Abstract
Objectives. We investigated associations between having a bus pass, enabling free local bus travel across the United Kingdom for state pension–aged people, and physical activity, gait speed, and adiposity.
Methods. We used data on 4650 bus pass–eligible people (aged ≥ 62 years) at wave 6 (2012–2013) of the English Longitudinal Study of Ageing in regression analyses.
Results. Bus pass holders were more likely to be female (odds ratio [OR] = 1.67; 95% confidence interval [CI] = 1.38, 2.02; P < .001), retired (OR = 2.65; 95% CI = 2.10, 3.35; P < .001), without access to a car (OR = 2.78; 95% CI = 1.83, 4.21; P < .001), to use public transportation (OR = 10.26; 95% CI = 8.33, 12.64; P < .001), and to be physically active (OR = 1.43; 95% CI = 1.12, 1.84; P = .004). Female pass holders had faster gait speed (b = 0.06 meters per second; 95% CI = 0.02, 0.09; P = .001), a body mass index 1 kilogram per meter squared lower (b = –1.20; 95% CI = –1.93, –0.46; P = .001), and waist circumference 3 centimeters smaller (b = –3.32; 95% CI = –5.02, –1.62; P < .001) than women without a pass.
Conclusions. Free bus travel for older people helps make transportation universally accessible, including for those at risk for social isolation. Those with a bus pass are more physically active. Among women in particular, the bus pass is associated with healthier aging.
Maintaining physical activity is key to good physical functioning in older age,1 aging healthily,2 and reducing obesity risk,3 but only 49% of men and 36% of women aged 65 years and older in England met physical activity guidelines in 2012.4 Active modes of transportation, including public transportation, can contribute substantially to total physical activity.5 Among working-age adults, commuting by public transportation increases physical activity levels6 and can improve health,7–9 but evidence about older people is sparse.
The UK older people’s bus pass (“bus pass” herein) enables people of the state retirement age for women (previously 60 years) and older to travel free of charge on local buses, anywhere in the country.10 To our knowledge, this nationwide policy of free bus transportation for older people, irrespective of financial circumstances, is unique. The bus pass was introduced in Scotland in 2002, England and Wales in 2006, and Northern Ireland in 2008, with concessionary policies operating previously. There remain various additional local benefits; for instance, older people living in London are eligible for a Freedom Pass, which provides free travel on all public transportation.
Of the forms of public transportation available in the United Kingdom, buses serve the widest range of communities; even the majority of very rural areas have some bus services. Buses operate over relatively short distances, transporting people between residential areas and urban centers, shopping areas, and hospitals. The bus pass is a widely recognized state benefit for older people often discussed in the media. Advice on obtaining a pass is offered by many organizations including older people’s charities and local authorities. The application form is short and simple, and can either be completed online or acquired locally—for example, from a Post Office or government offices.
The aim of the bus pass is to “tackle social exclusion” among older people.11 Evidence suggests that it has been successful, providing opportunities for social interaction, giving a feeling of visibility and belonging, improving quality of life, reducing feelings of social exclusion, and improving access to services.12–14 The bus pass has been estimated to cost the UK government approximately £1 billion a year15 and the recent climate of austerity has led to suggestions that eligibility for the bus pass should be means tested, whereby only older people with income and wealth below a certain level would be eligible. However, many of the benefits derive, at least in part, from the universality of free bus travel for older people and the lack of stigma therefore associated with the pass.12,13
In addition to the benefits to older people’s social inclusion, there may be unanticipated benefits of the bus pass—for instance, to physical health. We have previously shown that the bus pass is linked to increased walking frequency16 and reduced obesity17; however, it has not been possible to investigate these relationships directly or in detail. We hypothesized that older people who hold bus passes will be more physically active and will have better physical functioning and lower adiposity. We contend that, if these hypothesized relationships are observed, this would indicate that the bus pass helps enable healthier aging, which leads to health care expenditure savings that may mitigate the cost of providing the bus pass to older people.
We used data from the English Longitudinal Study of Ageing (ELSA) to determine (1) among those eligible, who takes up the bus pass; (2) what factors are associated with frequency of bus use among those who have a bus pass; (3) whether having a bus pass is associated with how often people use any public transportation; and (4) whether having a bus pass is associated with physical activity levels, gait speed, and adiposity.
METHODS
We drew data from wave 6 of ELSA, a nationally representative cohort study of people aged 50 years and older living in England (n = 10 601). We restricted the analytic sample to those eligible for a bus pass at the wave-6 interview in 2012–2013 (n = 6870) who had complete data on the variables of interest (n = 4650). Most missing values were for body mass index (BMI; defined as weight in kilograms divided by the square of height in meters [kg/m2]; missing n = 1604) and waist circumference (missing n = 1447), both of which were measured at a separate visit by a nurse, and gait speed (missing n = 1121). We ran sensitivity analyses on a population with complete data on all other variables, irrespective of missingness on BMI, waist circumference, and gait speed (n = 6274).
Eligibility for the bus pass for men and women is linked to the state pension age for women, which has been increasing incrementally from 60 years since April 2010. Exact dates of birth and interview are removed from the ELSA data set to ensure confidentiality; therefore, eligibility for the bus pass at wave-6 interview is certain only for those aged 62 years and older, so we restricted the analytic sample to these people.
All participants were asked how often they use public transportation (of any type, including buses), and those who had a bus pass were asked how often in the past month they had used their pass. Participants without a bus pass were not asked about bus use. Possible responses to the 2 items differed, so they were recoded to improve comparability. For descriptive analyses and analyses in which use of public transportation or buses was an independent variable, we coded responses as never, 1 to 5 times a month, or 6 or more times a month. For analyses in which use of public transportation or buses was the dependent variable, we recoded these variables as binary variables indicating whether participants ever used public transportation or buses.
We derived a binary variable for physical activity level—(1) sedentary or low levels or (2) moderate or vigorous levels—from 3 items on the frequency with which participants undertook mild, moderate, and vigorous sports or activities, to which they could respond more than once a week, once a week, 1 to 3 times a month, hardly ever, or never. Those who undertook moderate sports or activities at least once a week or vigorous sports or activities at least once a month were coded as having moderate or vigorous levels of physical activity following Demakakos et al.18
Gait speed was measured as follows: participants were timed while walking 8 feet (2.44 meters) at their usual walking speed, and this test was performed twice. We calculated the mean speed (meters per second) from the 2 walks and treated it as a continuous variable.19
We measured adiposity by BMI and waist circumference. We calculated BMI from height and weight, which were measured by a nurse using, respectively, a stadiometer and calibrated Tanita-305 scales (Tanita Corp, Arlington Heights, IL). A nurse measured waist circumference (in centimeters) twice over light, nonrestrictive clothing by using a popper fixing tape measure. If these measurements differed by 3 centimeters or more, a third measurement was taken. We calculated a mean from the valid measurements (the 2 closest if 3 were taken). We treated BMI and waist circumference as continuous variables.
Other variables of interest were as follows. We categorized age as 62 to 69 years, 70 to 79 years, and 80 years or older. We divided nonpension household wealth into quintiles (wealth range in the study sample of the poorest quintile: −£56 800 to £48 000; second quintile: £48 001 to £168 000; third quintile: £168 001 to £273 000; fourth quintile: £273 001 to £453 000; and richest quintile: £453 001 to £14 000 000). We coded labor market status as working (employed, self-employed, semiretired), retired, and other (unemployed, permanently sick or disabled, looking after home or family).
Participants were asked if they had difficulty with 6 activities of daily living (ADLs; dressing, walking across a room, bathing or showering, eating, getting in and out of bed, using the toilet). Difficulties with these basic self-care tasks are an indicator of the functional status of older people.20 We summed and dichotomized difficulties with ADLs into no difficulties and 1 or more difficulties. Participants were asked about 10 potential mobility problems (i.e., walking 100 yards; sitting for 2 hours; getting up from a chair; climbing 1 flight of stairs; climbing several flights of stairs; stooping, kneeling, or crouching; reaching above shoulder level; pulling or pushing large objects; lifting or carrying weights heavier than 10 pounds; picking up a coin).21 We summed mobility difficulties and created a variable categorizing participants into no difficulties, 1 to 3 difficulties, and 4 to 10 difficulties. Finally, we derived car access from a question asking participants if they had use of a car when needed, as driver or passenger.
Analysis Plan
Holders and nonholders of bus passes were described according to their age, gender, wealth quintiles, labor market status, bus and public transportation use, access to a car, difficulties with ADLs, mobility problems, gait speed, BMI, waist circumference, and physical activity. We used the t test and the χ2 test to test whether differences between those who do and do not hold bus passes were statistically significant.
We used multivariable logistic regression to determine the associations with (1) holding a bus pass, (2) using buses, and (3) using any public transport. We selected variables by using the existing literature on older people’s concessionary travel as a guide.14,16,17,22,23 The variables we considered were sociodemographic characteristics, car access, and, for transportation use analyses, physical functioning variables. Because the variables associated with using buses could be investigated only among those who held bus passes, we ran an analysis of use of any public transportation for comparison.
Finally, we tested whether holding a bus pass was associated with our health-related outcomes of interest. We tested the association with physical activity by using multivariable logistic regression, and we tested the associations with gait speed, BMI, and waist circumference by using multivariable linear regression. First, we adjusted these models for potential confounders of the relationship—sociodemographic characteristics and physical functioning variables. Second, we made a further adjustment for use of public transportation.
We tested multivariable analyses for gender interactions by using likelihood ratio tests. Where we found an interaction, we stratified analyses by gender.
We undertook analyses with Stata version 13.1 (StataCorp LP, College Station, TX). We used ELSA cross-sectional survey weights to adjust for differences among key subgroups in the propensity to respond.
RESULTS
Descriptive analyses (Table 1) suggested that those who did and did not hold a bus pass differed in a number of characteristics. Of the study population, 86% held a bus pass, with older people, women, those in the middle of the wealth distribution, those not in paid work, those who use any public transportation more frequently, and those who do not have access to a car more likely to hold a pass. However, people with and without difficulties with ADLs or mobility, or who had different levels of physical activity were not more or less likely to hold a bus pass. Women with bus passes had a lower BMI and smaller waist circumference than those without bus passes; men with bus passes had a slower gait speed.
TABLE 1—
Description of Study Population: The English Longitudinal Study of Ageing, England, 2012–2013
| % or Mean (95% CI) |
||||
| Characteristic | No. | Bus Pass Holders | Non–Bus Pass Holders | P |
| Overall | 4650 | 86.3 (85.3, 87.3) | ||
| Age, y | ||||
| 62–69 | 2177 | 83.0 (81.4, 84.6) | < .001a | |
| 70–79 | 1832 | 89.4 (87.9, 90.8) | ||
| ≥ 80 | 641 | 88.9 (86.5, 91.4) | ||
| Gender | ||||
| Female | 2559 | 89.1 (87.9, 90.3) | < .001a | |
| Male | 2091 | 82.9 (81.3, 84.5) | ||
| Wealth, quintiles | ||||
| Lowest | 613 | 86.0 (83.2, 88.7) | < .001a | |
| 2nd | 808 | 89.9 (87.8, 91.9) | ||
| 3rd | 1084 | 88.8 (87.0, 90.7) | ||
| 4th | 1067 | 87.4 (85.3, 89.3) | ||
| Highest | 1078 | 80.3 (78.0, 82.7) | ||
| Labor market status | ||||
| Paid work | 636 | 73.1 (69.7, 76.6) | < .001a | |
| Retired | 3747 | 88.8 (87.8, 89.8) | ||
| Other | 267 | 83.5 (79.0, 88.0) | ||
| Car access | ||||
| Yes | 4025 | 85.0 (83.9, 86.1) | < .001a | |
| No | 625 | 94.9 (93.1, 96.6) | ||
| Activities of daily living | ||||
| None | 3919 | 86.5 (85.4, 87.6) | .411a | |
| ≥ 1 | 731 | 85.4 (82.8, 87.9) | ||
| Mobility difficulties | ||||
| None | 1986 | 85.6 (84.1, 87.1) | .383a | |
| 1–3 | 1722 | 87.2 (85.6, 88.7) | ||
| 4–10 | 942 | 86.3 (84.1, 88.5) | ||
| Physical activity | ||||
| Sedentary or low | 935 | 85.2 (83.0, 87.5) | .281a | |
| Some moderate or vigorous | 3715 | 86.6 (85.5, 87.7) | ||
| Used public transportation at each frequency | ||||
| Bus use, among bus pass holders | ||||
| Never | 1534 | 38.2 (36.7, 39.7) | . . . | . . . |
| 1–5/mo | 1177 | 29.3 (27.9, 30.7) | . . . | |
| ≥ 6/mo | 1303 | 32.5 (31.0, 33.9) | . . . | |
| Public transportation use | ||||
| Never | 1143 | 17.9 (16.7, 19.1) | 66.8 (63.2, 70.5) | < .001b |
| 1–5/mo | 2421 | 55.4 (53.8, 56.9) | 31.3 (27.7, 34.9) | |
| ≥ 6/mo | 1086 | 26.8 (25.4, 28.1) | 1.9 (0.8, 2.9) | |
| BMI, waist circumference, or gait speed | ||||
| Mean BMI, kg/m2 | ||||
| Female | 2559 | 28.0 (27.8, 28.3) | 29.1 (28.4, 29.9) | .001c |
| Male | 2091 | 28.0 (27.8, 28.2) | 28.3 (27.8, 28.7) | .305c |
| Mean waist circumference, cm | ||||
| Female | 2559 | 91.5 (91.0, 92.3) | 94.5 (92.8, 96.2) | < .001c |
| Male | 2091 | 102.0 (101.5, 102.6) | 102.6 (101.4, 103.8) | .361c |
| Mean gait speed, m/s | ||||
| Female | 2559 | 0.87 (0.86, 0.88) | 0.83 (0.79, 0.87) | .068c |
| Male | 2091 | 0.92 (0.90, 0.93) | 0.96 (0.93, 0.99) | .007c |
Note. BMI = body mass index; CI = confidence interval.
χ2 test testing whether there are differences in the proportion of people holding a bus pass in each category.
χ2 test testing whether there are differences in the public transport use of bus pass holders compared with nonholders.
t test testing whether there are differences in the BMI, waist circumference, or gait speed of bus pass holders compared with nonholders.
Holding a Bus Pass, Using the Bus, and Using Any Public Transportation
After mutual adjustment (Table 2), women, people aged 70 to 79 years, retirees and others not in paid employment, those who did not have access to a car, and those who had no mobility problems were more likely to hold a bus pass. Those in the first and fifth wealth quintiles were less likely to hold a bus pass, and having difficulties with ADLs was not associated with bus pass holdership.
TABLE 2—
Factors Associated With Holding a Bus Pass on Multivariable Analysis: The English Longitudinal Study of Ageing, England, 2012–2013
| Variable | OR (95% CI) |
| Gender | |
| Male (Ref) | 1.00 |
| Female | 1.67*** (1.38, 2.02) |
| Age, y | |
| 62–69 (Ref) | 1.00 |
| 70–79 | 1.29* (1.05, 1.60) |
| ≥ 80 | 1.18 (0.87, 1.60) |
| Wealth, fifths | |
| Lowest | 0.59** (0.42, 0.81) |
| 2nd | 1.04 (0.76, 1.42) |
| 3rd (Ref) | 1.00 |
| 4th | 0.86 (0.66, 1.14) |
| Highest | 0.54*** (0.41, 0.69) |
| Labor market status | |
| Paid work (Ref) | 1.00 |
| Retired | 2.65*** (2.10, 3.35) |
| Other | 1.66* (1.11, 2.46) |
| Car access | |
| Yes (Ref) | 1.00 |
| No | 2.78*** (1.83, 4.21) |
| Difficulties with ADLs | |
| Yes (Ref) | 1.00 |
| No | 1.04 (0.77, 1.40) |
| Mobility problems | |
| 0 | 1.49* (1.09, 2.03) |
| 1–3 | 1.33 (1.00, 1.77) |
| 4–10 (Ref) | 1.00 |
Note. ADLs = activities of daily living; CI = confidence interval; OR = odds ratio. The sample size was n = 4650.
*P < .05; **P < .01; ***P < .001.
Among those with a bus pass, multivariable analysis showed that those in the wealthiest quintile and aged 80 years or older were less likely to use buses (Table 3). The following characteristics were associated with increased odds of using buses: female gender, being in the second wealth quintile, being retired, having no car access, having no difficulties with ADLs, and having fewer than 4 mobility problems.
TABLE 3—
Factors Associated With Use of Buses Among Bus Pass Holders and Use of Any Public Transportation by the Whole Study Population on Multivariable Analysis: The English Longitudinal Study of Ageing, England, 2012–2013
| Use of Busesa (n = 4014) |
Use of Public Transportationb (n = 4650) |
|||
| Variable | % Use | OR (95% CI) | % Use | OR (95% CI) |
| Bus pass | ||||
| Noc (Ref) | . . . | . . . | 33.2 | 1.00 |
| Yes | 61.8 | . . . | 82.1 | 10.26*** (8.33, 12.64) |
| Gender | ||||
| Male (Ref) | 56.3 | 1.00 | 73.1 | 1.00 |
| Female | 65.9 | 1.44*** (1.24, 1.66) | 77.3 | 1.18* (1.00, 1.39) |
| Age, y | ||||
| 62–69 (Ref) | 61.8 | 1.00 | 77.3 | 1.00 |
| 70–79 | 64.2 | 0.99 (0.85, 1.16) | 76.3 | 0.74** (0.62, 0.89) |
| ≥ 80 | 54.9 | 0.52*** (0.41, 0.65) | 66.6 | 0.44*** (0.34, 0.56) |
| Wealth quintile | ||||
| Lowest | 66.4 | 1.04 (0.80, 1.34) | 71.8 | 0.96 (0.73, 1.27) |
| 2nd | 68.5 | 1.44** (1.15, 1.80) | 74.9 | 1.06 (0.84, 1.34) |
| 3rd (Ref) | 60.9 | 1.00 | 74.1 | 1.00 |
| 4th | 63.3 | 1.21 (0.99, 1.48) | 76.2 | 1.19 (0.95, 1.48) |
| Highest | 52.8 | 0.74** (0.60, 0.90) | 78.5 | 1.66*** (1.30, 2.13) |
| Labor market status | ||||
| Paid work (Ref) | 54.6 | 1.00 | 73.3 | 1.00 |
| Retired | 63.1 | 1.49*** (1.20, 1.85) | 76.5 | 1.07 (0.83, 1.39) |
| Other | 57.9 | 1.18 (0.83, 1.67) | 65.9 | 0.67* (0.46, 0.99) |
| Car access | ||||
| Yes (Ref) | 58.0 | 1.00 | 73.9 | 1.00 |
| No | 83.5 | 3.74*** (2.89, 4.84) | 85.4 | 2.43*** (1.84, 3.19) |
| Difficulties with ADLs | ||||
| Yes (Ref) | 50.5 | 1.00 | 64.3 | 1.00 |
| No | 63.9 | 1.42** (1.14, 1.78) | 77.5 | 1.27* (1.00, 1.62) |
| Mobility problems | ||||
| 0 | 64.2 | 2.01*** (1.60, 2.53) | 80.1 | 2.18*** (1.69, 2.79) |
| 1–3 | 63.8 | 1.71*** (1.38, 2.12) | 76.3 | 1.69*** (1.34, 2.13) |
| 4–10 (Ref) | 53.0 | 1.00 | 63.9 | 1.00 |
Note. CI = confidence interval; OR = odds ratio.
Participant never vs ever used bus in past month.
Participant never vs ever uses public transportation.
Nonholders of bus passes were not asked how frequently they used the bus.
*P < .05; **P < .01; ***P < .001.
In the whole study population, the strongest association with use of any public transportation was holding a bus pass: those with a bus pass were more than 10 times more likely to use public transportation (Table 3). Further associations with increased odds of use of any public transportation were as follows: female gender, being in the wealthiest quintile, having no car access, having no difficulties with ADLs, and having fewer than 4 mobility problems. Associations with decreased odds of use of any public transportation were being aged 70 years or older and not being in paid employment or retired. When we restricted this analysis to holders of bus passes, there were no substantive differences in the results (data not shown).
Holding a Bus Pass and Health
We found gender interactions for the relationships between holding a bus pass and gait speed (P = .005), BMI (P = .024), and waist circumference (P = .020), so we gender-stratified analyses of these associations. We adjusted initial models for sociodemographic characteristics, car access, difficulties with ADLs, and mobility problems: those holding a bus pass were more likely to undertake moderate or vigorous physical activity; women holding a bus pass were likely to have faster gait speed, lower BMI, and smaller waist circumference (Table 4).
TABLE 4—
Association of Having a Bus Pass With Physical Activity, Gait Speed, and Adiposity on Multivariable Analysis: The English Longitudinal Study of Ageing, England, 2012–2013
| Model 1 | Model 2 | |
| Variable | OR or b (95% CI) | OR or b (95% CI) |
| Some moderate or vigorous physical activity | 1.43** (1.12, 1.84) | 1.04 (0.80, 1.34) |
| Gait speed, m/s | ||
| Women | 0.06** (0.02, 0.09) | 0.04 (0.00, 0.08) |
| Men | −0.01 (–0.04, 0.02) | −0.02 (–0.06, 0.01) |
| Adiposity | ||
| BMI, kg/m2, women | −1.20*** (–1.93, −0.46) | −0.97** (–1.75, −0.19) |
| BMI, kg/m2, men | −0.08 (–0.63, 0.46) | 0.06 (–0.52, 0.65) |
| Waist circumference, cm, women | −3.32*** (–5.02, −1.62) | −2.67** (–4.49, −0.86) |
| Waist circumference, cm, men | −0.59 (–1.99, 0.82) | 0.05 (–1.45, 1.56) |
Note. BMI = body mass index; CI = confidence interval; OR = odds ratio. Model 1 adjusted for age, gender (where not stratified), wealth, labor market status, activities of daily living, mobility problems, and car access. Model 2 additionally adjusted for frequency of use of public transport. The sample size was n = 2559 women and n = 2091 men.
*P < .05; **P < .01; ***P < .001.
Further adjustment for use of any public transportation reduced the effect sizes: in analyses of BMI and waist circumference, reductions were slight; in analyses of physical activity and gait speed, associations were reduced to nonsignificance (Table 4), suggesting mediation of the relationship between the bus pass and these outcomes by public transportation use.
Missing Data
We based analyses on a study population with complete data on the variables of interest. Those participants who had missing data on BMI, waist circumference, and gait speed differed in a number of respects from the study population. They were more likely to be aged 80 years or older, be in the lowest 2 wealth quintiles, have a labor market status classified as “other,” have a problem with at least 1 ADL, have 4 or more mobility problems, and have sedentary or low levels of physical activity (each P < .001). They were less likely to hold a bus pass, use buses or any public transportation, or have access to a car (each P < .001). Despite these differences, sensitivity analyses including those with missing data on BMI, waist circumference, and gait speed gave very similar effect estimates (data not shown).
There were substantive differences to the estimated effects only in the analysis of the associations with holding a bus pass, in which those aged 80 years and older were less likely to hold a bus pass (odds ratio [OR] = 0.78; 95% confidence interval [CI] = 0.63, 0.96; P = .017) and those with no difficulties with ADLs (OR = 1.41; 95% CI = 1.15, 1.73; P = .001), with no mobility problems (OR = 1.75; 95% CI = 1.40, 2.20; P < .001), or with 1 to 3 mobility problems (OR = 1.70; 95% CI = 1.39, 2.09; P < .001) were more likely to hold a bus pass.
DISCUSSION
Our findings suggest that provision of free bus travel for older people in England has both anticipated and unanticipated benefits. Those who held bus passes were 10 times more likely to use public transportation than those who did not, and were more than 40% more likely to be physically active, after we took sociodemographic characteristics and mobility difficulties into account. Although it is possible that only those wishing to travel by bus took up their bus pass, the proportion of older adults who sometimes or regularly travel by bus has increased since the free passes were introduced.24 Female holders of bus passes had better physical health than their peers, with faster gait speed, lower BMI, and smaller waist circumferences, but male bus pass holders did not show similar differences. This gender difference may be attributable to more frequent bus use among female bus pass holders, conferring greater incidental physical activity.
The ability of this study to investigate the impact of the bus pass on older people’s health has been limited for the following reasons. First, although ELSA is a longitudinal survey, participants were asked about bus passes for the first time at wave 6, the most recently available wave of data. This study is therefore only able to examine characteristics associated with holding a bus pass cross-sectionally. Second, although all participants were asked about their public transportation use, participants were only asked frequency of bus use if they held a bus pass. An investigation of the influence holding a bus pass has on bus use was therefore not possible. Third, because of the nature of the data used, it has not been possible to quantify the amount of physical activity associated with use of buses and public transportation. It has been assumed here that getting to and from bus stops and other public transportation hubs entails some amount of physical activity that is greater than if the same journey were undertaken by private transportation, an assumption that is supported by existing literature.6,25–27 However, if holding a bus pass results in some journeys that would otherwise have been walked being undertaken at least partially by bus, physical activity could fall.
There is an established literature on the social and psychological benefits of concessionary bus travel for older people12,13,22,28 to accompany the growing evidence of health benefits of public transportation use among children29 and working-age people.7,8,30,31 Our previous work suggested that the bus pass is associated with reduced adiposity,17 but was limited by having to use eligibility for a pass as a proxy measure for holdership because of having no direct measure. Other previous work indicated benefits to physical activity levels of bus pass holdership16 but relied on walking frequency as the measure of physical activity.
This article contributes novel findings, providing evidence to suggest that the bus pass is associated with better physical health for older women and may promote healthier aging, with faster gait speed and lower adiposity observed among women who hold bus passes. Our finding of increased physical activity levels among bus pass–holding older men and women extends the existing evidence16 by using a broader measure of physical activities undertaken. Our analyses suggest that the higher physical activity levels, as well as the faster gait speed among women, which we found to be associated with the bus pass, may be explained by the greater use of public transportation encouraged by the bus pass. However, our cross-sectional results are also consistent with those who are more obese, less able to walk, or less willing to use a bus not applying for a bus pass. Further research should use longitudinal data to explore the temporality of the relationship between the bus pass and older people’s health and use objectively measured physical activity data to ascertain more directly the relationship of physical activity with bus pass holdership.
The proportion of older people holding bus passes is high in our study population at 86% compared with the 75% observed in the National Travel Survey32; however, our description of the characteristics of bus pass holders broadly concurs with our previous findings from the National Travel Survey.16 Women, retirees, and those who do not have access to cars are all more likely to take up their bus pass. We have been able to investigate in greater detail the socioeconomic patterning of bus pass holdership because of the more comprehensive data collected by ELSA, and have shown that bus passes are most commonly held by those in the middle of the wealth distribution, with the most and least wealthy less likely to take up their bus pass. Despite the observed differences in uptake, less wealthy holders of the bus pass are as likely, if not more likely, to use buses than their wealthier peers. This suggests that greater efforts are required to encourage uptake of the bus pass among the most disadvantaged older people. Furthermore, we contend that means testing would be particularly detrimental to uptake of the bus pass, as the most disadvantaged are disproportionately deterred from applying for means-tested benefits.33 In light of the large financial contribution made to the economy by older people, and because these journeys often result in spending money and supporting the local economy,24 the net costs of the bus pass scheme are overestimated even without consideration of any health benefits.
We have shown that, although older people with reduced physical functioning are not less likely to take up their bus pass unless these problems are very severe, use of public transportation and buses by older people with any such difficulties is restricted. As discussed by Andrews et al., although by removing the barrier of cost the bus pass improves access for many older people, there is a substantial group of older people who remain socially excluded by their physical inability to access buses.22 Policies already in place, including reserved space for wheelchairs and priority seating for older people, should be maintained and reinforced. Further measures, such as the more widespread introduction of buses with lowering suspensions and wheelchair ramps, should also be considered.
We conclude that the older people’s bus pass has a number of benefits through which it supports healthy aging. First, it enables access to transportation for older people who may otherwise be at risk for social exclusion. Second, it may increase physical activity among older people who are otherwise likely not to meet recommended levels. Third, among women, it is associated with better physical health, as indicated by faster gait speed and lower adiposity. These findings should be noted when one is considering any alterations to the policy of free bus transportation for older people in England.
ACKNOWLEDGMENTS
This study was commissioned and funded by the Department of Health Policy Research Programme (PR-R5-0213-25006; “Health and economic benefits of providing free bus travel to older people in England”). C. Millett is supported by a National Institute for Health Research (NIHR) professorship. The funding for the English Longitudinal Study of Ageing is provided by the National Institute of Aging in the United States, and a consortium of UK government departments coordinated by the Office for National Statistics.
The data were made available through the UK Data Archive. The English Longitudinal Study of Ageing was developed by a team of researchers based at NatCen Social Research, University College London, and the Institute for Fiscal Studies. The data were collected by NatCen Social Research.
Note. The views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the NIHR, or the UK Department of Health. The developers and funders of ELSA and the Archive do not bear any responsibility for the analyses or interpretations presented here.
HUMAN PARTICIPANT PROTECTION
This study involved analysis of secondary data; therefore, ethical approval was not required.
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