E, Marques da Costa N, Louro A, Barata M. "Geographies" of primary healthcare access for older adults in the Lisbon metropolitan area, Portugal—A territory of differences. Saúde e Sociedade. 2020;**29**:1-13

[33] Ferreira R, Marques da Costa N, Marques da Costa E. Accessibility to urgent and emergency care services in low-density territories: The case of Baixo Alentejo, Portugal. Ciência & Saúde Coletiva. 2021;**26**:2483-2496. DOI: 10.1590/1413-81232021266.1. 40882020

[34] Penchansky R, Thomas JW. The concept of access: Definition and relationship to consumer satisfaction. Medical Care. 1981;**19**:127-140

[35] Saurman E. Improving access: Modifying Penchansky and Thomas's theory of access. Journal of Health Services Research & Policy. 2016;**21**: 36-39. DOI: 1177/1355819615600001

[36] Freitas C, Marques da Costa N. Accessibility to primary health care in low-density regions. A case study: NUTS III – Baixo Alentejo – Portugal. Ciência & Saúde Coletiva. 2021;**26**:2497-2506. DOI: 10.1590/1413- 81232021266.1.40892020

[37] Du M, Cheng L, Li X, Yang J. Mint: Factors affecting the travel mode choice of the urban elderly in healthcare

activity: Comparison between core area and suburban area. Sustainable Cities and Society. 2020;**52**:101868. DOI: 10.1016/j.scs.2019.101868

[38] Munir BA, Hafeez S, Rashid S, Iqbal R, Javed MA. Geospatial assessment of physical accessibility of healthcare and agent-based modeling for system efficacy. GeoJournal. 2020;**85**:665-680. DOI: 10.1007/s10708-019-09987-z

[39] Censos. 2021. Available from: https:// censos.ine.pt/scripts/db\_censos\_2021. html. [Accessed: May 15, 2022]

[40] Censos. 2011. Available from: https:// censos.ine.pt/xportal/xmain?xpid=CEN SOS&xpgid=censos2011\_apresentacao. [Accessed: May 15, 2022]

[41] Carta de Uso e Ocupação do Solo para 2018 [Internet]. 2020. Available from: https://www.dgterritorio.gov.pt/Cartade-Uso-e-Ocupacao-do-Solo-para-2018. [Accessed: May 07, 2022]

[42] Diário da República n. 38/2008, Série I de 2008-02-22 – Estabelece o regime da criação, estruturação e funcionamento dos agrupamentos de centros de saúde do Serviço Nacional de Saúde [Internet]. 2008. Available from: https://dre.pt/dre/ detalhe/decreto-lei/28-2008-247675. [Accessed: May 26, 2022]

[43] Cuidados de Saúde Primários [Internet]. 2022. Available from: https:// www.arslvt.min-saude.pt/pages/6247675. [Accessed: May 06, 2022]

[44] Beard JR, Petitot C. Ageing and urbanization: Can cities be designed to Foster active ageing? Public Health Reviews. 2010;**32**:427-450

[45] Louro A, Marques da Costa N, Marques da Costa E. A Cidade Saudável no planeamento municipal: exemplos de atuação na AML, Portugal. In: Soares BR, *Walking Accessibility to Primary Healthcare Services: An Inequity Factor for Olders… DOI: http://dx.doi.org/10.5772/intechopen.106265*

Marques da Costa N, Lima SC, Marques da Costa E, editors. Construindo cidades saudáveis: utopias e práticas. Uberlândia: Assis Editora; 2017. pp. 35-66

[46] Câmara Municipal da Amadora. VIVER BEM A IDADE – Plano Estratégico para o Envelhecimento Sustentável da Amadora 2016-2025. Amadora: CMA; 2021. p. 11

[47] Idosos vacinados contra a gripe em Lisboa sem terem de se deslocar ao centro de saúde [Internet]. 2020. Available from: https://dignus.pt/2020/09/23/ idosos-vacinados-contra-a-gripe-emlisboa-sem-terem-de-se-deslocar-aocentro-de-saude/. [Accessed: May 19, 2022]

[48] Cinco apoios sociais para quem vive em Oeiras [Internet]. 2020. Available from: https://www.oeirasvalley.com/ cinco-apoios-sociais-para-quem-viveem-oeiras/. [Accessed: May 19, 2022]

[49] Transporte solidário para idosos – Serviços da Junta [Internet]. 2021. Available from: https://www.jf-carnide. pt/para-a-populacao/servicos-da-junta/ servicos/Transporte-solidario-paraidosos/291/. [Accessed: May 19, 2022]

[50] Serviço de mobilidade inclusiva "Almada BUS Saúde" atinge os 500 mil utilizadores [Internet]. 1999. Available from: https://www.ageneal.pt/noticia/ servico-de-mobilidade-inclusivaalmada-bus-saude-atinge-os-500-milutilizadores. [Accessed: May 19, 2022]

[51] Portal Viva. Passes Navegante [Internet]. 2022. Available from: https:// www.portalviva.pt/pt/homepage/ t%C3%ADtulos-de-transporte/ uso-frequente/passes-navegante.aspx. [Accessed: May 01, 2022]

Section 3
