by Sara Hashemi1*, Estie Kruger1, Marc Tennant1
The Foot and Ankle Online Journal 13 (1): 5
This study examined the spatial accessibility of podiatry services to aged people living in the Greater Perth area, and access to these services for people from different socioeconomic groups, using geographic information systems (GIS). All persons older than 65 years (n=216 062) were included in the study and divided into two subgroups (retirees and elders) by age. Census data, bus stops (high and medium accessible stops) and train station data were integrated with GIS to analyse population spatial accessibility. The study found that most of the aged population resided within 2 kilometers of podiatry clinics, and the podiatry services are well distributed. In terms of access to buses, around three-fifths of aged people lived within 1 kilometer of high-access bus stops, and more than four-fifths of this population resided within 1 kilometer of medium-access bus stops. The distribution of podiatrists among people from different socioeconomic areas showed the density of podiatry services was higher in more affluent areas, therefore, the Inverse Care Law is evident in access to podiatry services in the Greater Perth region.
Keywords: aged population, podiatry services, spatial accessibility, density, buses, trains
ISSN 1941-6806
doi: 10.3827/faoj.2018.1301.0005
1 – International Research Collaborative – Oral Health and Equity, Department of Human Sciences, The University of Western Australia.
* – Corresponding author: 21642772@student.uwa.edu.au
Western Australia is geographically the largest state in Australia, with a total area of more than 2.5 million square kms (a third of the total area of Australia) and a population (in 2011) of 2.2 million people [1]. Of this population 1.7 million people (77%) are living in the capital city, Perth. In recent years, the population growth was double that of other cities in Australia [2]. A little over 200,000 residents of Perth are over the age of 65 years, and it is forecasted that the age structure in Perth will change consistent with the global trend in developed countries. The predictions are that there will be a decrease in the working-age population from 89% to 64%, and an increase in retirement age proportion of people to 66% by 2026 [3]. Clearly this shift in population demographics will require substantial and rapid planning for health and welfare services over the next decade. Australia is thus facing the classic developed country issues of an aging population whilst being relatively wealthy and it being substantially a healthy population [4]. Many health services are available, both public and private, but the use of these services depend on geographic accessibility. Australian cities are not densely packed cities and the reliance on vehicle transport is high. Geographical accessibility to healthcare services is one of the fundamental components of healthcare [5]. The ageing of the Australian population has already, and will continue to drive strong growth in podiatry services (https://www.aihw.gov.au/). This study examined the spatial accessibility of podiatry services to the population of the Australian metropolis of Perth, using a geographic information system (GIS) approach, with a focus on the retired and elders, and taking transport options into consideration.
Methods
As only openly accessible and freely available data were used in this study, no ethics approval was required.
Podiatry practice locations: The podiatry directory from November 2015 was used to determine public service locations [7]. This directory updates every year and shares information about the Department of Health (DOH) and publicly funded podiatry services available in Western Australia. The private services were gathered from the yellow pages and addresses were confirmed with Google maps.
Population data: All population data (including age distribution) were obtained from the 2011 Census. The data frameset for this study include all people living within 50 km of the Central Post Office in Perth. Population groups were categorized according to age, with a focus on retirees and elders. Retirees included all people older than 65 years old, and elders include all those older than 85 years.
Train systems in Perth: Perth, like the other Australian capital cities, has a comprehensive local train network. There are four Perth train lines, radiating out from the main Perth city train station [8]. All the train stations were included in this study. The geographic data for train stations is available on the TransPerth website (http://www.transperth.wa.gov.au).
Bus system in Perth: Two bus terminals are located in the Perth metropolis: the Wellington street bus station and the City Bus port. The Wellington street bus station is approximately 200m from the main city centre train station, and services the northern suburbs. The geographic data for bus stations were available from the Transperth website (http://www.transperth.wa.gov.au). High and medium frequency bus stops were considered separately. The “high” frequency stops were where busses stop at least 48 times per day (every 15 minutes) and “medium” had a lower frequency of less than 48 busses per day.
Population data and socioeconomics: Census data from the most recently available (and geo-coded) census (2011) were used for the study (http://www.abs.gov.au). A total of 1976 Perth SA1’s (the smallest geographic area the census data is divided into) had centroids within 50 km of the central post office. Consistent with previous studies this was deemed to be the Greater Perth region and used in the study as the definition of Perth.
The socioeconomic status of the population was analyzed using the Socioeconomic Index for Areas (SEIFA). The Australian Bureau of Statistics (ABS) uses SEIFA, a composite index of relative socioeconomic disadvantage, and determined from indicators collected by the ABS within each set of census data. In this research the deciles of SEIFA will be dichotomized, with deciles 1-5 classified as low socioeconomic, and the deciles 6-10 classified as high socioeconomic.
Data integration and analysis: All data were integrated using QGIS (version 10.0), and analyses were completed using Excel (version 2010;Microsoft Corporation, Seattle, WA, USA). QGIS software was used to formulate an integrated buffer zone around each podiatry service location, train and bus stations. Two optional zone radii were applied; zone A was 1 km wide, and zone B was within a 2 km radius from a podiatry service location.
Results
The aged population and podiatry locations: The aged population (65 years and over) living in the Greater Perth area was 216,062, of which 187,925 were retired (65-84 years old) and the others, 28 137, were elders (over 85 years old). A total of 104,928 adults (retiree and elderly) lived within zone A (within 1km of a podiatry service), whilst 73,875 adults lived within zone B (between 1 km and 2 km of a podiatry clinic). These, respectively, constituted 48.6% and 34.2% of the total retirees and elders’ population of Greater Perth. For retirees, 89,21 (47.6%) lived within zone A, and 64,118 (34.1%) lived within zone B. For the elders, 15,407 (54.7%) and 9,757 (34.7%), respectively, resided in zone A and B (Table 1).
The aged population and bus stops (high and medium stops): In this study high and medium bus stops have also been investigated (the stations with high and medium numbers of times that the bus stops, or frequency of stops).
| Adults | Within 1 km
(Zone A) |
Within 2 km
(Zone B) |
Outside 2 km | Total |
| Retirees | 89,521
(47.6%) |
64,118
(34.1%) |
34,286
(18.3%) |
187,925
(100) |
| Elderly | 15,407
(54.7%) |
9,757
(34.7%) |
2,973
(10.6%) |
28,137
(100) |
| Total | 104,928
(48.6%) |
73,875
(34.2%) |
37,259
(17.2%) |
216,062
(100) |
Table 1 The number and percent of retirees (65-84 years old) and elderly (over 85 years old) living within 1 km, 2 km and outside 2 km of a podiatry service in Greater Perth.
Figure 1 Podiatry services locations in the Perth metropolitan area (green stars for private services and the pink for public services), and 1 km buffer zones around high frequency bus stops (blue circles).
A total of 129,485 retirees and elderly lived within 1km of high frequency bus stops (Figure 1), and 182 459 adults lived within 1 km of medium frequency bus stops (Figure 2). These, respectively, constituted 60% and 84% of the 216,062 total retirees and elders’ population of Greater Perth. For retirees, 110,426 (59%) lived within 1 km of high frequency bus stops, and 157,778 (84%) lived within 1 km of medium frequency bus stops. For the elders, 19,059 (68%) and 24,681 (88%), respectively, lives within 1km of high and medium frequency bus stops (Table 2).
The aging population and train stations: This study identified the density of the aging population living next to train stations (Table 3). A total of 35,273 retirees and elders lived within 1km of train stations, and this amounts to around 16% of the aged population in Greater Perth (Figure 3).
| Adult | Within 1km of high bus stops | Within 1km of medium bus stops |
| Retirees | 110,426
(59%) |
157,778
(84%) |
| Elderly | 19,059
(68%) |
24,681
(88%) |
| Total | 129,485
(60%) |
182,459
(84.4%) |
Table 2 The number and per cent of the aging population living within 1 km of high and medium bus stops in Greater Perth.
Figure 2 Podiatry services locations in the Perth metropolitan area (green stars for private services and the pink for public services), and 1 km buffer zones around medium frequency bus stops (orange circles).
| Within 1km | Within 2km | Outside 2km | Total | |
| Retirees | 29,547
(15.7%) |
37,762
(20.1%) |
120,616 (64.2%) | 187,925
(100) |
| Elderly | 5,726
(20.35%) |
6,280
(22.3%) |
16,131
(57.3%) |
28,137
(100) |
| Total | 35,273
(16.3%) |
44,042
(20.4%) |
136,747 (63.3%) | 216,062
(100) |
Table 3 The number of older people living next to 1km of train stations.
Around 20% of this population lived within 2km of train stations and the rest (63%) lived outside 2km of train stations.
Socioeconomics: SEIFA was used to examine the relative socioeconomic status and proximity to podiatry services and public transport, and found lower percentages of the most disadvantaged half of the population (the first five deciles) lived closer to podiatry services, compare to the least disadvantaged half of the population (Table 4).
Figure 3 Podiatry services locations in the Perth metropolitan area (green stars for private services and the pink for public services), and 1 km buffer zones around train stations.
Table 4 The number and percent of retirees (older than 65 years old) and elderly (older than 85 years old) living within zone A, zone B, high and medium bus stops and 1km and 2km of a train station, divided by Socioeconomic Index for Areas (SEIFA) deciles* in metropolitan Perth. Note: The percent shows the percentage of total aging population. * Decile 1=poorest, decile 10 =wealthiest.
Discussion
Spatial accessibility to healthcare facilities has been the focus of many studies in Australia, with the distance to facilities being highlighted as a barrier to access and subsequent utilisation of services (10). In total, 82% of retired (48% in zone A and 34.1% in zone B) and 89.4% of elders (55% in zone A and 35% in zone B) lived within 2 km of podiatry clinics, which it is 82.8% of the total aging population in Greater Perth. This information shows that podiatry services are distributed relatively uniformly among this population (Table 1) and most aged people have access to a podiatrist within a 2 km distance at most. Most of the aging population resided within 1km of high and medium bus stops, and therefore most of the retired and elders can use buses to visit podiatrists (Table 2).
There was a different trend in the distribution of train stations among the retired and elders, compared to proximity of them to bus stops, the train stations were not a suitable selection to access podiatry locations. In total, 36% of the retired population lived within 2km of train stations (15.7% within 1km and 20.1% within 2km) and 43% of elders resided within 2km (20% within 1km and 22% within 2km). In total, 36.7% of the whole aging population resided within 2 km of a train station.
In conclusion, access to podiatry services via train stations, does not seem to be a suitable option (Table 3), because 63% of total aging people resided outside of 2km from a train station. This study also focused on the public transportation accessibility of aged people from different socioeconomic backgrounds. Public transportation is very important to the older population in general, as they depend more on public transportation than young people. Also, older people, (especially after 70 years of age) start to surrender their driving licenses and depend on others to transport them to health facilities (11). They have limitations of using and driving personal vehicles, whilst at the same time experiencing a greater need for health care (12). However although retirees and elders depend on public transport, a lower proportion of them were living in close proximity to train stations.
The relative socioeconomic status and proximity to podiatry clinics, bus stops and train stations have been investigated, and the most disadvantaged of the retired and elders were less likely to live within up to 2 km of podiatry services (zone A and B) compared to wealthier older people. This data shows that the distribution of podiatrists were more likely to be among wealthier people, than people from lower socioeconomic areas. Only 17.4% of the total aged population lived outside of zone B. In terms of accessibility to bus stops (high and medium) within 1km, the wealthier groups had more spatial accessibility to both high and medium bus stops (34.4% and 48% respectively), while the low income people had less accessibility to bus stops, 25.5% for high and 36.5% for the medium stops. This difference is not too significant. In comparison between poor and wealthy aged people and access to train stations (within 2km) has shown that there were significant differences between these two groups., Only 14.4% of retired and elders from disadvantaged areas were located within 1 and 2 km of train stations (12.2% retired and 2.2% elders). The percentage of the aging population with high socioeconomic status was 22% within up to 2km of train (19% retired and 3.3% elders). This study indicated that the higher percentage of the aging population (63.3%) with different socioeconomic resided outside of 2km of train stations. According to this data, the Inverse Care Law applies to the aged population in the Greater Perth metropolitan area. The definition of this law is “The availability of good medical care tends to vary inversely with the need for it in the population served”(13). On the other hand, public transportation was located closer to wealthier populations. It should be investigated to determine if people from wealthier areas suffer from higher burdens of foot problems or diseases associated with foot health (such as diabetes), than those from poorer areas. It might be that those from more disadvantaged areas are more unaware of feet health, or that the cost and affordability of podiatric care act as a barrier to obtain care.
References
- Western Australia. Available from: http://www.lookatwa.com.au/AboutPerth/.
- Population of Perth in 2016. [Cited 2016 Jan 7]. Available from: http://australiapopulation2016.com/population-of-perth-in-2016.html
- City of Perth. Population and age structure. Available from: http://forecast.id.com.au/perth/population-age-structure
- Zainab U, Kruger E, Tennant M. Major metropolis rail system access to dental care for the retired and elderly: a high- resolution geographic study of Sydney, Australia. Gerodontology. [Serial online]. 2014. Doi: 10.1111/ger.12157.
- Lara J, Sanders a, Glenn D, Aguilar b, Catherine J. Bacon. A spatial analysis of the geographic distribution of musculoskeletal and general practice healthcare clinics in Auckland, New Zealand. Applied Geography. 2013; 44: 69-78.
- What is a Podiatrist? John J. Swierzewski, D.P.M. [cited 1999 31 Dec]. Available from: http://www.healthcommunities.com/foot-pain/what-is-podiatrist.shtml#sthash.oGDU4mGG.dpuf.
- Podiatry services. DoH and public funded podiatry services WA Metro and Rural. Version 5, Nov 2015. P: 25-35.
- Perth Train. Available from: http://www.getting-around-perth.com.au/perth-trains.html.
- Look at WA. Perth’s online portal. Available from: http://www.lookatwa.com.au/Transport/buses.html.
- Kruger E, Tennant M, George R. Application of geographic information systems to the analysis of private dental practices distribution in Western Australia. Rural Remote Health 2011; 11: 1736.
- Kihl MR. The need for transportation alternatives for the rural elderly. In: Bull CN ed. Aging in Rural America. Thousand Oaks, CA: Sage; 1993: 84–98.
- Rocha CM, Kruger E, McGuire S, Tennant M. The geographic distribution of patients seeking emergency dental care at the Royal Dental Hospital of Melbourne, Australia. Community Dent Health 2013; 30: 149–54.
- Hart JT. The inverse care law. The Lancet 1971:297;405-412.
