Background
The European countries are all facing a structural housing shortage due to strong population growth within metropolitan areas and large cities [
1,
2]. The biggest share of the European population resides in cities (40.4%) as well as towns and suburbs (31.6%) [
3]. Low property values in areas outside of growth regions have created a high-risk situation for developers to produce new housing in these areas, which has been reported particularly in Luxemburg, Germany, Ireland, the Netherlands, and Sweden [
1,
4].
Furthermore, the current demographic change is a challenging phenomenon as low birth rates and a higher life expectancy transit the population structure towards a much older population, and will therefore sooner or later affect all European countries. The proportion of individuals aged 80 years or older is expected to increase from 5.9% in 2020 to approximately 9.1% in 2040, and the expected increase is 11.1% in 2050 [
5]. Hence, the ageing population, as well as the accompanying demographic change, will put financial pressure on old-age support systems as well as on housing provision policies when it comes to accessible housing development [
6].
Moreover, the ageing of the population in many European countries has resulted in policymakers giving more attention to how to improve and develop sustainable approaches to meet the needs of senior citizens. For instance, to accommodate the desire of an ageing generation that wants to live in their homes as long as possible, “ageing in place” has become a major policy strategy in many countries and is defined as “remaining living in the community, with some level of independence, rather than in residential care” [
7]. From a societal perspective, “ageing in place” can be supported by measures taken to design or adapt the physical home environment in a way that enables older people to maintain independence in activities of daily living and thereby potentially decrease public expenditures through less need for institutional care and home services [
8]. The physical environment is a central health determinant and previous as well as recent research shows that the housing environment may impact older people’s autonomy [
9], independence [
10], and participation [
11]. Moreover, there is evidence that living in an inappropriately designed housing environment may increase risks of fall accidents [
12], poor mental health [
13], and mortality [
14]. Housing policies can therefore be instrumental in addressing several major public health issues.
Although all European countries have similar difficulties to meet the needs of senior citizens, housing policies differ widely both with regard to how they are realized and the culture in which they emerge. The Swedish public housing system stands out among the countries within the European Union, even if it is sometimes considered as an example of “social housing” [
2,
15]. There is no generally agreed-upon definition of social housing, but a recent literature review suggested that social housing is a system that provides long-term housing to a group with limited financial resources, utilizing a distribution system and subsidies [
16]. The housing systems in many European countries include policies that meet this definition of social housing. For instance, in Germany “publicly subsidized housing” for vulnerable household groups such as single parents, people with lower incomes, or migrants is common [
15]. In Denmark, to take another example, social housing is provided by non-profit housing associations owned and organized by its members but regulated by the state. Although the Swedish system includes subsidies to low-income and other vulnerable groups, in general, a queue system based on time and housing availability is applied, and there is no special housing market for low-income or socially disadvantaged households. While not social housing according to the definition suggested by Granath Hansson and Lundgren [
16], the Swedish public housing market is characterized by the societal responsibility of the municipalities [
17] to plan and provide adequate and affordable housing for all citizens [
18,
19]. Unlike the other European countries, Sweden also has an association of public housing companies, Public Housing Sweden; the Swedish name is “Allmännyttan”, which literally means “public utility” or “for the benefit of everybody” [
15,
20]. However, at the same time as these public housing companies have a societal responsibility, they are required to be business-oriented and make profit, which in reality may be difficult to combine [
21].
The policy choices of the different countries may also reflect different value systems and ideologies, as well as the supply and demand of public and social housing. As an example, Germany is characterized by the principle of subsidiarity and relies in the first instance on the individual as well as on family responsibility. Only in the second instance on solidarity in society as a whole, that is, on state support [
22]. Concerning housing policies, an important turning point in Germany in the 1980s was the abolition and marketization of nonprofit housing companies which resulted in a general decrease in social housing. The amount of social housing is only about 4% of the total housing stock today and should mainly support individuals with a lower income [
23]. Denmark, in comparison, is a country with a long tradition of social renting that has not registered a decrease in the share of social housing out of the total housing stock since the early 2000s and represents a generally high share of social accommodation with 21% of the total housing stock [
1,
2]. In Sweden, the association of public housing companies has been instrumental in the implementation of housing policies. At present, approximately 50% of all rental apartments are owned by public housing companies. Particularly in the 1940s and 1950s, there was overcrowding and a big shortage of accommodations in Sweden, which gave rise to the “Million Homes Program” that was introduced in the early 1960s. The objective was to build multi-family dwellings in a high quantity and speed [
24] nationwide. The Swedish societal planning of the housing market is organized on three different levels. The national building targets are set out in the budget that the government submits to the Parliament while the County Councils (21 in total) are responsible for the regional spatial planning and the Municipalities (290 in total) are working with the physical execution which includes location and physical appearance of buildings [
25].
To accommodate the growing number of senior citizens, housing needs to be accessible, since multimorbidity, functional decline, and dependence on mobility devices [
26] tend to increase in older age and make it more onerous to reach objects, move around in the environment and manage everyday life [
27]. According to the current Swedish Planning and Building Act (PBL) new housing must be accessible in its design and technical characteristics for individuals with functional limitations [
28]. However, environmental barriers (e.g. wall-mounted cupboards and shelves placed extremely high or high thresholds and/or too high steps at the entrances) in or outside the homes are common in the existing Swedish housing stock and hinder older people and people with functional limitations from using their homes adequately [
29]. Furthermore, recent research expounded that a lack of stair handrails at entrances was associated with increased mortality risk [
14]. Additionally, a previous Swedish governmental report identified three major issues in Sweden. First, approximately 50% of inhabitants aged 65 years or older live in single-family houses where the bathroom is installed on the second floor, which leads to difficulties for individuals with functional limitations to use their sanitation facilities. Second, 50% of all accommodations built before the 1970s are still in use, but before the late 1970s, no law considered lifts for buildings with more than one floor. Third, an absence of maneuvering space for a rollator or wheelchair within ordinary housing is a major challenge for people with functional limitations and disabilities, since they have difficulties moving within or entering/exiting their homes [
4].
Addressing the challenges created by the housing shortage in metropolitan areas and rapidly ageing populations within the ordinary housing stock are also topics of intense interest in worldwide politics and Public Health research. An important aspect of appropriate housing for older people is the extent to which the physical housing environment facilitates or impedes activities of daily living when people age and their functional capacity is declining, that is, how accessible the housing environment is [
30]. For instance, there is sufficient maneuvering space while using a walking device, kitchen cupboards are placed at a height easy to reach, or entrance doors stay in the open position. While some studies focused on housing accessibility in this sense [
29,
31] as well as on housing adaptations [
11,
32‐
34], other research has concentrated on older people’s preferences and experiences [
35]. Also, the economic perspective [
36] and outcomes such as fear of falls [
37] or quality of life [
32] are topics that get particular attention in current studies. Although the research on housing accessibility has been recognized as important, there is a paucity of studies that focus on examining the actual policies of municipalities addressing current and future housing needs. As policies at the municipal level play an important role in achieving overarching political goals, it is important to understand the processes and reasoning behind them to serve policymakers to make the most informed decisions and thereby improve the housing situation and health of the population. Thus, this study aimed to gain an in-depth understanding of how municipalities currently address housing accessibility issues and to explore what types of policy solutions they consider in the future to better support housing accessibility for an ageing population.
Discussion
The study revealed four main factors that were perceived to influence current and future housing policies, described as legal, organizational, socio-demographic, and political factors. Concerning how municipalities currently and in the future deal with housing accessibility issues, six themes were identified. That is, organizational, economic, research and development, preventive, housing construction and design, as well as legal policies. The theme of economic policies appeared to play a central role in how the municipalities handled housing accessibility issues. This theme included, among others, economic incentives to stimulate relocation and subsidies for the renovation of the existing housing stock. To better support housing accessibility for the future, a list of prioritized policies was formulated, where the highest priority was given to legal policies and in particular sharpening building legislation in a manner that puts more specific requirements on building and construction companies to design and build housing that is accessible for all. Coordination of housing accessibility issues at a national level was also considered to be of the highest priority. The participatory approach, where key actors and senior citizens together prepared this priority list of suggested housing accessibility policies for the future, was a novel aspect of the study.
The interviews revealed a common perception that the municipalities are caught in a dilemma between their strategies and goals regarding housing accessibility and the current law as their operational framework. Several participants expressed frustration that they could not require actions by the housing companies that would improve the physical accessibility unless it was clearly supported by the current building legislation. For example, they mentioned how they often struggled with the limited leeway they have towards private housing companies in order to renovate and adjust existing buildings to improve housing accessibility. This reflects the variety and complexity of societal planning problems that municipalities are facing through the involvement of various actors. The complexity of this issue was examined in a recent study, suggesting that the provision of accessible housing for all is a societal issue which by its nature cannot be solved in a way that satisfies all involved stakeholders and actors [
46]. Additionally, conflicting interests such as keeping costs down and still providing accessible housing are difficult to balance [
47] for the municipalities. In several interviews there was reasoning around the necessity to provide housing of diverse tenure, such as rental apartments, co-operative apartments, and self-owned single-family houses that can attract people with different needs and financial resources. Moreover, the suggestions for interventions focusing on social division and socially mixed housing shows there is pressure on the municipalities and a need to meet the challenges without creating a social housing market for low-income or socially disadvantaged households. The demand for municipal housing companies to adapt to a competitive market and strive for profit makes it difficult to uphold the societal responsibility to vulnerable groups and to realize innovative ideas that may involve economic risks [
21].
The interviews showed that legal factors such as the Swedish Planning and Building Act [
44] were at the forefront of factors that influence how housing accessibility issues are addressed today. For instance, they argued that barriers that complicate access for persons with cognitive limitations are often overlooked by current legislation and therefore even in newly built dwellings, barriers related to cognitive limitations still occur. However, it was also emphasized in the interviews, that the current building legislation sometimes appears vague and leaves room for interpretations of how housing accessibility requirements should be practically implemented. These results are in line with previous literature that provides examples of how legislation can affect housing accessibility both positively and negatively [
47]. Legislation supporting measures for people with functional limitations such as the Swedish Planning and Building Act were generally considered positive by the participants, while negative impacts included the limited leeway towards private housing companies regarding essential renovations and adaptations as well as the vague formulation of the current law in terms of accessibility and usability. These results suggest that political decision-makers at the national level in collaboration with municipalities and other housing provision actors, continuously need to revisit how legislation can be strengthened to support municipalities struggling to enforce housing accessibility policies.
The expressed need to elevate housing accessibility issues to a higher political level than the municipality was a prominent feature of the results, emphasized in the discussions of the research circle. Both the key actors and the senior citizens saw the coordination of accessibility issues at a national level and the sharpening of the housing and building legislation as top priorities, overarching other policies. Especially participants from smaller municipalities expressed, that they needed support and backing from higher national authorities. Earlier research points to the lack of EU regulations on housing accessibility, and this issue remains to be a matter for the national legislation of the EU member states [
48]. Initiatives on the EU level could serve to give policies addressing housing accessibility issues further impetus in the member states [
49].
Furthermore, how the municipalities addressed housing accessibility in their official policy documents for the ageing population differed. In one of the smaller municipalities, the housing accessibility issues were not evident in the housing supply plans, while the content was richer and more obvious in the plans of the bigger municipalities. However, the participants recognized both in the interviews and the research circle the importance of having policies that are intended to improve housing accessibility. Yet, the participants found the goals set in the policy documents challenging to achieve due to insufficient financial resources or to limited collaboration between municipal committees and other involved actors, e.g. private housing companies. This could indicate a need for policy documents to more clearly outline the resources and conditions needed to fulfill ambitious goals.
The results showed that the level of policy was crucial for implementing adequate measures on a municipal level. Some policies such as renovations of existing buildings and demanding more from private housing companies than what is regulated in the law [
4] were constrained by factors on a national level, for instance, the national legislation or economic resources, and were therefore hampering the implementation of measures on the municipal level. As perhaps could be expected organizational factors were considered to influence how housing accessibility issues are addressed. For instance, it was mentioned that issues managed by the social welfare committee tended to apply more of an individual perspective, while issues managed by the building committee tended to apply more of a municipal perspective. As indicated by a previous study, the formal hierarchical structure of bureaucracy can create challenges that decrease information-sharing activities within the organization [
50]. Acknowledging the presence of such conflicting perspectives should stimulate key actors to strengthen dialogue and collaboration with each other.
Strengths and limitations of the study
Although this study did not aim to make any comparisons between municipalities, it should be noted that the challenges within the municipalities e.g. the increasing amount of senior citizens, as well as the current and future policies appeared to be similar across the municipalities. The findings may not reflect a national view on housing policies of the 290 Swedish municipalities. However, they might be an indicator for current and future housing accessibility policies and priorities for the future on a national level, since we purposefully selected the municipalities to reflect diversity in size, geographic location, socio-economic condition as well as ethnicities. Moreover, we strived to cover different areas of responsibilities while including key actors with a variety of different professional and administrative positions, to increase generalizability.
As a consequence of the Covid-19 restrictions, the interviews and the research circle were mainly conducted online. Not meeting in person and using digital communication might on the one hand have impacted the interview situation and conversation to be more efficient and to the point, but on the other hand, may have kept some participants from speaking more freely. However, we were able to gain rich content through the online meetings. To strengthen the study, we included participants that represented a gender-balanced sample with a variation of professional position, and we applied a participatory approach by the inclusion of senior citizens and the use of the research circle methodology. Furthermore, due to Covid-19 restrictions, we could not visit the municipalities to gather information about their physical appearance, governance, and administration, which otherwise would have enriched our results with observations.
Several measures were taken to address the trustworthiness of this study. To ensure credibility, investigator and method triangulation was used. Investigator triangulation was met through the independent coding by two researchers focusing on the same material, as well as the inter-coder-agreement checks within the analysis [
42]. By gathering data from different data collection methods such as individual interviews, document analysis as well as research circle, method triangulation was addressed. To apply a member check, the priority list was sent out to the participants of the research circle after the first meeting for feedback and adjusted after discussions. By providing information about the context and research process of this study, we aimed to increase transferability [
51].
Implications
Overall, similar topics were raised in the interviews, policy documents, and the research circle. Our results suggest that collaboration and sharing knowledge between different policy levels within a municipality but also on a national level from one municipality to another would be beneficial to target housing accessibility issues in a joint effort and make informed decisions. Extensive measures such as after-installation of lifts can be economically challenging. However, it might benefit many, such as older people and families with children, and therefore lead to long-term societal gains in terms of increased participation, autonomy, and quality of life in these groups. Moreover, effective communication of the results of existing research on housing accessibility may help key actors in the municipalities to understand areas of concern, such as barriers in the housing environment that increase the risk for falls, and how these can be addressed. Whilst housing accessibility is a complex matter, future studies should focus on the impact of both neighborhood and housing environment in creating supportive environments for the ageing population, in order to improve the health of the population.
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