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Transportation Research Procedia 25 (2017) 4381–4391
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World Conference on Transport Research - WCTR 2016 Shanghai. 10-15 July 2016
World Conference on Transport Research - WCTR 2016 Shanghai. 10-15 July 2016
The effect of accessibility on aged people's use of long-term care
The effect of accessibility on aged people's use of long-term care
service
service
Kuniaki Sasakiaa* Yoko Aiharabb Kiyoshi Yamasakicc
Kuniaki Sasaki * Yoko Aihara Kiyoshi Yamasaki
a
University of Yamanashi, 4-3-11 Takeda, Kofu, 4008511 Japan
b
Kobe
a
City College
University of Nursing,4-3-11
of Yamanashi, 3-4 Gakuen-Nishimachi 6512103
Takeda, Kofu, 4008511 Japan
Japan
c
Value Managemen
b
InstituteofInc.,
Kobe City College 2-2-13-4
Nursing, Otemachi, Chiyoda-ku,6512103
Gakuen-Nishimachi Tokyo 1000004,
Japan Japan
c
Value Managemen Institute Inc., 2-2-1 Otemachi, Chiyoda-ku, Tokyo 1000004, Japan

Abstract
Abstract
Managing the cost of the long term care service is critically important to provide the better service to the aged people in the
Managing
hyper-agedthe cost of
society. In the
suchlong term care we
management, service
need is
to critically
be sensitiveimportant
in keepingto provide the better
the necessary service
services to the the
in cutting aged people
cost. in the
Therefore,
hyper-aged
identifying society. In such management,
what determines we need
the aged people’s to be sensitive
service in keepingMobility
user is necessary. the necessary
wouldservices
be oneinofcutting
the keysthe cost.
to theTherefore,
decision
identifying what determines
making in choosing the because
the service, aged people’s
most ofservice user is
the nursing necessary.
care service isMobility
related towould be one of theNursing
the transportation: keys toservice
the decision
offers
making
not onlyin choosing
facility carethe service,
services butbecause most ofcare
home nursing theincluding
nursing care service
shopping is relatedIntothis
assistance. the study,
transportation: Nursingtheservice
we investigated offers
relationship
not only facility
between care services
the transportation but home nursing
environment and the care including
use of shopping
the service. assistance.
We focused In thiswho
on those study,
do we
not investigated
use nursing the relationship
service, despite
the certification
between of the long-term
the transportation care, in
environment andorder to find
the use of thewhy they do
service. Wenot use. We
focused analyzed
on those whowhatdo notleduse
one to useservice,
nursing or not use the
despite
the certification
nursing of the
care service by long-term care, inlogistic
using multilevel order regression
to find why they dobecause
analysis, not use.it We analyzed
allowed us to what led the
consider one difference
to use or of notthe
useerror
the
nursing care
structure. Weservice
appliedbytheusing
modelmultilevel logistic
to the data regression
of a local city inanalysis, because
Japan. The resultitshows
allowed ussome
that to consider theindicating
variables differenceaccessibility
of the error
structure. We affected
significantly applied the
one’smodel to the whether
decision data of aonelocaluses
city the
in Japan.
serviceTheor result shows
not. The that some variables
accessibilities of car to indicating accessibility
clinic, hospital and
significantly affected
neighborhood one’s decision
shops significantly whether
affected one useswhile
the decision, the only
service
the or not. The accessibilities
accessibility to the hospital of wascar to clinic,when
significant hospital and
one uses
neighborhood
public transport.shops
More significantly affected
than 50 percent theaged
of the decision,
people while only the accessibility
use motorcars to the
to travel in this hospital
city, wasmight
and this significant
be whywhenmoreone uses
number
of the accessibility
public transport. Moreby using
than 50thepercent
car significantly
of the agedaffected
people the
use nursing service
motorcars use. in
to travel We might
this city,be able
and thistomight
manage the cost
be why moreof number
service
of the
use accessibility
more effectivelybyand
using the car significantly
efficiently affected the improvement.
through the accessibility nursing service use. We might be able to manage the cost of service
use more effectively and efficiently through the accessibility improvement.
© 2017 The Authors. Published by Elsevier B.V.
© 2017 The Authors. Published by Elsevier B.V.
© 2017 The Authors.
Peer-review Published by
under responsibility of Elsevier
WORLDB.V. CONFERENCE ON TRANSPORT RESEARCH SOCIETY.
Peer-review under responsibility of WORLD CONFERENCE ON TRANSPORT RESEARCH SOCIETY.
Peer-review under responsibility of WORLD CONFERENCE ON TRANSPORT RESEARCH SOCIETY.
Keywords: Aging Society; Long-term Care Insurance; Accessibility; Built Environment; Multilevel Analysis
Keywords: Aging Society; Long-term Care Insurance; Accessibility; Built Environment; Multilevel Analysis

* Corresponding author. Tel.: +81-55-220-8671.

E-mail address:author.
* Corresponding sasaki@yamanashi.ac.jp
Tel.: +81-55-220-8671.
E-mail address: sasaki@yamanashi.ac.jp
2214-241X © 2017 The Authors. Published by Elsevier B.V.
Peer-review©under
2214-241X 2017responsibility
The Authors.of WORLDbyCONFERENCE
Published Elsevier B.V. ON TRANSPORT RESEARCH SOCIETY.
Peer-review under responsibility of WORLD CONFERENCE ON TRANSPORT RESEARCH SOCIETY.

2352-1465 © 2017 The Authors. Published by Elsevier B.V.

Peer-review under responsibility of WORLD CONFERENCE ON TRANSPORT RESEARCH SOCIETY.
10.1016/j.trpro.2017.05.320
24382 Kuniaki
Author Sasaki
name et al. / Transportation
/ Transportation Research 00
Research Procedia Procedia
(2017)25 (2017) 4381–4391
000–000

1. Introduction

The aging population over 65 years old in Japan is rapidly increasing and expected to reach 40% in 2055. To cope
with this increase, the Japanese government introduced long-term care insurance system (LTCI) in 2000 funded by
the tax from those who are 40 years old or older. But such a system is hardly sustainable as the ratio of those who
pay tax is shrinking†. Therefore, the society needs to keep the aged people as healthy as possible. One of the key
approaches is increasing their mobility that is indispensable to keep their health well maintained. Therefore, the
society needs to provide the solid and useful transportation: Where the public transportation is not useful, the aged
people are more likely to stay home instead of using available health care facilities. Consequently, they might get
weaker as they lose the opportunity to use their body. In reality, the Japanese public transportation environment,
particularly in the rural area, has been deteriorating due to the motorization. By focusing on the relationship between
transportation environment and the elder people’s health care facility use, this paper will shed the light on the
importance of improving the transportation environment to sustain the aged society.
In practice, this paper analyzed whether and how the convenience level of transportation affected the level of
elder people’s use of LTCI. The convenience level was indicated by the accessibility to the community facilities, and
we use the official data to regarding the service use.

2. Former research

There are two approaches to analyze LTCI use. One approach is to analyze the way one decides to buy insurance
or not, though this is possible where having insurance is not mandatory. One of such study is Brown and Finkelstein
(2008). They considered the relationship between Medicare and LTCI. They concluded that the bottom two-thirds of
the wealth distribution would not want to purchase private insurance when Medicaid is provided. They found only
the wealthy people would be willing to pay for private LTCI because much of the benefit accrues to the government
in lower Medicaid expenditure. Another approach is to focus on what determines the LTCI use. Some of the
researches using this approach are motivated by the necessity to reduce unnecessary LTCI institutionalization. Hicks
et al (1981) reported that patients who received coordinated home care services through project Triage had higher
subsequent rates of LTCI institutionalization than members of a matched comparison group who did not receive
these services. Weissert et.al (1980) studied patients' physical, psychological and health data in every three months
with their bills to Medicare. There was a possibility that life was extended for some day-care patients, though day-
care patients showed no benefits in physical functioning ability at the end of the study, compared with the control
group.
Some studies focus on LTCI purchase by using the Health and Retirement Study (HRS) data, the outcomes of the
University of Michigan Health and Retirement Study. This study project is a longitudinal panel study that surveys a
representative sample of approximately 20,000 Americans over the age of 50 every two years. The study has
collected information about income, work, assets, pension plans, health insurance, disability, physical health and
functioning, cognitive functioning, and health care expenditures. One of the researches that use this data is Brown
et.al (2007) which provides empirical evidence of Medicaid crowd-out of demand for LTCI. The paper indicates that
the majority of households would find it unattractive to purchase private insurance due to Medicaid eligibility. By
analyzing HRS data, Sun and Webb (2013) showed that the partnership programs of purchasing LTCI will increase
insurance coverage among single household by only a small percent, assuming plausible preference parameters in
the model.
Recently it has been reported that the built environment impacts the health condition through the physical activity
experience. Li et al (2009) showed the impact of the built environment, such as the walking-score and the number of
fast food restaurant, on BMI (Body Mass Index) of the aged people. John et al (2010) also indicated the effect of

†
The ratio of the LTCI users is 4.2 % in the group from 65 to 74 years old, while the ratio in the group over 75 years old is 29.2%. The total
payment for the service and had passed 740 billion yen in 2013 (about $7 billion?). use.
 Kuniaki Sasaki et al. / Transportation Research Procedia 25 (2017) 4381–4391 4383
Author name / Transportation Research Procedia 00 (2017) 000–000 3

installing LRT (Light Rail Transit) in the city. The propensity score method is adopted to adjust the departure from a
randomized experiment. They concluded that LRT use for commuting would reduce BMI and the risk of obesity.
There are many studies focusing on what determine the LTCI service use and on the relationship between the
built environment, especially the transportation environment, and health. Also, LTCI use is the basic topic in public
health. For designing the comfortable and sustainable environment, the impact on health of transportation as the built
environment should be studied, too. This study focused on that topic and will show some evidences in this article.
Generally, measures used to evaluate the personal transportation environment have focused on the concept of
mobility. Meanwhile, accessibility measures assess the potential for interaction and measure the environment of the
community. Elements of an accessibility measure would describe how destinations are distributed and how easy to
reach them. A typical accessibility measure has two components. The first one is related to the destinations and is
commonly called the attractions portion of the measure. The second component describes how easy to reach those
attractions. Because difficulty increases over distance, this component is commonly called the impedance factor.
There are a lot of measures to assess the accessibility of community. The simplest accessibility measure is the
distance or a separation measure to the destination. Another is the gravity measure, which includes an attraction
factor as well as a distance. The third way is a utility-based measure which is based on an individual utility for travel
choices. Ben-Akiva and Lerman (1979) prove that the utility form of accessibility meets several criteria.

3. Outline of data

3.1. Accessibility index

One of the common indexes to describe the transportation environment of a location is accessibility. As shown in
the previous section, the utility-based approach can include more variables relevant to accessibility, so that this is a
more generalized form of accessibility. To operationalize this concept, we use the accessibility index employed by
Policy Research Institute for land, infrastructure, transportation and tourism (PRILIT), a national institute of MLIT
(Ministry of Land, Infrastructure and Transport). Hase et.al (2013) reported their nationwide accessibility study and
defined accessibility index. Their index measures the transportation environment to three destinations in each mesh
zone designed for the national census: medical care facilities, grocery shop and public administration office. The
transportation environment is measured by two different travel modes, cars and public transportation including
buses and trains. In total, six index items measure each zone’s accessibility nationwide; each of three destination
categories is further divided into two by the transportation types. The expected generalized cost from the centroid of
a zone to two zones which have the lowest generalized cost of all the three types of facilities accounts for the
accessibility of zone for each type of facility. There are two reasons to consider two facilities of each type. One is
the redundancy to important facility that is ensured by taking the second nearest alternative into account. Another is
to consider the case that the closest one is at a close distance while the second closest is not. In this definition, the
accessibility of a zone that has two alternatives in close location becomes higher than that of the area that has only
one alternative in a close location. Basically the utility-based accessibility has to evaluate all the options in the
choice set, but the choice set differs among the individuals even in the same community. That is, this study assumes
that the combination of the nearest two destinations is the choice set. The domain of the expected generalized cost in
this definition would cover from the minus area to plus area. Adding the constant equivalent to the minimum of the
generalized cost, the accessibility is finally defined as equations (1) and (2). Equation (1) is accessibility of public
transport and the equation (2) is that of car users.
1 (1)
AM i = - ln[exp(-θM TM i1 ) + exp(-θM TM i 2 )] +α
θ1M
ACi = - ln[exp(-θCTCi1 ) + exp(-θCTCi 2 )] +α (2)
θC
AMi: the accessibility (the expected minimum generalized cost) of zone i by using public transport only
(minutes)
ACi: the accessibility (the expected minimum generalized cost )of zone i by using automobile (minutes)
TMi1: the generalized cost of the nearest facility from zone i by public transport only (minutes)
TMi2: the generalized cost of the second nearest facility from zone i by public transport only (minutes)
4384 Kuniaki Sasaki et al. / Transportation Research Procedia 25 (2017) 4381–4391
4 Author name / Transportation Research Procedia 00 (2017) 000–000

TCi1: the generalized cost of the nearest facility from zone i by automobile (minutes)
TCi2: the generalized cost of the second nearest facility from zone i by automobile (minutes)
q: the parameter of variance of destination choice model (qM=0.0162, qC=0.0159)
a: constant that is equivalent to the minimum of generalized cost (a =43.6)

The parameters qM and qC are estimated by the destination choice model using the person trip data collected in
2000 in Japan. The data were collected in seventy typical cities and the number of the sample is 2,007. The model
structure is the two-stage nested logit model. The upper tier is the mode choice and the lower tier is the destination
choice model. The cost of the public transport is the fare of public transport and that of the car is the basic unit
based expense. These are converted into travel time using the value of time defined in the governmental manual of
cost benefit analysis of public transport, which is about $0.5 per minute. Because this way to measure accessibility
measure uses only the data commonly provided by PRILIT, it is applicable to the entire area in Japan and allows to
compare the accessibilities among the areas. Value Management Institute, a private consulting company in Japan,
applied this index to measure the accessibility of all zones in Japan and compared the aggregated accessibility of
each prefecture. We apply this accessibility to the data of LTCI service data in a city. So, we calculate this
accessibility based on the definition.

3.2. Accessibility index of a city

We apply this accessibility index to the empirical study of LTCI service use in a city located in the central part of
Japan. The city has 200 thousand population and the percentage of the aged population in the city is about 28%. The
number of those who are approved to have nursing care is about nine thousand. The mode share of public transport
is 18% and that of automobiles is 46%, in 2008. One of the results of the accessibility assessment there is shown in
Fig. 1. This is the assessed accessibility of each mesh zone to the clinic by public transport. The level of the
darkness of purple color indicates the accessibility. The lower the accessibility is, the darker the colors become. The
red circle is the main train station with six railway lines, including the bullet train. The bus route is shown in Fig. 2.
Because the bus route mostly stretches between suburban area and the central station, they are dense around the
station and sparse in the suburban area.

0-26.9
26.9-40.6
40.6-65.8
65.8-128.2
128.2-
Fig. 1. the zone system and the accessibility of each zone in the objective city (clinic by public transport)
 Author
Kuniakiname / Transportation
Sasaki Research
et al. / Transportation Procedia
Research 00 (2017)
Procedia 25 000–000
(2017) 4381–4391 43855

Fig. 2. the bus route of the city

Since the zone system used in the national census uses square mesh based on the latitude and longitude, it is
related neither to the actual living community nor administrative district. Most of the surveys, such as health
condition and individual trip records, are conducted based on the administrative district. Because we also use survey
data based on the administrative district, we re-calculated the accessibility outcomes from the census zones to fit the
administrative district. In practice, we estimated the population-weighted average of the accessibility of an
administrative district based on accessibility of the mesh zones that belong to the district. The facilities used to
measure the accessibility assessment are the medical, shopping and administrative services. The medical facilities
were categorized into two, hospitals and clinic type medical facility. The shopping and administrative facilities were
combined into one. Therefore, we used four categories of accessibility. The area we focused in this study had 25
administrative districts. The estimated result of accessibilities of public transport in the 25 administrative areas is
shown in Fig. 3., and that of automobile is in Fig. 4. 25 administrative areas are denoted by the character from A to
Y. Since the generalized cost of accessibility was measured in minute unit, the small value of accessibility indicates
the relatively superior accessibility. The result shows that the accessibility by public transport is generally not as
good as that of automobiles, but the variance of the accessibility by public transport is larger than that of
automobiles. The accessibility by automobile has higher average and does not vary significantly among the
administrative districts. The accessibility to the hospital by public transport varies among the administrative area and
the average level of the accessibility is higher than other facilities. The average of automobile accessibility is 22.1
and the average of the variance is 5.7, while the average of accessibility of public transport is 24.7 and the variance
of the accessibility of public transport accessibility is 32.1. Specifically, L district does not have good accessibility
in most situations, because it is in the mountain area and most of its parts have no bus access. In this way, this
indicator clearly shows the difference among the areas particularly on the public transport.
4386
6 Kuniaki
Author Sasaki
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/ Transportation Research Research
Procedia Procedia
00 (2017)25 (2017) 4381–4391
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50,0
Clinic Hospital Shopping Administrative Office
45,0

40,0

35,0

30,0

25,0

20,0

15,0

10,0

5,0

0,0
A B C D E F G H I J K L M N O P Q R S T U V W X Y
Fig.3. accessibility of each zone by public transport

35,0
Clinic Hospital Shopping Administrative Office

30,0

25,0

20,0

15,0

10,0

5,0

0,0
A B C D E F G H I J K L M N O P Q R S T U V W X Y
Fig. 4. accessibility of each zone by automobile
 Kuniaki Sasaki et al. / Transportation Research Procedia 25 (2017) 4381–4391 4387
Author name / Transportation Research Procedia 00 (2017) 000–000 7

3.3. Use of the LTCI services

Then we analysed the survey data of LTCI service use that each social welfare council collected in its municipal
zone to find aged people who need long term care. The respondents were over 75 years old and staying home, but
not those who had been in hospitals or nursing homes for more than three months before the survey was taken. This
survey is a cross-sectional survey conducted from 2007 to 2011. We used the entire survey. In the first year, the
survey was taken over the residents who were 75 or older, but from the next year on, it was over the residents who
had become 75 after the prior survey or those who moved into the city after the prior survey and 75 or older. The
total number of respondents in the survey was 24,488 and we used 2,556 respondents who responded as receiving
care from their family members. To identify what affected LTCI services use, we selected the respondents who
actually needed the facilities.

4. Empirical Analysis

4.1. Framework of the model

The analysis here uses the data introduced in the previous chapter and demonstrates the relationship between the
transportation environment and LTCI services use. To get more information about what affects LTCI service use,
we used some attributes of households and individuals listed below in addition to the accessibility indexes.

• a) Household composition
• b) Activities of daily living (ADL) stage
• c) Having PCD (primary care doctor)
• d) Friendly with people in the neighborhood
• e) Presence of person who can confide
• f) Insecure about the economic future
• g) Anxiety about living environment

These data are collected in the same survey of LTCI use. The basic demographics of these variables ADL
measure is scored by the five activities, one being able to eat, go to toilet, transfer, bathe and dress, and oral care.
These five activities symbolize independence or dependence. Independence: NO supervision, direction or personal
assistance. Dependence: WITH supervision, direction, personal assistance or total care. The score counts the number
of dependence activities in these five activities, so that the maximum is five points and minimum is zero. The more
dependent one is, the higher score one gets. The demographics of these variables are shown in Table1.
The basic demographics in the Table 1 indicate the distribution of each variable. The average age was over 83
years because the samples were those who were approved to need nursing care. Most of them had a primary care
doctor and more than half of them lived with other family members. More than half of them felt insecure and
anxious about their economic future and living environment. ADL is distributed largely uniformly.
The objective variable of our analysis is LTCI services user or non-user. Since it is a binary variable, we
adopted the logistic regression model. We specifically used the hierarchical logistic regression analysis to examine
the effect of unobserved variable of area characteristics. We assumed two tiers and estimated parameters
simultaneously: upper tier as the area level variables of 25 areas and the lower tier as the individual variables. Two-
tier model is introduced to examine the difference of variance of unobserved variables between individual variable
and area variables as shown in Fig. 5.
4388 Kuniaki Sasaki et al. / Transportation Research Procedia 25 (2017) 4381–4391
8 Author name / Transportation Research Procedia 00 (2017) 000–000

Table 1. demographic characteristics of study samples (n = 2,556)

Variables number
Mean age (SD) 83.8 (6.5)
Gender (%) Men 879 (34.4)
Women 1,675 (65.5)
Missing 2 (0.1)
Household composition (%) Living alone 279 (10.9)
All members are aged 65+ year 560 (21.9)
Living with member age <65 year 1,717 (67.2)
Having a primary care doctor (%) Have 2,439 (95.4)
No 117 (4.6)
Friendly with people in the Yes 1,530 (59.9)
neighborhood (%) No 975 (38.1)
Missing 51 (2.0)
Presence of person who can Yes 1,694 (66.3)
confidante (%) No 797 (31.2)
Missing 65 (2.5)
Insecurity about the economic Yes 838 (32.8)
future (%) No 1,636 (64.0)
Missing 82 (3.2)
Anxiety about living environment Yes 601 (23.5)
(%) No 1,869 (73.1)
Missing 86 (3.4)
Activities of daily living stage (0-5, 0 605 (23.7)
higher stage means poor ADL) 1 420 (16.4)
2 437 (17.1)
3 299 (11.7)
4 271 (10.6)
5 524 (20.5)

Samples

District Level

District Y
District A District B ・・・

Individual Level

Ind. A1 Ind. A2 Ind. A3 Ind. B1 Ind. B2 Ind. B3 ・・・ Ind. Y1 Ind. Y2 Ind. Y3

Fig. 5. the structure of the multilevel model

æ p ö
lnçç 1 ÷÷ = a 0 + a1 x1 + … + a i xi + … + b1 z1 … + b j z j + … + e i + e j (3)
è 1 - p1 ø

P1: probability of LTCI service use

xi : area variables
z i : individual variables
a1 , b1 : coefficients
e i : error term of area variable
e j : error term of individual variable
 Kuniaki Sasaki et al. / Transportation Research Procedia 25 (2017) 4381–4391 4389
Author name / Transportation Research Procedia 00 (2017) 000–000 9

4.2. Estimation of the model parameters

The ratio of the users of LTCI services was about 73 %, and 85 % of the single-person households are the users.
If all the household members are older than 65 years, the 67 % of them are users, while the 73 % of other
households are the users. We estimated the parameters, and the results are shown in Tables 2 and 3. The bold font in
variable names indicates a significant variable. + and - sign on variable name shows the positive and negative effect
on the use of LTCI services.

Table 2. the estimation result of the LTCI service use and area and individual variables (public transport)
Odds ratio
Variable P-value
(95%confidence interval)
District level
Clinic 0.87 (0.69-1.10) 0.24
Hospital+ 1.08 (1.03-1.13) 0.002
Accessibility
Shopping 1.16 (0.79-1.69) 0.44
Administrative office 1.00 (0.90-1.10) 0.94
Individual level
ADL stage+ 1.50 (1.41-1.59) <0.001
Individual Presence of PCD+ 3.35 (2.03-5.55) < 0.001
attributes Age 1.01 (0.99-1.03) 0.20
Sex+ 1.47 (1.19-1.80) < 0.001
Household All are older than 65 0.94(0.75-1.18) 0.59
attributes Single-person household+ 3.27(2.36-4.53) <0.001
Constant 0.03(0.01-0.18) <0.001
Final Likelihood －1240.5

Table-3 The estimation result of the LTCI service use and area and individual variables (car)
Odds ratio
Variable P-value
(95%confidence interval)
District level
Clinic- 0.92 (0.87-0.97) 0.001
Hospital+ 1.05 (1.03-1.06) <0.001
Accessibility
Shopping+ 1.10 (1.02-1.19) 0.02
Administrative office 0.99 (0.97-1.02) 0.64
Individual level
ADL stage+ 1.50 (1.41-1.59) <0.001
Individual Presence of PCD+ 3.40 (2.06-5.60) < 0.001
attributes Age 1.01 (0.99-1.03) 0.19
Sex* 1.46 (1.19-1.79) < 0.001
Household All are older than 65 0.94(0.75-1.18) 0.59
attributes Single-person household* 3.29(2.38-4.5) <0.001
Constant 0.01(0.00-0.50) <0.001
Final Likelihood －1241.5

Table 2. shows the result of the accessibility of public transport only, and the result in Table 3. is that of
automobile only. The estimated parameter of accessibility was significant on the both models. In particular, the
number of significant parameters is superior on the automobile accessibility. One possible reason is the low modal
share of public transport in this city. The recent statistics of transport share reported that the share of public transport
was about 18 % in 2008 including commuting. Because the modal share of public transport is generally high in
commuting, the share of public transport use among the aged people would be less than 18 %. On the other hand, the
modal share of automobile exceeds 45 %. Fig. 2 is the route of the bus in this city. The number of passengers in the
red line amounts over 1,500 per day, while that of the blue- and the sky-blue line is less than 100 per day. The red
line connects the city’s central station only to the centre of the hot spring resort, and the blue and the sky-blue lines
connect various areas.
4390 Kuniaki Sasaki et al. / Transportation Research Procedia 25 (2017) 4381–4391
10 Author name / Transportation Research Procedia 00 (2017) 000–000

The value of accessibility would increase when the transportation environment is bad, and the objective variable
is LTCI service use, which is one if the respondent is the user. If, on the other hand, the estimated parameter is over
one, the increase in the independent variable has a positive impact on LTCI service use. The estimated parameters of
accessibility to the hospital are significantly larger than 1. This indicates that in the area where the accessibility to
the hospital is bad, LTCI service use is higher than the area with good accessibility to the hospital. Similarly, the
accessibility to shopping by car has a significant positive sign on LTCI service use. This means that bad
accessibility to the shopping place encourages the LTCI service use. Contrary to the accessibility to the hospital, the
accessibility to the clinic by car has a negative sign on LTCI service use. This can be interpreted such that the bad
accessibility to the clinic reduces LTCI use. The area of bad accessibility to the clinic is mainly rural area, while the
bad accessibility to the hospital is not necessarily limited to the rural area. The rural areas do not have enough LTCI
facilities. Therefore, transportation service is necessary to use LTCI services. This might cause the low LTCI service
use in the rural areas. Another possible explanation is that those who have an easy access to the clinic tend to get
more advice from the medical doctors. As a result, they would take LTCI services along with the advices by those
doctors. In terms of individual attributes, all variables, including ADL self-performance measure, the presence of a
personal medical doctor, sex (female) and single-person household, have a positive sign. The increase in the ADL
score means that an individual becomes dependent on the support by others for daily activities. The ADL measure
has a positive sign, implying that the increase in the ADL score will promote LTCI service use. Because the
parameter of sex (female) has also a positive sign, female person tends to use LTCI services. Moreover, the presence
of PCD promotes LTCI service use, consistent with the result of the accessibility to the clinic. Single-person
household has a positive parameter and promotes LTCI service use. These results of the regression analysis of
individual attributes are reasonable.

5. Summary and Discussion

In this study, we analysed how the accessibility was related with LTCI service use with the focus on LTCI
service use among those who are 75 years old or older in the areas. We applied hierarchical logistic regression
analysis to treat the difference of the unobserved effects. The result of the parameter estimation indicated that the
accessibility affects LTCI service use, especially the accessibility by cars. This analysis was to examine what made
the difference between the LTCI service users and non-users. The accessibilities to the hospital by public transport
and automobile were found to be the important determinants of LTCI services use. The accessibilities to shopping
and to the clinic by automobile were found to be the significant factors, too. Since the LTCI service use is not
sustainable when it overwhelms the budget, keeping the aged people healthy is critical. Improving the accessibility
to the hospital and shopping will reduce LTCI service use. In contrast, the accessibility to the clinics had the
opposite effect on LTCI service use: Improving the accessibility to the clinic promotes LTCI service use. Therefore,
cooperation with the medical doctors about the proper LTCI service use is likely to limit such increase because PCD
was found to reduce LTCI service use. In sum, we found some evidences of the effects of the transportation
environment on LTCI service use, that suggests that collaboration between transportation engineer and public health
experts would be beneficial for the goal to build sustainable communities in aging society

Acknowledgements

We are deeply grateful to Mr. Kurebayashi at Shizuoka Prefecture government for converting accessibility.

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