Understanding the Spatial-Related Abstraction of Public Health Impact Goals and Measures: Illustrated by the Example of the Austrian Action Plan on Women’s Health

Abstract

The influence of spatial aspects on people’s health is internationally proven by a wealth of empirical findings. Nevertheless, questions concerning public health still tend to be negotiated among social and health scientists. This was different in the elaboration of the Austrian Action Plan on Women’s Health (AAPWH). On the example of the target group of older women, it is shown whether and to what extent the inclusion of the spatial planning perspective in the discussion of impact goals and measures is reflected in the respective inter-ministerial policy paper. The retrospective analysis on the basis of a document analysis of the AAPWH and qualitative interviews with public health experts who were also invited to join, or rather were part of, the expert group, brings to light the following key reasons for the high degree of spatial-related abstraction of the content of this strategic health policy paper: the requirement for general formulations, the lack of public and political awareness for the different living situations in different spatial archetypes, and the lack of external perception of spatial planning as a key discipline with regard to the creation of equivalent living conditions. Nonetheless, this research has promoted the external perception of spatial planning as a relevant discipline in public health issues in Austria. Furthermore, first thematic starting points for an in-depth interdisciplinary dialogue were identified.

1. Introduction

Women’s health is in the focus of global interest [1,2] and therefore is a central concern of the WHO [3]. In line with the health-in-all-policies approach of the WHO, health should be implemented in all policies and become a focal subject of political action [4] in order to achieve the following UN Sustainability Goals [5]: SDG 3 “Good Health and Well-being“ (in particular sub-target 3.8) [5] (p. 71), SDG 11 “Sustainable Cities and Communities” (in particular sub-targets 11.3, 11.7 and 11.a) [5] (p. 73) and SDG 17 “Partnerships for the Goals” (in particular sub-targets 17.14 and 17.17) [5] (p. 76).

In Austria (women’s) health is already an important public responsibility [6,7]. This becomes evident when it comes to the international comparison of the availability and quality of the supply structures of health care facilities [8,9], the life expectancy of women (at old age) [10] and self-rated state of health [11]. Nevertheless, in Austria regional differences in the provision of ambulant social and care services and the spatial distribution of in-patient health and care facilities exist [12]. Other relevant issues are the increase in the absolute and relative proportion of older women in the population and a growing heterogeneity of women relating to educational level, fertility behavior and economic status related to life phases [13,14].

The Austrian Action Plan on Women’s Health (AAPWH) [15] starts exactly here and defines general and target group-specific impact goals and measures in order to better satisfy the various needs and demands of women for the promotion of physical and mental health, taking into account the current position in the life cycle. Therefore, the AAPWH refers to the following three target groups: (1) “Girls and Young Women”, referring to females going through puberty, or rather females aged 12 to 16 years [15] (p. 42), (2) “Women of Working Age”, referring to women up to 60 years of age [15] (p. 53) and (3) “Older Women”, referring to women aged 60 and older, or rather to women of retirement age [15] (p. 69).

1.1. AAPWH in Brief

The Austrian Action Plan on Women’s Health (AAPWH) as an inter-ministerial strategic policy paper of the Federal Ministry of Social Affairs, Health and Consumer Protection and the Federal Ministry of Women, Families and Youth, Federal Chancellery of the Republic of Austria is unique in Europe [16].

It comprises ninety-eight pages and defines seventeen impact goals and forty measures and aims in order to achieve equity in the quality of life of women in Austria, which is fully in line with the European Health Goals [17] and in accordance with the principle of “leaving no one behind” [18].

Following the Health 2020 policy framework [19], the AAPWH was elaborated in an interdisciplinary and inter-ministerial development process consisting of sixty invited experts from different disciplines and an additional online-consultation process [15].

The AAPWH is published in German and is available online [20].

1.2. The Leading Role of Public Health and the Inclusion of the Author in the Circle of Public Health Experts

At the time the AAPWH was prepared, in Austria public health and women’s health mainly were discussed among (public) health, nursing and social care experts, although health is a central subject of spatial planning due to the close interrelations between health and spatial aspects [21,22,23]. Moreover, spatial planning is perceived as a key scientific and policy sector-relevant discipline for public health [24]—particularly in the context of healthy cities [25].

The author of this article was therefore pleased to be invited to join the expert group on “Women in Old Age” on the recommendation of an expert who played a key role in the elaboration of the AAPHW.

With the participation in the expert group which dealt with public health impact goals and measures for older women, the author pursued two purposes: (1) raising the awareness of the working group members of the necessity of to taking into account the spatial dimension in the definition of impact goals and measures in the short run and (2) involving spatial planning as a cross-cutting, system- and action-oriented key professional discipline in the discussion on demand and supply planning in the long run by addressing:

• The spatial-related reasons for health inequality (of women) and how they influence the future quality of ageing and being old in different spatial contexts or rather spatial archetypes, as well as to the negative consequences of an ongoing spatial polarization in structurally strong and structurally weak regions and
• Presenting spatial planning approaches to create equivalent living conditions.

2. The Purpose of the Paper

This article discusses whether and to what extent the interdisciplinary discussion of health policy impact goals and measures, including the expertise of spatial planning, generates merit for evidence-informed health policy [26] with a focus on the target group of older women.

In the following paper this is illustrated by the example of the AAPWH. In this context, this Austrian pilot study addresses the following aspects:

• The opportunities for and limitations of raising the awareness of public health experts about the relevance of the spatial dimension in defining impact goals and measures.
• The factors that determine the degree of spatial abstraction of target group-specific impact goals and measures.
• The frontiers of knowledge implementation in strategic policy papers.
• Recommendations for spatial planning scholars who are interested in, or rather already engaged in, inter-sectoral collaboration and issues of public health.

Thus, this research not only fills a knowledge gap in Austria, but also complements the findings of (recent) thematically related studies from other European countries, namely the Netherlands [27] and the United Kingdom [28], which for their part discuss the need for and the merit of inter-sectoral collaboration between the public health and spatial planning sectors for the purpose of alleviating health inequalities on the basis of selected health-related (national) policy papers. In comparison to the study from Austria presented in this article, the above-mentioned studies neither focus on one specific target group, nor do they discuss the degree of spatial-relatedness of the formulated impact goals and measures in more detail.

3. The Space–Health Nexus and the Relevance of Spatial Planning

Space and health are interlinked in manifold ways. Amongst others, the availability and quality of affordable housing, the level of infrastructural provision for daily supply as well as for social, medical and nursing care, being embedded in a stable social surrounding and neighborhood, having access to a safe public space and the availability of accessible green and open spaces determine the well-being and quality of life, particularly of older people. This applies in particular to those who suffer from health restrictions, or rather dementia [22,29,30,31,32]. Against the background of demographic and climate change, particular importance must be attached to all of these aspects [33,34].

In this context, the particularities of different spatial archetypes (e.g., cities, small towns, remote rural areas) with regard to supply structures and the degree of supply with infrastructure, as well as public and open (green) spaces, but also with regard to the availability and structure of social networks, must not be disregarded. For example, the infrastructural supply in larger cities compared to rural, sparsely populated areas is more diverse and characterized by short trips, whereas rural areas tend to be better equipped with open or rather green spaces within walking distance [12,22]. With regard to infrastructure supply and accessibility, ageing in the rural periphery, or rather in dispersed (alpine) settlement structures, is particularly challenging [35].

Due to the continuing polarization in structurally strong and weak regions, the different supply structures with hospitals [36], the trend towards the retention of doctors in rural areas [37], changes of family and household structures as well as quality of ageing and being old differ not only between urban centers and rural peripheries, but also within a single municipality in alpine areas and dispersed settlement structures due to the lack of a comprehensive, adequate public transport system and the spatial locations of infrastructure and one’s own place of residence [12].

Therefore, following the principle of health-in-all policies, the main task of spatial planning is to ensure an appropriate land use in order to provide people with green spaces, building land and traffic areas and to balance competing interests and needs, in order to provide livable settlement structures for people at all stages of life [22].

In German-speaking countries spatial planning as a cross-cutting subject and in its policy advisory function in connection with health issues in general and with regard to older people in particular takes on the following important tasks:

• Ongoing spatial observation for the purpose of identifying changes in the infrastructural supply levels as well as for the derivation of fields of action, options and measures [12,38]
• Identifying the right places for allocating (new) infrastructure as well as maintaining stable infrastructures [12]
• The development of concepts and strategies that serve to create equal opportunities in access to infrastructure at the regional level [39].

Nonetheless, in Austria spatial planning is still is not involved in the strategic development of social care and health provision planning [12].

4. The Expert Group on “Women in Old Age”

The following initial situation formed the starting point for the expert group’s discussions on impact goals and measures in the areas of health protection and health promotion of older women: their economic disadvantage compared to men of the same age; the special challenges in connection with role attributions and expectations with regard to the assumption of care for older people; and ageism [15].

In total, 35 national experts from various public health related professions and professional positions participated in this expert group in order to deal with the subject of women’s health against the backdrop of various professional contexts. Four out of the 35 experts were men.

The participants held, or rather still hold, positions in administration (federal ministries, divisions for gender equality in the offices of federal governments), science and practice (amongst others, women’s health care facilities, professional agencies, social insurance institutions, interest groups). An overview of the members of the expert group is provided in AAPHW [15], pages 85 and 86. Depending on their professional skills, some of the experts also joined the two working groups “Girls and Young Women” and “Women of Working Age”.

Between April and November 2015, the expert group on “Women in Old Age” elaborated four target group-specific impact goals and ten measures and considered cross-target group-related impact goals and measures, taking into account already existing initiatives, projects and actors’ landscapes in Austria. The number of impact goals and measures was predefined.

During this period the working group met three times for full-day workshops in Vienna (cf.

Table 1. Overview of the agendas and working methods of the workshops of the expert group on “Women in Old Age”.

Number of Workshop	Date, Location and Duration	Agenda 1	Working Methods
Workshop No. 1	28 April 2015, Federal Ministry of Social Affairs, Health and Consumer Protection, 10.00 a.m. to 5 p.m.	Presentation of the project “Austrian Action Plan on Women’s Health”, Keynote speech given by the expert group leader Stocktaking of initiatives, and projects: focus on “Women in Old Age” and Development of 3 to 4 key topics Impact goals for the prioritized key topics	PowerPoint-presentation in plenary working in small groups/World Café (guided by key questions, result documentation using flipcharts) plenary discussion
Workshop No. 2	26 May 2015, Austrian National Public Health Institute, 10.00 a.m. to 5 p.m.	Retrospection on the project activities and results so far Feedback on the impact goals from the organizations involved in the making of AAPWH Completion of impact goals Compilation of good practices, agreements, Laws, regulations, concepts related to the impact goals Description of measures related to the impact goals and collection of ideas for cross-age topics Suggestions for the AAPWH’s monitoring prioritization of measures	PowerPoint-presentation discussions in small groups and plenary discussion
Workshop No. 3	10 November 2015, Austrian National Public Health Institute, 10.00 a.m. to 5 p.m.	Discussion of the results of the online consultation and Project finalization 2	PowerPoint-presentation and plenary discussion

¹ Sources: Minutes of Workshops No. 1 and No. 2 [40,41], ² Source: Notes by the author of this paper. There are no minutes for Workshop No. 3.

).

The workshops were moderated and documented by the Austrian National Public Health Institute and the minutes were sent out to the expert group members by e-mail. Additionally, the experts were asked to seize the timespan between the workshops in order to prepare for the following session by completing defined work tasks.

5. Materials and Methods

5.1. Research Design

This is a qualitative, retrospective and descriptive research applying a mixed-methods approach which consists of (1) a theme-centered document analysis of the AAPWH focusing on the above-mentioned aspects and (2) semi-structured expert interviews with members of the expert group on “Women in Old Age” (cf. Figure 1) in order to avoid any misinterpretation from the author’s reflection of the handwritten notes of the three workshops.

As this research does not contain any experimental studies on human beings, no approval from an ethics committee was required. The research was carried out in compliance with the General Data Protection Regulation of the European Union.

5.2. Procedure

5.2.1. Development of an Analysis Grid for the Document Analysis of the AAPWH

As shown in Section 3, the interrelations between space and health (in old age) are complex and the (further) development of health protection and health promotion measures depends on the existing infrastructural level, the authorities and their legal competencies—in Austria the public health sector is characterized by federalism [42]—the financial margins of action in both the public and private sectors, and the heterogeneity of the (potential) demanders (among women in old age).

Basing on the author’s research findings on the spatial-related challenges of the everyday life in old age as well as of caring for the elderly for various Austrian spatial contexts, the document analysis of the AAPWH addressed the following aspects:

• The challenges of organizing and coping with everyday life, including the accessibility of infrastructure and the social inclusion of physically impaired, or rather mobility-reduced, older people, taking into account topography (alpine rural areas), settlement structures, population density, infrastructural supply structures, (limited) freedom of choice related to goods and services and changes in family and other social networks, as well as considering the differences between urban and rural places of residence [22,35,43]
• The relevance of the region as the appropriate spatial reference of action with regard to the allocation of cost-intensive social infrastructures and the importance of regional centers or so-called central places as a result of the financially limited opportunities for action of low-income and/or ageing municipalities [12,44]
• Taking into account the stakeholder group of long-distance caregivers. This group is considered to be of great importance in quantitative terms in Austria [45] due to the ongoing polarization into prosperous and unfavorable regions on the one hand and thus, regions with continuing population loss and growing urban centers on the other hand.

5.2.2. Document Analysis of the AAPWH

The analysis of the spatial-related aspects of the impact goals and measures addressing the target group “Women in Old Age” was carried out by means of a theme-centered document analysis according to Boyatzis [46] without the use of specific software. The procedure was as follows:

• In the first screening, the spatial references were checked. For this purpose, the text was searched for the following terms: “city/urban/urban space”, “land/rural/rural space”; “local/communal”; “region/regional”; “municipality/district/province”; “public space/social space”.
• In the second screening, the causalities between the state of health (or rather disadvantages and health inequalities) of women in old age and their housing and living environments were checked. To this end, all text paragraphs marked in the first screening as well as all impact goals and measures relevant to the target group on “Women in Old Age” were checked.
• In the third screening, interlinkages between the results of the first and the second screening were searched for. Moreover, the impact goals and measures were analyzed with a view to spatial-related differentiations of the theme-related recommendations for action.
• In the fourth screening, the AAPWH was checked for paragraphs which relate to a call for a more interdisciplinary (scientific) debate on the determinants of women’s health. For this, the search terms “interdisciplinary” and “interdisciplinarity” were chosen.

5.2.3. Expert Judgements

The idea was to reflect on the spatial-related contents of the AAPWH and the discussion on the relevance of spatial-related aspects of well-being and health in older women in the context of the three workshops of the expert group on “Women in Old Age”. For that purpose, semi-structured in-depth expert interviews were conducted with those members of the respective expert group who joined at least two out of the three workshops.

Aim of Expert Survey and Design of Questionnaire

The aim of the survey was to identify the key arguments of the experts: (1) regarding the reasons for the degree of spatial abstraction of the AAPHW’s impact goals and measures for the target group of “Women in Old Age”; (2) to grasp the interviewed experts’ perceptions of spatial planning experts (both, scientists and practitioners) as dialogue partners in the context of public health issues, and; (3) to explore the limitations of implementing profession-specific knowledge and spatial-related empirical evidence in strategic policy papers.

Based on the conceptual framework of the spatial relatedness of (women’s) health in old age, the findings from the qualitative content analysis of the AAPWH, the workshop minutes as well as on the author’s own handwritten notes, a catalogue of guiding questions consisting of 16 open questions was developed (cf.

Table 2. Questionnaire for the expert interviews.

Theme	Questions (Verbatim)
General questions on the three workshops of the expert group on “Women in old age”	Q 1: How did you experience the interdisciplinary debate on the topic of “women in old age and health”? What challenges—in your opinion—were associated with the comprehensibility of the argumentation of experts from other disciplines?
Interrelations between health and space	Q 2: What do you associate with the terms “space” and “place”?” Q 3: What do you associate with the term “urban”? Q 4: What do you associate with the term “rural”? Q 5: If you interlink the three terms “rural”, “older women” and “health”, what will come to your mind? Q 6: How do you define quality of life? Q 7: What spatial aspects do you associate with “good” or “bad” quality of life in old age?
Perception of spatial planning as a professional discipline and retrospection on the discussions during the workshops	Q 8: What do you associate with the term “spatial planning”? Q 9: Did you deal with “spatial planning” as a discipline before the workshops? Q 10: What competences or fields of expertise do you ascribe to spatial planning? Q 11: What, in your opinion, constitutes “good spatial planning”, and who do you think is responsible for that? Q 12: How did you experience the introduction of spatial planning arguments during the discussions in the workshops? Do you remember something special of it? If so, why and what? If not, why not? Q 13: Has “acquaintance with spatial planning” changed a) your perception of the discipline of spatial planning, b) your awareness of the relevance of spatial aspects to the quality of getting old (as a women), c) your way of thinking and reasoning? (Please explain.) Q 14: How do you deal with the fact that the target group-specific impact goals and measures are characterized by a high level of abstraction in spatial terms?
Outlook	Q 15: How, in your opinion, could it succeed in future to anchor spatial aspects more firmly in health and care-related policy papers as well as in public health recommendations for action? Q 16: May I ask you for your further thoughts.

).

Sampling and Data Collection

As mentioned above, this research intended to gather the opinion of those experts who joined in with the whole discussion process on impact goals and measures for women in old age. The selection criterion was defined as presence in at least two out of the three workshops. The experts were identified by comparing the attendance lists of the available workshop minutes. Twelve experts met the selection criteria. In January 2018 the experts were contacted by e-mail. Six out of twelve could be recruited for an interview.

The questionnaire was sent out to all experts by e-mail a few days prior to the interview in order to give them the opportunity to prepare for it.

The interviews took place between January and March 2018. In order to meet the preferences of the interviewees, the interviews took place either at their workplaces, by telephone or in external locations such as cafés. The interviews lasted at least 60 min and were recorded on tape.

Five out of the six interviewees gave their oral consent to use the findings for a poster presentation at the biannual conference of the Austrian Society for Geriatrics and Gerontology in March 2018 in Austria [47] and for international publications on occasion. After the conference, the poster was sent out to the five interviewees as a PDF-file by e-mail.

Due to the fact that saturation had not yet been reached, the author decided to increase the sample size. Finally, two more national public health experts were interviewed in May 2018. One of them was invited to the expert group on “Women in Old Age”, too, but did not attend the workshops; the other expert held and still holds a relevant position in the AAPHW development and implementation process. For these two interviews the same catalogue of guiding questions was applied as for the first wave of interviews—except for the questions Q 1, Q 12 and Q 13. That is why the interviews lasted about 30 min each.

The author of this paper pursued the strategy to recruit as many members of the expert group on “Women in Old Age” as possible for interviews. However, this was challenging due to the fact that some of the experts were on maternity leave or had since retired.

Finally, seven expert judgements were available for further analysis.

Table 3. Profile of the interviewed experts.

Identifier of the Interview Partners	Gender	Educational Background/Place of Work	Interview Method/Date of Interview
Interviewee 1	female	nursing and health care, humanities/ public health institution	live one-to-one interview, 19 January 2018
Interviewee 2	female	medical sciences/ health care facility	live one-to-one interview, 22 January 2018
Interviewee 3	female	nursing and health care/ professional association	live one-to-one interview, 23 January 2018
Interviewee 4	female	public health, nursing, social sciences/ interest group	live one-to-one interview, 30 January 2018
Interviewee 5	female	journalism and communication sciences/ interest group	phone interview, 27 February 2018
Interviewee 6	female	nursing and health care, humanities, public health/ blue-light organization	live one-to-one interview, 4 May 2018
Interviewee 7	female	natural sciences/ federal authority	live one-to-one interview, 4 May 2018
Interviewee 8 1	female	social work/ professional association	live one-to-one interview, 5 March 2018

Due to the small sample size, the respective function of the interviewees in the elaboration process of the Austrian Action Plan on Women’s Health (AAPHW) as well as the exact designation of their place of work are not listed for data protection reasons. ¹ This interviewee withdrew her consent to publish the results of the interview without giving any reasons.

gives an overview of the profiles of all interviewed experts.

Data Extraction

The tape recordings of the seven expert interviews were listened to several times and transcribed mutatis mutandis. Particularly pithy statements were transcribed verbatim in order to use them as direct quotations in this article.

The transcripts, which consist of four to six handwritten manuscript pages each, were analyzed according to the method of continuous comparison by Glaser and Strauss [48].

6. Results

6.1. Findings from the Document Analysis

It should be noted that the AAPWH argues that discrimination against women in terms of access to services regardless of age is associated with income, migration background and social disintegration, and not with where women live, work and care. Nationwide equal opportunities of access to infrastructure and other services is requested.

The content analysis shows that spatial aspects serve to describe the background of the challenges or disadvantages faced by older women. For example, with regard to the issue of violence prevention (Measure 5), the reference to public space is directly addressed. The term “violence in the public social space” is used here [15] (p. 33).

With regard to those impact goals and measures which specifically address the target group of older women, spatial-related aspects found their way in the text as follows:

• Spatial-related challenges in organizing and coping with everyday life
• The region as spatial reference of action as an appropriate spatial reference level for infrastructure measures

Impact Goal 17 “Developing a differentiated, appreciative picture of the diverse realities of older women’s lives and secure older women’s opportunities for participation in society” [15] (p. 79) identifies spatial-related challenges of organizing and coping with everyday life are referring to the need to “design a public and safe space” as a structural prerequisite for the “social participation of older women” [15] (p. 79). This is explained in more detail by “Measure 38 Improving the living situation and ensuring the participation opportunities of older women in the long term” [15] (p. 80f): “Scientifically sound findings on the life situation of older women enable the targeted promotion of diverse, high-quality projects, initiatives and events close to home to ensure the participation opportunities of older women and to improve their life situation. The target group of this measure are in particular older women who are living alone, women with health restrictions, structurally caused mobility impairments and women with low income. Since there are differences between urban and rural areas with regard to older women’s opportunities for participation, all activities must take into account spatially specific aspects” [15] (p. 80f).

This measure expresses the awareness of spatial-related challenges experienced by older women with reduced mobility and limited participation opportunities and points out the importance of local daily supply structures and supportive initiatives.

The terms “urban”, “rural” and “space-specific” are used in the text for the purpose of pointing out spatial differences.

Impact Goal 14 “Ensuring gender-appropriate, individualized medical, psychosocial and nursing care up to old age, regardless of the [spatial] setting” [15] (p. 71) addresses the need for nationwide and accessible infrastructures. This is specified by “Measure 32 Establishing regional platforms for women’s health” [15] (p. 72), which is envisaged as a short-term measure and which refers to a specific spatial reference of action.

The regional level as an appropriate spatial reference of action is also addressed in Impact Goal 16 “Women at old age and at risk of poverty are given conditions that enable them to maintain their capabilities for self-help and to live self-determined and autonomous lives” [15] (p. 78). “Measure 37 Establishing a one-stop shop” for the application for and processing of social benefits and for care counselling” [15] (p. 79), which is assigned to this impact goal, may—among other measures—facilitate access to counselling and information services for women at risk of poverty in structurally weak rural areas—especially if the so-called “one-stop shops” are established regionally.

However, the term “region” is not further specified with regard to its catchment area or accessibility for older people who are not, or rather who are no longer capable of, driving a car.

On the other hand, the following objectives of the author of this paper are not directly addressed in the AAPHW:

• The subject of “long-distance caregiving”. Nonetheless, this issue is addressed by Impact Goal 15 “Creating framework conditions that enable the currently mainly female caregivers to maintain their own health, self-determination and dignity” [15] (p. 74), specified by short-term “Measure 36 Sensitizing companies to the situation of caregiving relatives and establishing counselling services” [15] (p. 77).
• The mention of spatial planning as a crucial discipline in the discussion of (older) women’s well-being and health. Nevertheless, the need for more interdisciplinarity was put in writing. This is shown by medium-term “Measure 31 Strengthening interdisciplinary research on health issues specific to women in the third and fourth phases of life” [15] (p. 72), which is related to Impact Goal 14 “Ensuring gender-appropriate, individualized medical, psychosocial and nursing care up to old age, regardless of setting” [15] (p. 71).

6.2. Findings from the Expert Interviews

According to the interviewed experts, the empirical findings presented in this section can be understood as the outcome of many years of professional experience, being up to date with the latest scientific knowledge (in some cases) as well as personal experiences and stories from the experts’ private lives.

6.2.1. The Meaning of Space and Place for the Health of Older Women and the Urban–Rural Mindset

The interviewees conceptualized the terms “space” and “place” in different ways, addressing the material, or rather physical and social, characteristics of place, which in their view are relevant to the health of older women. Thus, they addressed selected features that are also assessed as important by geographical gerontologists [49]. From the point of view of the interviewed experts, “place” is a construct of natural surroundings, human intervention and political categorization. The significance for (older) women’s health shows in several ways (cf. Figure 2):

• The basic importance of unspoiled nature and appropriate sanitary conditions
• Space as a basic prerequisite for personal development
• The importance of opportunities for social participation. Therefore, space is “a sphere where people are living together” (I 6).

The interviewees thought in distinct spatial categories: “urban” and “rural” areas. Above all, they associated urban areas with high density and diversity of infrastructure, and rural areas with the exact opposite; low density and challenges with regard to the supply of goods and services in daily demand, and the provision of socio-medical services as well as the resulting restrictions in freedom of choice and accessibility of services and facilities.

6.2.2. Perceived Spatial-Related Challenges for Maintaining and Improving Quality of Life and Health of Women in Old Age in Urban and Rural Areas and the Tendency of Marginalization of Women Living in Rural Areas

From the interviewees’ perspective, the quality of the built environment and of nature have a significant impact on health (see also [50]). In their opinion, it is essential to point out that the quality of housing and the living environment as well as the characteristics of the social networks of older women living in urban and rural areas differ fundamentally, which in turn results in differences in health care provision and quality of life for women in old age.

According to the interviewees, infrastructural deficiencies, long distances and a lack of public transport, eroding social networks and structural barriers in the built and residential environment coupled with health restrictions lead to challenges for living an independent life and participating in social life for women of all ages, regardless of the location of the place of residence. In the opinion of one interviewee, “security in and of public spaces” (I 3) is a key issue for older women living in cities.

The marginalization of especially very old women without a driving license in rural areas is the result of a thinned-out infrastructure supply, the lack of adequate cultural offerings, and poor public transport outside the main centers and villages. The changes of family structures and social environments imply a decline in informal support and increased loneliness. One interviewee commented as follows: “In my opinion the interrelations of rurality, quality of life and women’s health are more negative than positive—in the sense of a double devaluation. First, women care for men. The women are left behind. Second, women have no voice in society. Therefore, it is not so important to take care of them.” (I 1)

Furthermore, related to the need of action, rural areas are perceived as subordinated to urban areas. According to one interviewee, the reasons for that are also rooted in misunderstandings, for example with regard to the quality of social cohesion: “When they think of rural areas people are of the opinion that everything is still all right, and that is why many women are left behind” (I 1).

One interviewee stated that the rhetoric of a healthier old age and growing old (as a woman) in the countryside compared to the city is also the result of a non-reflected use of clichés and therefore needs to be readjusted: “You need to have to look at this in a more differentiated manner. In rural areas the availability of health care providers such as doctors, nurses, informal caregivers and various professional groups is more problematic” (I 2).

At the same time, the same interviewee points out that the urban–rural dichotomy is insufficient in order to appropriately describe infrastructure-related differences in daily supply with goods and services. She points to the need for a spatially more differentiated discussion: “Here [in rural areas] there are certain differences. The more peripheral the less available. It’s as simple as that” (I 2).

Moreover, it is difficult to derive valid spatial-related impacts on the entire collective of older women with regards to spatial health assessment and quality of life. The latter is why quality of life is something very individual and also depends on the respective demands and expectations. In this context some interviewees relate the questions concerning quality of life more to their own person than to the target group of women in old age.

6.2.3. The Significance of Spatial Planning for Public Health and the Merit of Integrating Spatial and Planning Sciences Scholars in the Debate on Older Women’s Health

Only one out of the eight interviewees was already professionally in contact with spatial planning experts prior to the workshops of the expert group on “Women in Old Age”.

The working context referred to various projects of designing public spaces and accessibility, as well as of fall and accident prevention. The author of this article was already well known to two of the interviewees.

The significance of the professional discipline “spatial planning” is perceived as strategic and project-oriented as well as object-related and is often associated with the terms “housing” and “public space”.

Some of the experts assign strategically important competencies to spatial planning by saying that spatial planning:

• … is “a political issue” (I 2), which nevertheless “is not yet on the radar.” (I 1, I 5)
• … is “a societal means of power” (I 1), which organizes human coexistence.
• … is addressed to all and “being done by all” (I 3).
• … is about “allocating spatial resources taking into account the needs of the population as well as of different target groups” (I 4).
• … “must ensure that offers are maintained right down to the last corner” (I 7).
• …is an important task in which “a great deal is about social responsibility” (I 2).

Good spatial planning, in the eyes of the experts interviewed, is therefore: “That one considers how an environment has to be designed so that people can cope with everyday life to a reasonable extent, regardless of their level of education and financial resources.” (I 2) This also includes providing opportunities “in order to enable unplanned communication” (ibid.).

Thus, those interviewees who took part in the workshops found the interdisciplinary dialogue with a spatial planning scholar enriching on the one hand and challenging, exciting and promising on the other hand.

Nonetheless, the following should always be borne in mind: “Each expert speaks for him- or herself or rather for one’s own profession” (I 5).

The discussion of spatial references was also complicated by the fuzzy use of terms. Although the interdisciplinary discussion sharpened the subjective perception of space and place and helped to create (more) awareness of the importance of spatial planning as a focal subject, the experts do not remember any specific spatial planning-related arguments, or rather key messages.

6.2.4. Explanations for the Degree of Spatial-Related Abstraction of the Impact Goals and Measures and Its Determining Factors

The experts’ judgements of the extent to which the integration of spatial planning expertise during the workshops influenced the way in which spatial references were taken into account in the impact goals and measures, and how the quality of their spatial relevance should ultimately be assessed, are controversial. Some of the interviewees were not surprised by the high level of spatial abstraction, as they know this from other contexts of work, and say: “The spatial reference is not considered in the action plan, which is a pity.” (I 4)

According to another expert, spatial references serve at best as justification for the impact goals. Another expert believes that the author could be pleased that the terms “space and region are addressed directly in the Action Plan” (I 7).

Addressing the high level of provision and quality of both social and health care facilities in international comparison, an interviewee comments as follows: “In Austria we discuss [health] at a relatively high level. Nevertheless, there is still so much to be done.” (I 2)

Moreover, there is an agreement on the need to pay more attention to spatial-related aspects in the context of the health of older women. However, in many cases, these aspects have been neglected in public affairs and politics:

• “There is hardly any understanding of how individual life is related to spatial conditions.” (I 6)
• “If it served the economy, this issue would carry more weight.” (I 1)

6.2.5. Recommendations for Spatial Planning Scholars

Established lobbies and power structures determine the implementation of inter- and transdisciplinary knowledge. Cross-cutting issues are nodded off, so they fall out of the prioritization phase. This could be alleviated by problem-centered evidence and ideas and strategies that address various spatial levels of action. An expert puts it as follows: “You should approach from two directions: case study based from below; in the general view from above” (I 6).

Furthermore, modifications are needed in the handling of knowledge production and knowledge transfer. There is disagreement among the interviewed public health experts on the merit of public consultation processes. The spectrum of opinions ranges from “each consultation is useful” (I 2) to thinking that consultation processes are a pure formality.

One expert recommends the following: a clear positioning and identification of content-related interfaces with other disciplines as well as investments in networking, which will help to increase the perception of spatial planning as a cross-cutting discipline. Furthermore, it must always be kept in mind that spatial conditions and critical events both determine the pressure for political action. Therefore, spatial planning can contribute to creating appropriate framework conditions for healthy ageing. That is why further in-depth discussions with spatial planning scholars are welcome.

7. Discussion

7.1. Methodological Strengths, Challenges and Limitations

This qualitative research is characterized by the application of mixed-methods and a retrospective multi-perspective reflection on the opportunities and limits of anchoring spatial aspects of women’s health using the example of the making of a specific strategic policy paper. This research design can therefore be assigned to action research [51].

The crucial methodological challenge with regard to the realization of the research design was the development of a conceptual evidence-based framework [52] in order to be able to capture the spatial-relatedness of the health of older women with special regard to the Austrian situation, which was to serve as a basis for the analysis of the AAPWH as well as for the expert survey. At that time, in German-speaking countries the spatial planning scientific debate on its contributions to public health has just begun. In early summer 2017, in Potsdam (Germany) the first relevant congress entitled “Anchoring Health in Spatial Planning” was organized by the Academy for Spatial Development in the Leibniz Association.

That is why the author of this article decided to base the conceptual framework on her own empirical findings. The suitability of the conceptual framing was proven during the in-depth discussions with the experts.

After having completed the eight interviewees it became apparent that despite the small sample size, content saturation has occurred. This was due to the comprehensiveness of the described space–health nexus as well as to the explanations relating to the degree of spatial abstraction of the impact goals and measures. The latter is probably also related to the fact that the interviewed experts are outstanding professionals employed in the Austrian public health scene and have various (academic) educational backgrounds. Moreover, some of them also held and still hold leading positions in the making of the AAPWH and its implementation.

Related to the analysis of the material—namely, the qualitative content analysis of the AAPWH and the transcripts of the expert interviews—it can be critically noted that the content analysis was carried out exclusively by the author of this article. Thus, this article does not claim to speak for the whole spatial planning community in Austria, but intends to fuel the discussion among spatial planning theorists and practitioners on the reasons for the lack of involvement in defining gender-related health policy impact goals and measures.

7.2. Considerations on the Validity of the Questionnaire and Reliability of the Findings from the Expert Survey

Validity is a much-discussed topic in qualitative social research, especially with regard to the question 1. of whether the information obtained in this way is right or wrong, 2. what significance can be assigned to the findings and 3. how they can be put into the larger, or rather international, context [53].

Regarding the validity of the questionnaire applied for this research, it should be noted that it was suitable for capturing the complexity of the topic. This was proven by (1) the fluency of the interviews, (2) the ability of the interviewees to put themselves back to the year 2015 very quickly, (3) staying close to the topic during the entire interview and (4) the lack of critical comments on the methodological approach chosen to reflect the making of the AAPWH and its results, as well as on the guiding questions for the interviews.

With regard to the reliability of the results of the expert survey, it should be noted that (1) the statements are in line with the empirical evidence of spatial science research in Austria on the spatial-relatedness of health in old age and (2) the explanations of the degree of the spatial-related abstraction of the impact objectives and measures of the AAPWH are logical and conclusive. The experts’ pragmatic attitude towards the predefined number of impact objectives and measures can be explained by their function in the AAPWH preparation process and is therefore perfectly understandable.

Looking at the applied research approach and the reliability of the expert judgements, it must be critically noted that more than two years passed between the third workshop of the expert group on “Women in Old Age” and the first expert interview. Whether and to what extent this time span had an effect on the quality of the content and the level of detail of the retrospective assessments cannot be assessed ex post. On the contrary, it should be emphasized that the willingness of the experts to reflect on the AAPHW in greater depth can be interpreted as a sincere interest in a cross-disciplinary discussion of health issues, including the spatial planning perspective.

7.3. The Merit of the Interdisciplinary Discussion within the Expert Group on “Women in Old Age” Including the Spatial Planning Perspective

The cross-disciplinary reflection on the impact goals and measures defined in the AAPWH has stimulated public health experts: (1) to take a different look at issues of (older) women’s health; (2) to reflect on the principles of informed political decision making and the feasibility of taking into account the spatial-related complexity of challenges and problems, taking into account a predefined number of impact goals and measures; and (3) to become aware of the similarities and differences of the objectives and differences in the approaches of public health and spatial planning.

7.3.1. Identifying Health-Relevant Spatial Aspects and Dealing with Spatial-Relatedness of (Older) Women’s Health: Similarities of and Differences between the Two Professions

Public health experts assign great importance to spatial aspects for the health protection and health promotion of women in different stages of life, or rather life situations—above all the accessibility as well as the availability and quality of health care and nursing facilities, as well as counselling services for those seeking information and advice.

It is interesting to note that the focus here is on the provision of social and health-related infrastructure facilities, and that the experts pay little attention to the importance of green spaces for maintaining health. With regard to the AAPWH this may be due to the fact that green space planning is not within the competence of the ministries responsible for the AAPWH. A follow-up of the cross-disciplinary dialogue on the importance of green infrastructure including the spatial planning perspective might perhaps lead to the involvement of other ministries in the AAPWH in the long run.

It was shown that public health experts ascribe a great importance to spatial planning with regards to health protection and health promotion (cf. Figure 2). Therefore, it is surprising that the interviewees have had little professional contact with other representatives of the discipline of spatial planning, or rather have not actively sought contact with them. Intensive cooperation between public health experts and spatial planning experts would be a good thing; both professions are dealing with cross-sectional issues [54,55], address important social and socio-political questions, put general interests at the center of their considerations, are used to working in a system- as well as target group-oriented manner and take the function of policy advisors. In addition, both professions, public health and spatial planning, call for a comprehensive discussion of health issues with particular attention to area-wide measures and equal access to infrastructure.

On the other hand, there are differences between public health and spatial planning experts with regard to dealing with spatial levels of action and the complexity of spatial-related inequalities of health in old age. When it comes to health and infrastructure disparities, spatial planning professionals think beyond urban–rural dichotomies and, within the framework of spatial research, draw attention to the importance of the functional interactions between different spatial archetypes in terms of the question of for what purposes people spend time in particular places and where health infrastructure should be located. The so-called multilocal lifestyle is becoming more and more important in this context [56].

7.3.2. Explanations for the Level of Spatial-Related Abstraction in the Impact Goals and Measures of the AAPWH

Despite the public health experts’ basic understanding of the relevance of spatial-related aspects for the health and well-being of women of all ages, they do not think beyond distinct spatial categories, or rather the so-called urban–rural dichotomy. Moreover, they do not mind the absence of a clarification of the so-called “regional reference level of action” with regard to the defined impact goals and measures.

On the contrary, from the public health experts’ perspective, the lack of a more precise spatial differentiation should be considered less a failure than a proof of the logic of dealing with cross-cutting and cross-sectional socio-political topics.

The experts’ explanations of the standards and particularities of the preparation of inter-ministerial strategic policy—formal specifications such as the predefined number of impact objectives and measures as well as the length of the policy paper on the one hand, and the basic challenge of implementing the requirements of cross-cutting disciplines such as spatial planning on the other hand—can be interpreted as an important limitation of knowledge transfer in the context of evidence-based policy making [57]. A strategic argument for this may also be the political “desire for a feasible plan” (I 5) aiming at a win-win-situation for all involved stakeholders [27], which requires to include measures, which build on existing measures or rather be suitable to be integrated into existing actors’ and supply landscapes as well as projects and initiatives. This also explains the political approval of the AAPHW and guarantees planning continuity. Despite all criticism, it should be noted that politically speaking “it is not easy to get everything together” (I 7).

Moreover, one expert recommends taking the AAPHW for what it is: a living inter-ministerial paper addressing the national level of and expressing the political commitment to the relevance of the subject of women’s health in Austria without a defined expiry date and thus, serving as a strategic and operational anchor point for the implementation of changing focal topics in public administration units which are responsible for health provision (planning) at different spatial levels of action [58], encouraging the inter-sectoral and cross-disciplinary networking of experts within the framework of so-called focal points on selected, or rather emerging health topics.

7.4. Some Considerations on the Fit of Findings into an International Perspective

The results from this research are in line with the findings from other recent studies from the Netherlands [24,27,59] as well as from United Kingdom [28,60] on the general anchor and sticking points in inter-sectoral public health policy making, including the spatial planning perspective.

More generally formulated, the findings from Austria most likely may fit into the perspective of other high-income welfare states where (1) the creation of equivalent living conditions is a supreme political imperative, (2) the public sector takes a major role in the provision of services of general interest and (3) spatial planning is a public responsibility.

Furthermore, it is necessary to point out that the discussion on health-in-all-policies as well as the need for and the potential of inter-sectoral collaboration in order to protect and promote health—with particular regard to older women—in the Global North differs much from the Global South, since in the latter the basic (spatial-related) requirements for good health and well-being such as nutrition, sanitation, housing, security and medical care are still not met. Particularly, this situation limits the international transferability of the inferred conclusions of this research presented below and moreover, underlies the challenge of creating a geographically and socio-culturally overarching global mindset on public health in the foreseeable future [61].

8. Conclusions and Outlook

Conclusion 1: The degree of the spatial-related abstraction of the impact goals and measures can be explained by the fact that in Austria spatial planning as a cross-cutting discipline—as stated by Storm et al. [24]—has not yet been included in the strategic discourse on health protection and health promotion.

Conclusion 2: Both professions, public health and spatial planning, have similar ideas about the complexity of the space–health nexus and the importance of (governing) values in planning [58,62]. Thus, the joint dialogue in the expert group and the reflection on the impact goals and measures were experienced as fruitful on the part of both sides. The spatially differentiated approach and the way of reasoning in spatial planning can thus enrich the interdisciplinary discourse on women’s health issues. For this reason, some of the interviewees also expressed their wish to keep in touch with the author of this article. This has already happened—for example in the context of network meetings or targeted information about current publications.

Conclusion 3: The need for a closer cooperation of public health and spatial planning—as claimed amongst others by Tomlinson et al. [63], by McKinnon et al. [60] as well as by Hendriks et al. [64] in general or Lowe et al. [65] for the urban context in particular—emerged during the expert discussions. A concrete thematic starting point for a further dialogue between the two disciplines could be the issue of long-distance caregiving, a topic still neglected in public health in Austria [45,66]. The main challenge of including “new” issues or target groups in the AAPWH is to integrate them into the right impact goal(s) and already existing measure(s).

Conclusion 4: It would be valuable to analyze the AAPWH in the context of an intertextual content analysis [67] with regard to the consideration of the spatial relatedness of the impact goals and measures for the two other target groups “Girls and Young Women” and “Women of Working Age” and subsequently—as shown here for the expert group of “Women in Old Age”—to reflect them in an interdisciplinary manner. An in-depth and continuous dialogue between public health and spatial planning experts may reveal cross-connections between target group-specific needs for action and thus perhaps bring to light the new cross-target group’s priority themes, impact goals and measures including explicit and implicit spatial references.

Conclusion 5: Spatial and planning scholars must learn to understand that a change towards a comprehensive, or rather holistic, approach to health issues including the “spatial dimension” takes time. At the academic level, key representatives of other relevant disciplines (including, above all, public health) must be introduced to the mindset of spatial planning; at the political level, much effort is still needed to raise awareness and to sensitize all relevant stakeholders to the space–health nexus as a main reason for inequalities in (women’s) health and to take ownership of the discovered interrelations [68,69]. Therefore, especially against the backdrop of demographic ageing, climate change and the impact of pandemics, as in line with the claim for more “evidence-informed public health policy” [26], spatial and planning scholars are encouraged to:

• Actively approach public health experts in science [29] and administration—the latter are focal points between scientists and political decision-makers [65]—and seize every opportunity for networking in order to bring expertise into the policy cycle in a timely manner [59].
• Describe complex and abstract issues in a low-threshold manner, depicting them visually and, for this purpose, explain the space–health nexus for example by means of storytelling, in order to convey the key messages appropriately [26].
• Discuss the impact goals and measures of the AAPWH in the light of the sound empirical evidence of spatial planning research together with public health experts, in order to bring these findings closer to policy makers [28].