Health in Shrinking Regions Breaking the Downward Spiral of Shrinkage

Master Thesis Health in shrinking regions Breaking the downward spiral of shrinkage, socio- economic status and health Final Version 21-11-2019 Josien Muns S1029379 1 Radboud University Master Thesis Human Geography Track: Economic Geography Thesis mentor Radboud University: Arnoud Lagendijk Internship organization: Witteveen+Bos Deventer Internship mentor: Peter van Weelden Second internship mentor: Koen Haans Number of words: 26734 2 Preface Before you lies my master thesis “Health in shrinking regions”. This thesis marks the end of my master program Human Geography, track Economic Geography at the Radboud University Nijmegen. This thesis combines spatial inequality, economic processes and political influence, and tries to investigate and explain the complex relationships between them. I want to use this preface to thank some people who have helped me complete this thesis. Firstly I want to thank my mentor from the Radboud University, Arnoud Lagendijk, who has throughout the process encouraged me to remain critical and improve on my work. Secondly, I want to thank my father, Bert Muns, who has patiently helped me improve the linguistic aspects of this thesis. Lastly, I want to mention my mentor from my internship organization, Witteveen+Bos. Where the completion of this thesis should have been a happy and proud moment, a tragic and unforeseen event cast a dark cloud upon these last steps in the process. Just one week before the end of my internship, my mentor Peter van Weelden passed away. I would like to utilize this foreword to share my thoughts, feelings and memories of these past six months. Peter, Almost 6 months ago I walked into Witteveen+Bos. I did not know exactly what to expect during this internship, but from the first moment you were ready and willing to show me direction. No matter how busy you were, you always had time to answer my questions, there was always time for discussion. We did not always find the solution immediately, but the moment where you found a creative way to solve a problem always arrived. You lit up, ideas and enthusiasm followed. The philosophical approach you liked so much was not always easy, but it taught me a lot and elevated the level of my thesis. I would have loved to conclude this internship in a different way, I would have loved to share the final product, but it was not meant to be. Peter, thank you for everything I have been able to learn from you. 3 Abstract Although the total world population continues to grow, many regions in the world, including the United States and Europe, are faced with the opposite: demographic decline. The Netherlands, despite an overall demographic growth, has got multiple regions with a declining population. A shrinking and aging population brings a unique set of problems, creating a downward spiral between a shrinking population, lowering socio-economic status and deteriorating health. Simultaneously, decentralization of government tasks has increased the need for self-management and participation, without a clear understanding of whether or not all layers of society are able to meet this demand. The aim of this thesis is to provide a framework of action to intervene in this spiral and improve the general health standard for shrinking regions. To create this framework, a qualitative study consisting of literature review, policy analysis and semi-structured in-depth interviews with 9 participants has been carried out. Analysis of the responses, literature review and policy analysis showed that although participation plays a central role in healthcare policy, there is no clear definition of participation, which makes setting goals and expectations very difficult. Defining what is meant with participation improves the ability to set goals and expectations, increasing the chances of successful participation. Additional interventions include a more integrated and long term approach to healthcare, combining functions and interventions to serve multiple purposes and changing the approach to healthcare prevention. 4 Table of Contents Preface ........................................................................................................................................ 3 Abstract ...................................................................................................................................... 4 Introduction ................................................................................................................................ 8 A changing population ........................................................................................................ 9 Causes and consequences of shrinkage ............................................................................. 9 Hidden effects of shrinkage: declining health ................................................................. 10 Societal relevance ................................................................................................................. 11 Scientific relevance ............................................................................................................... 12 Aim and research questions ................................................................................................. 13 Overview of the thesis .......................................................................................................... 13 Literature review ...................................................................................................................... 15 Contextual background......................................................................................................... 16 Theoretical Background ........................................................................................................ 17 What is urban shrinkage? ................................................................................................. 17 Demographic change ........................................................................................................ 17 Selective migration ........................................................................................................... 18 Socio-economic status ...................................................................................................... 19 Socio-economic status and health ................................................................................... 19 Health demand ................................................................................................................. 21 Built environment and health .......................................................................................... 21 Self-management and participation ................................................................................ 23 Conceptual framework, variables and definitions ................................................................... 25 Variables - defining and operationalizing ............................................................................. 27 Variables and indicators ....................................................................................................... 28 Methodology ............................................................................................................................ 30 Findings .................................................................................................................................... 34 Introduction to the findings and results ............................................................................... 34 Presenting the baseline: recent history and current situation ............................................ 35 The economic history of Groningen ................................................................................. 35 Economic history of Parkstad Limburg ............................................................................. 36 Changes in the built environment ........................................................................................ 39 5 The current situation - Socio-economic status and health statistics ................................... 50 Culture: heritage and change ............................................................................................... 53 Improving the health standard ............................................................................................. 54 Health policy in South Limburg ........................................................................................ 54 Health policy in Groningen ............................................................................................... 55 How the policies compare ................................................................................................ 56 Finance and law .................................................................................................................... 57 Participation.......................................................................................................................... 58 Participation through life ................................................................................................. 59 Conditions for participation ............................................................................................. 60 Participation summarized ................................................................................................ 62 Results .....................................................................................................................................

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