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Case Study

Health and its determinants in West Central Scotland compared to the Ruhr area in Germany uut2011 August

Case study: Health and its determinants in West Central Scotland compared to the Ruhr area in Germany.

Sophie Parcell, Anja Hartmann, Martin Taulbut and David Walsh

August 2011

Contents

Acknowledgements 3 Executive Summary 5

1.0 Introduction 9 1.1 Background 9 1.2 Why compare these two regions? 9 1.3 Aim and approach 10 1.4 Geographies 11 1.5 Data sources and limitations 14

2.0 Health and function: a further analysis of health outcomes in the regions 18 2.1 Life expectancy and mortality 18 2.1.1 Trends in life expectancy in the two regions 19 2.1.2 Age and cause-specific mortality 20 2.1.3 Sub-regional life expectancy 20 2.2 Self-reported measures of health and wellbeing 22 2.2.1 General health 22 2.2.2 Life satisfaction 23 2.2.3 Diagnosed diabetes and high blood pressure 24

3.0 Prosperity and poverty 27 3.1 Unemployment 27 3.2 Employment rates 30 3.3 Car ownership 32 3.4 Home ownership 33 3.5 Perceived adequacy of income 35 3.6 Family affluence 36 3.7 Relative poverty and inequality 37

4.0 Population 41 4.1 Population change 41 4.2 Migration 43 4.3 Population density 46 4.4 Population structure and dependency ratio 47 4.5 Fertility rates 50

5.0 Social environment 54 5.1 Education 54 5.2 Lone parent households 56 5.3 Single person households 57 5.4 Marital status 62 5.5 Social capital: religious affiliation 63 5.6 Social capital: voter turnout 64

6.0 Physical environment 68 6.1 Climate 68 6.2 Recorded crime 68 6.3 Perceived neighbourhood safety 71

7.0 Health behaviours 75 7.1 Smoking 75 7.2 Alcohol consumption 80 7.3 Body mass index 80

8.0 Child & maternal health 85 8.1 Births to mothers under the age of 18 85 8.2 Low birth weight babies 86 8.3 Termination of pregnancy 88

9.0 Conclusions 91

References 95 Appendix 1 97

Acknowledgements

As with the main report, grateful thanks are due to a considerable number of people who assisted in the creation of this case study. The authors would particularly like to acknowledge the help of the following:

 Prof. Dr. Klaus Peter Strohmeier (Ruhr-Universität Bochum, Germany), Marc Neu (ZEFIR – Zentrum für interdisziplinäre Regionalforschung, Germany) and Anne Saha (Ruhr-Universität Bochum, Germany) for helpful advice and the provision of data.  Dr. Nico Dragano and Dr. Natalia Wege, Heinrich-Heine- Universität Düsseldorf for use of data from the Heinz Nixdorf Recall (HNR) study.  The National Records of Scotland (NRS) (formerly the General Register Office for Scotland) for the use of mortality, population and census data.  Information Services Division (ISD) Scotland, in particular Morven Ballard, Kenny McIntyre, Etta Shanks.  Kerstin Hoffarth, University of Bielefeld in Germany, for the provision of German regional HBSC data.  Dr. Jan Goebel, Research Associate Socio-economic Panel Study (SOEP) at the German Institute for Economic Research (DIW Berlin) for provision of data on life satisfaction and household car ownership for the Ruhr area of Germany.  Joan Corbett and Rachel Ormston, Scottish Centre for Social Research for the provision of West Central Scotland data from the Scottish Social Attitudes Survey.  Kate Levin at the University of Edinburgh for helpful advice and the provision of Scottish regional HBSC (Health Behaviour of School Children survey) data.  Gary Lai, University of Edinburgh, for initial analyses of national and regional income inequalities data.

 Tom Spencer at the Scottish Government (Social Justice Statistics) for helpful advice in relation to the calculation of Gini coefficients using Scottish Household Survey data.  Gyrid Havåg Bergseth at the University of Bergen in Norway for helpful advice on the use of European Social Survey data.  The Luxemburg Income Study (LIS) database team, for use of their database and helpful advice on comparing income inequality between regions.

Finally, thanks to Richard Withington and Gregor Yates, both of the Glasgow Centre for Population Health, for their useful comments on earlier drafts of this case study.

Executive Summary

This case study – along with three others – is an accompaniment to the report entitled: Health and its determinants in Scotland and other parts of post-industrial Europe: the ‘Aftershock of Deindustrialisation’ study – phase two.

The case study presents the results of analyses of routine administrative and survey data for two post-industrial regions: West Central Scotland (WCS) and the Ruhr area in West Germany. This is part of a larger set of analyses exploring the reasons behind the poor health profile of WCS in comparison to other parts of Europe that have also experienced the economic, social and health impact of post-industrial decline.

The scope of this report is limited to comparisons of routine administrative and survey data in these two regions: for a broader discussion of the historical, cultural and social context in which these differences should be viewed, readers should refer to the main report.

As with the main section of the report and the other case studies, our aim here is to respond to two key questions:

1. Can WCS’s relatively poorer health status be explained purely in terms of socio-economic factors (poverty, deprivation etc.)? 2. Do comparisons of other health determinant information identify important differences between WCS and this post-industrial region of Germany?

Analyses of a large set of existing data were undertaken in an attempt to answer these questions. The principal findings of these analyses are that:

 Life expectancy for both sexes has been consistently higher in the Ruhr than in WCS over the past 25-30 years. At a sub- regional level, life expectancy in the majority of WCS local authority areas is lower than that of Gelsenkirchen, the Ruhr district with the lowest recorded life expectancy.

 Measures of health and function fail to provide clear insights into the reasons behind WCS’s poor health outcomes. Self-reported levels of health and life satisfaction are better in WCS compared to the Ruhr. Reported levels of doctor-diagnosed health problems are either very similar or show little regional variation.

 Socio-economic factors alone do not appear to explain WCS’s poor health status relative to the Ruhr. For a number of these measures (e.g. current levels of, and historic trends in, unemployment and employment) WCS compares favourably to the Ruhr, while survey data on perceived adequacy of income show little difference between the regions.

 Regional estimates of income inequalities also suggest little difference between WCS and this part of Germany, although at a national level, income inequality in Scotland (and indeed the UK) is greater than in Germany. Levels of relative poverty appear to be higher in the Scottish region, while family affluence is slightly lower.

 In relation to population measures, WCS has lower levels of population density, higher fertility rates, and a lower dependency ratio compared to the Ruhr. While both regions saw their population decline from 1995 to 2008, the German region experienced higher levels of population loss overall.

 Some, but not all, aspects of child and maternal health in WCS compare unfavourably to the Ruhr. For example, the rate of births

to women under the age of 18 was three times higher in WCS than in the Ruhr area in 2008. However, the Ruhr had a slightly higher rate of low birth weight babies than WCS in 2008 and rates in the region have increased over the last 20 years, while those for WCS have remained largely static.

 Comparisons of social indicators show a mixed pattern. In terms of educational attainment, WCS has a higher proportion of working-age adults with tertiary level qualifications (but a much lower proportion with intermediate level qualifications) compared to the Ruhr. The percentage of ‘vulnerable’ (lone parent or single person) households is similar in both regions. Marriage rates are slightly lower in WCS. Aspects of social capital (e.g. voting, participation in religion) may be more developed in the Ruhr compared to WCS.

 In terms of the physical environment, WCS has less exposure to sunshine (and therefore vitamin D) than the Ruhr area. In addition, while recorded crime levels and perceptions of community safety are similar at a regional level, this may disguise the higher levels of concern over safety among citizens of Glasgow compared to their counterparts in key cities of the German region.

 Prevalence of certain health behaviours, such as female smoking rates and (self-reported) alcohol consumption, appear to be much higher in WCS than in the Ruhr area. However, other measures, such as obesity among the middle-aged and male smoking rates, show little difference between the regions.

This case study has identified a number of potentially important differences between WCS and an important post-industrial part of Germany, but it is difficult to quantify their impact on health outcomes, or on the rate of improvement in health outcomes.

However, these results add to the evidence that economic issues alone do not appear to be the principal issue. Further research is required, focussing not on routine administrative data, but based on the collation of new data to test specific hypotheses. This is now being undertaken as part of a programme of work focussing on the key WCS city, Glasgow, and its most comparable post- industrial cities in the UK, Liverpool and Manchester. The results of that research will be complete in 2012.

1.0 Introduction

1.1 Background

This case study is an accompaniment to the main report entitled: Health and its determinants in Scotland and other parts of post- industrial Europe: the ‘Aftershock of Deindustrialisation’ study – phase two. The overall aims of the project, its history, rationale, and development are discussed within that report.

The case study presents the results of analyses of routine administrative and survey data for two post-industrial regions: West Central Scotland (WCS) and the Ruhr area in Germany. As described fully in the main report, this is part of a larger set of analyses exploring the reasons behind the poor health profile of WCS in comparison to other parts of Europe that have also experienced the economic, social and health impact of post-industrial decline.

1.2 Why compare these two regions?

The Ruhr Area is an urban region of West Germany defined historically by its industrial activity: coal mining, iron and steel works. However, like WCS, it has experienced long-term industrial decline in recent decades: between 1970 and 2005 the region lost almost 700,000 industrial jobs – a reduction of around 55%1.

The region consists of almost 4,500 square kilometres and has a population of over five million. The Ruhr is located in the German Federal State of North Rhine-Westphalia (NRW) which borders Belgium and the Netherlands, covers over 34,000 square kilometres, and has a population of around 18 million (about 22% of the total German population). Like WCS, the Ruhr area remains very disadvantaged compared to its parent country, with some of the

highest levels of poverty and unemployment in West Germany concentred in the region (see main report).

1.3 Aim and approach

As with the main section of the report and the other case studies, our aim here is to respond to two key questions:

The approach taken here was to assemble a range of comparable social, economic and health-based data for the Ruhr area and WCS (and where possible, sub-regions). Indicators were grouped beneath the headings used in the main report. These included:

 Health and function, covering aspects such as life expectancy and self-assessed health and well-being;  Prosperity and poverty;  Population-related factors;  The social environment (including educational attainment, and vulnerable households);  The physical environment;  Health behaviours; and  Child and maternal health.

Many of the limitations of this approach – such as gaps in the data, cultural differences (e.g. in car or home ownership), and variation in the history and context of deindustrialisation – have been noted in the main report. They apply equally to this case study.

1.4 Geographies

Wherever possible, direct comparisons are made between the Ruhr area and WCS and their sub-regions. The definition of the Ruhr area matches that used in the first Aftershock report1, based on 15 districts (‘kreise’) and urban districts (‘kreisfreie stadt’)i, as shown in the map in Figures 1a and 1b below, and the chart in Figure 3 below. Where data for the Ruhr were not available, data for the larger North Rhine-Westphalia state are shown instead as a proxy. Sub-regional data for the 15 ‘kreise’ are presented where possible. In addition, survey data for three of these areas (cities) – Bochum, Essen and Mulheim – are presented for the Heinz Nixdorf Recall Study discussed below.

Figure 1(a) Map of the Ruhr area within North Rhine-Westphalia and Germanyii

i All but three of the Ruhr districts (Wesel, Unna and Recklinghausen) are kreisfreie stadt. Wesel, Unna and Recklinghausen cover both the urban districts of the same name and their surrounding rural municipalities. ii Note: map is not to scale.

Figure 1(b) More detailed map of the Ruhr areaiii

The WCS region is defined by the boundaries of 11 local authority areasiv (see Figure two below) and covers over 6,500 square kilometres with a population of over two million. This again matches the definition used in the first Aftershock report. Where data matching this precise geography were unavailable, proxy geographies were again used as a substitute. These were: Greater Glasgow (and Clyde) Health Board areav, and South Western Scotlandvi. Sub- regional data are presented, where possible, for the 11 local authority areas. In addition, for data on voter turnout, parliamentary constituencies were used.

iii Note: map is not to scale. iv East Ayrshire, East Dunbartonshire, East Renfrewshire, Glasgow City, Inverclyde, North Ayrshire, North Lanarkshire, Renfrewshire, South Ayrshire, South Lanarkshire, and West Dunbartonshire. v The Greater Glasgow and Clyde Health Board area comprises six local authorities (East Dunbartonshire, East Renfrewshire, Glasgow City, Inverclyde, Renfrewshire and West Dunbartonshire) plus parts of North and South Lanarkshire. The former Greater Glasgow Health Board, which existed before 2006, covered Glasgow City, East Dunbartonshire and parts of West Dunbartonshire, East Renfrewshire, North and South Lanarkshire. vi South Western Scotland covers the 11 local authorities of West Central Scotland, plus Dumfries & Galloway and Argyll & Bute.

Note that for the main sub-regional comparisons, the populations in the 15 Ruhr kreise range from 118,000 to 636,000 while those in the 11 WCS local authorities range from 81,000 to 585,000. Figure 3 shows the distribution of population across these 26 areas in 2008, with Ruhr kreise shown in yellow and WCS local authorities highlighted in blue (a colour scheme employed throughout the report).

Figure 2 Map of West Central Scotland local authoritiesvii

vii Note: map is not to scale.

Figure 3

Total Populations, West Central Scotland Local Authorities & Ruhr Area Kreise: 2008 Sources: GRO(S) Mid-year estimates; Federal Statistical Office

700000

600000

500000

400000

300000 Total population

200000

100000

s e e e e r r ne r r ire und sen ei hen yde s esel c shi er shi shi l m Unna kshi r H nsh t E W ki Hagen Hamm yrshire yr Bottrop or s Bochum rew A to tonshirerewshire Duisburg en t A r nverc linghausenD rei Ruhr-Kr s th Ayr I lasgow City K Kreis Lanar enf as enf G el Oberhausen R E eck h G North Sou unbar epe- Dunba D s R Nort st i Enn South Lanarkshire East R re East K Mülheim an der Ruhr We Area

The limitations in using the proxy regions listed above are discussed in the full accompanying report.

1.5 Data sources and limitations

Mortality data for each of the post-industrial regions, including the Ruhr, are presented in the first Aftershock report1. To represent a broad model of health, as much additional health outcome data as were available for the two regions were analysed.

Population, migration and births data were provided for the German areas by The Federal Statistical Office of Germany, and for Scottish areas by The General Register Office for Scotland (GRO(S)). These data are based on compulsory local registration of events reported to the respective central organisation. Data on child and maternal health variables reported here, such as teenage motherhood, termination of pregnancy and low birth weight were supplied for the German areas by The NRW Institute of Health and Work (LIGA.NRW) and Information and Technology NRW (IT.NRW), and for Scottish areas

by ISD Scotland and GRO(S). These data were collected systematically by the respective central organisations. Self-assessed health data were provided for the German areas by the Robert Koch Institute (RKI), and for Scottish areas by the Scottish Government, based on comparable survey measures (from the RKI telephone health survey in Germany, and The Scottish Health Survey in Scotland).

This report also aims to present analyses of data on the wider determinants of health. Data for socio-economic variables were provided for the German areas by Eurostat, The Federal Statistical Office of Germany, The Federal Employment Agency, The Federal Criminal Police Office of Germany, and IT.NRW, and for Scottish areas by NOMISviii, GRO(S), and The Scottish Government. These data are measured objectively on a regular basis by these administrative organisations. Health behaviours data were supplied for the German areas by LIGA.NRW and RKI, and for Scottish areas by the Scottish Government. Smoking and alcohol consumption data were collected via survey (census, RKI, Scottish Health Survey and Scottish Household Survey). Data on body mass index (BMI) were collected by survey but verified by measurement of height and weight by a health practitioner.

The case study also uses data from the Heinz Nixdorf Recall Study from 2000-2003, which collected data on more than 4800 adults (aged 45-74) resident in the three cities of Mulheim, Bochum and Essen in the Ruhr area. Comparisons are made with Greater Glasgow health board residents of the same age group, interviewed in the 2003 Scottish Health Survey. Indicators compared from these two samples include diagnosed diabetes and high blood pressure; obesity; smoking; alcohol consumption; perceived community safety and marital status.

viii Nomis is a service provided by the Office for National Statistics, ONS, providing access to the most detailed and up-to-date UK labour market statistics from official sources.

Note that where data for the Ruhr area was unavailable, North-Rhine Westphalia has been used as a proxy. Since socio-economic disadvantage is less pronounced in NRW than the Ruhr, the results shown are likely to overstate levels of prosperity, and understate poverty, in the German region relative to WCS.

A full list of data sources and definitions is included within Appendix 1.

As with the main report and the other three case study reports, a number of limitations and caveats should be borne in mind in interpreting the data presented, not least in relation to the use of routine administrative data. These issues are discussed in more detail in the main report. However, in relation to this case study specifically, the following should be noted:

 Comparing health outcome and determinant data between different countries may be difficult due to known or unknown differences in culture, economy, historical influences, and political systems. As discussed in the main report, some of these issues are currently being researched in a separate but related part of the project.  Although data were available for districts in WCS, equivalent data were not always available for the Ruhr at an equivalent sub- regional level.  Data definitions are not identical between countries for every indicator; where this is the case it has been indicated in the report. As stated above, definitions are listed in Appendix 1.  It has not been possible to show trends for every indicator due to the lack of available time-series data (mostly in relation to the Ruhr districts).

 Data for indicators throughout this report have been collected from a variety of sources. Although some indicators have been objectively and accurately measured, many population rates are estimated from samples taken by survey and some may be subject to recall bias (e.g. alcohol consumption in the last 12 months).

2.0 Health and function: a further analysis of health outcomes in the regions

In this section we revisit life expectancy trends in the two regions, examine the most recent life expectancy data at a sub-regional level and compare self-reported measures of health and well-being, including subjective general health, doctor-diagnosed diabetes and high blood pressure and life satisfaction.

2.1 Life expectancy and mortality

2.1.1 Trends in life expectancy in the two regions In the first Aftershock report, we showed that life expectancy for both sexes was consistently higher in the Ruhr than in WCS over time. The gap in life expectancy between these regions and their parent countries also widened for both sexes, with the change being more notable in the Ruhr (Figure 4 and Figure 5).

Figure 4

Estimates of male life expectancy at birth, Scotland/West Central Scotland & Germany/Ruhr, 1991-2005 (3-year averages) Sources: GRO (S) mortality & population data (Scotland); LIGA.NRW mortality & population data (Ruhr); Health for All Database

77.0 Germany 76.0 The Ruhr Scotland 75.0 West Central Scotland

74.0

73.0

72.0

71.0 Life expectancyLife at birth 70.0

69.0

68.0

67.0 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Figure 5

Estimates of female life expectancy at birth, Scotland/West Central Scotland & Germany/Ruhr, 1991-2005 (3-year averages) Sources: GRO (S) mortality & population data (Scotland); LIGA.NRW mortality & population data (Ruhr); Health for All Database

83.0 Germany 82.0 The Ruhr Scotland 81.0 West Central Scotland

80.0

79.0

78.0

77.0 Life expectancy at birth 76.0

75.0

74.0

73.0 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

2.1.2 Age and cause-specific mortality Previous analysis undertaken for the first ‘Aftershock’ report provides more detail on the different patterns of mortality in the two regions between 1980-82 and 2003-05. In summary:

 Mortality rates for children aged 0-14 were very similar in the two regions throughout the period.

 Mortality rates for younger working-age adults (aged 15-44) were very similar in the Ruhr and WCS throughout much of the 1980s. However, in the 1990s, mortality for this age group rose steadily in WCS and fell steadily in the German region.

 For the middle-aged (aged 45-64) and elderly (65+), mortality rates were consistently lower in the Ruhr than in WCS.

 Mortality from most forms of cancer was lower among Ruhr residents than those in WCS throughout the period, especially for women.

 Rates of both suicide and chronic liver disease-related mortality fell in the Ruhr over time but increased steadily in WCS.

For more details of the above analyses, please consult the first ‘Aftershock’ report.

2.1.3 Sub-regional life expectancy Life expectancy at birth varies widely across the Ruhr area. In 2006- 08, men in the Wesel and Mulheim an der Ruhr kreise could expect to live two years longer than those in Duisberg or Oberhausen, and three years longer than those in Gelsenkirchen (Figure 6). A similar spatial pattern was observed for women.

Figure 6

Male life expectancy at birth, by Ruhr Area kreise: 2006-08 Sources: LIGA.NRW 77.0 76.7 76.5 76.5 76.2 75.9 76.0 75.8 75.6 75.5 75.3 75.3 75.3 75.1 75.0 75.0 75.0 74.8 74.7

74.5

74.0 73.7 Life expectancy at birth 73.5

73.0

72.5

72.0

l r m n n p g n reis rne e ur e usen m ttro b chen Ruh a He is ir Wese d. Ha Hage Ess Bo u k is . Bochum e a eis Unna Dortmund D Kr Ruhr-K lingh Kr - Oberhaus Gelsen nepe Mülheim En eis Reck Kr

Figures 7 and 8 compare life expectancy at birth in the Ruhr kreise and WCS districts for men and women. Life expectancy in East Renfrewshire and East Dunbartonshire compares favourably with the Ruhr kreise for both sexes. For men, five of the 11 WCS districts have male life expectancies that compare unfavourably with

Gelsenkirchen – the district with the lowest male life expectancy within the Ruhr area. For women, seven of the WCS districts have lower life expectancies at birth than Gelsenkirchen.

Figure 7

Male life expectancy at birth, West Central Scotland local authorities & Ruhr Area kreise: 2006-08 Sources: LIGA.NRW; GRO (S)

72 Life expectancy at birth 70

a e g e e n e e y ire m nd ne en ir ir ir um eis sen m u r ur hire h Kr u us sh s sh Ruhr Unn ch tm He Essen r rclyd d. is Ha r Hagen Bottrop ha yr rk e Bo Ayrshirgha A a Ay gow Cit a. n Do Duisb er t enkirche rtons s Kre Ruhr- h th s Inv a Kreis Wesel - ut kli Ob r Eas h Lan o Renfrewshire Gla epe So t N Gel Rec t Dunb North Lanarkshires East RenfrewshMülheim Enn Sou e East Dunbartonshire Kreis W

Figure 8

Female life expectancy at birth, West Central Scotland local authorities & Ruhr Area kreise: 2006-08 Sources: LIGA.NRW; GRO (S)

83.0

82.0

81.0

80.0

79.0

78.0

77.0 Life expectancy at birth

76.0

75.0

74.0

l s n p n d e e e y ire hr i o ne en ir ire ire t se mm tr um r urg Ru e t use us b sh clyde nshire W r-Kre Hage ch Essen He tmun is r wshir r nsh ewsh o d. Ha Bo ha r ha e o fr eis Unna Bo Du Ay fr rt gow Ci n Do er h Ayrshire h t Ayrshir Inve Kr a. -Ruh ling t rt s as m Kreis e Ob o Lanarksh nba unbart i Ren Ea u Gl D Sou Gelsenkirchen N t D North East Re Mülhe Ennep South Lanarkshire East eis Reck Kr Wes

2.2 Self-reported measures of health and wellbeing

2.2.1 General health In the main report, we show self-rated health data which indicate adults in North Rhine-Westphalia (as a proxy for the Ruhr area) were less likely to rate their general health as good or very good compared to those in Greater Glasgow and Clyde (used here as a proxy for WCS). This issue can be explored more directly (for adults aged 45- 74) by comparing results from the Heinz-Nixdorf Recall Study (discussed earlier) with the Scottish Health Survey.

Figure 9 shows the percentage of men and women aged 45-74 rating their health as good or very good in the three cities of the Heinz Nixdorf Recall Study and in Greater Glasgow. In 2002-03, middle- aged residents of Greater Glasgow were significantly more likely to rate their health as good or very good than those in the three Ruhr cities.

Figure 9

Percentage of adults aged 45-74 who rate their health as good or very good, c. 2003 Mulheim, Bochum & Essen (Ruhr) 2000-2003 and Greater Glasgow 2003 Source: Heinz-Nixdorf Recall Study data; Scottish Health Survey 2003

100

70 58.9 57.2 60 50.7 44.0 50

Percentage 40

0 Mulheim, Bochum & Essen (Ruhr Greater Glasgow Mulheim, Bochum & Essen (Ruhr Greater Glasgow area) area) Men Women

Sample sizes: HNRS 2000-2003 (3 cities) – 2385 men and 2416 women; Scottish Health Survey 2003 (Greater Glasgow) – 242 men and 318 women.

2.2.2 Life satisfaction There is continuing interest in measures of life satisfaction as an indicator of subjective well-beingix. The indicator presented here is based on the mean score from 0-10 based on adult responses to how satisfied they are with their life as a whole nowadays. Life satisfaction scores were slightly higher in Greater Glasgow and Clyde (used here as a proxy for WCS) than in the Ruhr areax (Figure 10).

Figure 10

Mean life satisfaction score (0-10): 2008 Sources: European Social Survey Rounds 1-4; Scottish Health Survey 2008; German Socio-Economic Panel

8 7.4 7.2 6.7 7 6.9

Percentage 4

0 Ruhr area Greater Glasgow & Clyde Ruhr area Greater Glasgow & Clyde Men Women Sample sizes: German Socio-Economic Panel (Ruhr area) - 569 men and 626 women; Scottish Health Survey 2008 (Greater Glasgow & Clyde) - 703 men and 843 women.

ix For example, the adoption of a question on life satisfaction by the European Survey, the Scottish Health Survey and the Scottish Household Survey. x Ruhr figures were provided by Dr. Jan Goebel, Research Associate German Socio- economic Panel Study (SOEP) at DIW Berlin.

2.2.3 Diagnosed diabetes and high blood pressure Using the Heinz Nixdorf Recall Study, we can compare selected biological markers of health for older working-age adults (aged 45- 74) in three cities of the Ruhr and Greater Glasgow. The measures included are diagnosed diabetes and high blood pressure.

Figure 11 shows that the percentage of middle-age adults with diagnosed high blood pressure was much higher in the three Ruhr cities than in Greater Glasgow. However, Figure 12 shows that among the same age group, the percentage of adults with diagnosed diabetes did not vary significantly by region.

Figure 11

Percentage of adults aged 45-74 diagnosed with high blood pressure, c. 2003 Mulheim, Bochum & Essen (Ruhr) 2000-2003 and Greater Glasgow 2003 Source: Heinz-Nixdorf Recall Study data; Scottish Health Survey 2003

100

70 58.9 60 55.1

Percentage 34.0 40 33.8

0 Mulheim, Bochum & Essen (Ruhr Greater Glasgow Mulheim, Bochum & Essen (Ruhr Greater Glasgow area) area) Men Women

Samples sizes= HNRS 2000-2003 (3 cities) –2,372 men and 2,407 women, Scottish Health Survey 2003 (Greater Glasgow) – 242 men and 316 women.

Figure 12

Percentage of adults aged 45-74 diagnosed with diabetes, c. 2003 Mulheim, Bochum & Essen (Ruhr) 2000-2003 and Greater Glasgow 2003 Source: Heinz-Nixdorf Recall Study data; Scottish Health Survey 2003

14 10.5 12 6.5 6.2 10 6.8 Percentage 8

0 Mulheim, Bochum & Essen (Ruhr Greater Glasgow Mulheim, Bochum & Essen (Ruhr Greater Glasgow area) area) Men Women

Samples sizes= HNRS 2000-2003 (3 cities) –2395 men and 2419 women, Scottish Health Survey 2003 (Greater Glasgow) –242 men and 318 women.

Summary: Health and function

 Life expectancy was consistently higher in the Ruhr area compared to WCS for both sexes between 1991 and 2005.  Patterns of mortality differ by age, sex and cause in the two regions. The relatively high mortality rates for women, and rising mortality rates for young adults, seen in WCS appear to be driving the slower improvement in life expectancy in WCS compared to the Ruhr.  Despite higher mortality rates, middle-aged adults in Greater Glasgow were more likely to rate their general health as good or very good than their counterparts in three large cities of the Ruhr area.  Mean life satisfaction scores were also higher in Greater Glasgow than in the Ruhr area.  The percentage of middle-age adults with diagnosed high blood pressure was much higher in the three Ruhr cities than in Greater Glasgow. Prevalence of diagnosed diabetes was, however, very similar in the two regions.  Overall, self-reported measures of health and function appear to be ‘worse’ in the Ruhr than WCS: this is at odds with higher objective rates of mortality in the Scottish region, and probably reflects cultural differences in the self-reporting of health between the two countries (note that this is discussed further in the main report).

3.0 Prosperity and poverty

As highlighted in the introduction to the main report, a key research question of this project is whether WCS’s relatively poorer health status can be explained purely in terms of socio-economic factors, such as poverty and deprivation. This section presents some data comparing a range of measures of prosperity and poverty in the Ruhr area and WCS to test the plausibility of this idea. The available socio- economic data that have been analysed here include: unemployment and employment rates; access to a private car; home ownership; perceived adequacy of household income; relative poverty; and income inequality.

3.1 Unemployment

The measure of unemployment uses the International Labour Organisation (ILO) definition2 . This includes all those who are out of work, want a job, have actively sought work in the previous four weeks and are available to start work within the next fortnight; or who are out of work and have accepted a job that they are waiting to start in the next fortnight. The unemployment rate is the number of unemployed people divided by the economically active population (employed plus unemployed).

In Scotland, the unemployment rate in 2007 was around 5%. Rates across the WCS local authority areas ranged from 3.1% in East Dunbartonshire to 7.1% in Inverclyde (Figure 13). Unemployment in Germany in 2007 was more than 8%3. As with WCS in relation to Scotland as a whole, the majority of districts in the Ruhr (12 out of 15) had unemployment rates that were higher than that of Germany or NRW state (8%). There was, however, substantial variation across the Ruhr, with rates varying from around 7% to more than 14% (Figure 14).

Figure 13

Unemployment Rates, West Central Scotland Local Authorities: 2007 Source: NOMIS

8 7.1 6.8 7 6.3 6.3 6.4 6 5.4 on of economically active (%) 5.0 5.1 5 4.2 4 3.4 3.1 3

0 Unemployed as population proporti re re re e re re e ty e i i i yd shi hi sh Ci l k sh c w er ton ews ar ton Ayrshir v fr frewsh go n ar an h Ayrshir n anarkshire th I b L ut L bar r as Re East Ayrshire o Gl t Ren th So N Dun s Dun st Ea Sou North Ea West Area

Figure 14

Unemployment Rates, Ruhr Area Kreise: 2007 Source: Eurostat

16 14.5 14.0 14.2 14

11.7 12 11.5 11.1 11.3 10.8 10.8 11.1 10.1 10 9.1 8.1 8.2 8 6.8

0 Unemployed population as proportion of economically active (%) s n n d n hr e sen Ru che r Es aus Herne e Bottrop Hamm h Hage kir d Bochum Duisburg Dortmun en n Kreis Unna s Kreis Wesel a Ober epe-Ruhr-Krei Gel n Recklinghausen s En ei Mülheim Kr Area

Figure 15 compares all Ruhr kreise and WCS local authorities. It is quite obvious that, in general, unemployment in 2007 was a greater problem in the Ruhr than it was WCS.

Figure 15

Unemployment Rates, West Central Scotland Local Authorities and Ruhr area districts: 2007 Sources: Annual Popualtion Survey, Eurostat 16 14.5 14 14.2 14

11.7 12 11.3 11.5 10.8 10.8 11.1 11.1 10.1 10 9.1 8.1 8.2 8 6.8 6.8 7.1 6.3 6.3 6.4 Percentage 6 5.4 5 5.1 4.2 4 3.1 3.4

e e e e l y s r n a n ire ire ir ir ir ir it h se ei se gen sh sh h e Ruh use k r rclyde -Kr r Unn Essen chum Herne W e Bottrophau Hamm ha Ha rewsh ar Ay gow C is r Bo nkirchen narksh t nv de Duisburg e nfrews a th Ayrshirenf an th Ayrshire as I Ruhr ling Dortmunds r Kreis - an Kre l Re L Re L Eas o Gl ck Obe h Sou h N pe e Ge t Dunbartonshireut Dunbartons eim s Nort lh East So Enne ü Ea eis R West M Kr Area

The figures above all refer to unemployment rates in 2007. Figure 16, however, shows how unemployment had changed over the period from 1985 to 2008. Note that South Western Scotland is used as a proxy for the WCS region. In the mid-1980s, unemployment was much higher in the Scottish region. However, rising unemployment in the Ruhr and falling unemployment in WCS meant that rates converged in the early 1990s. These trends continued until the middle of the last decade: by 2005, unemployment in the Ruhr was nine percentage points higher than in South Western Scotland.

Figure 16

Unemployment as % of economically active adults, South Western Scotland and the Ruhr area: 1985-2008 Sources: Eurostat; Overman and Puga (2002); Esch and Langer (2003); Federal Statistics Office

10 Percentage 8 South Western Scotland Ruhr area

0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

3.2 Employment rates

As discussed in the main report, unemployment rates alone may provide an incomplete picture of labour market change in the regions over time, given the diversion of working-age adults from unemployment to early-retirement and onto sickness benefits. To partly compensate for this, crude employment rates were calculated for men and women aged 15-64 for both regions for the period 1981- 2005. The gender division is important given that since the 1970s, female labour market participation has been higher in the UK than in Germany4.

Employment rates for men aged 15-64 were a little higher in the Ruhr in the 1980s and similar in both regions until the late 1990s, when they diverged as rates rose in WCS but fell in the Ruhr (Figure 17).

Figure 17

Male crude employment rates, West Central Scotland and the Ruhr area: 1981-2005 Sources: LIGA.NRW; Regionalverband Ruhr; Labour Force Survey; 1981 Census

West Central Scotland 80 Ruhr area

Percentage 40

0 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

For women, employment rates rose steadily in both regions between 1985 and 2005, but were consistently higher in WCS than in the Ruhr (Figure 18).

Figure 18

Female crude employment rates, West Central Scotland and the Ruhr area: 1981-2005 Sources: LIGA.NRW; Regionalverband Ruhr; Labour Force Survey; 1981 Census

80 West Central Scotland Ruhr area

40 Percentage

984 1981 1982 1983 1 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

3.3 Car ownership

This section examines access to private cars as a proxy for household and individual wealth. As discussed in the main report, although levels of car ownership have been shown to be a very useful proxy measure for household income with the UK, cross country comparisons of this indicator are more problematic, given differences in relative cost and affordability within different countries, as well as potential cultural influences.

Bearing those caveats in mind, Figure 19 shows the percentage of households with no access to a private car or van in the Ruhr area compared to WCS. In 2001-03, households in the Scottish region were twice as likely as those in the Ruhr to be without a car (40.4% vs. 19.9%).

Figure 19

Percentage of households without access to a car, West Central Scotland and the Ruhr area: 2001-03 Sources: GRO (S) Census of Population; German Socio-economic Panel

40.4 40

19.9

Percentage 20

0 Ruhr area West Central Scotland

Although it was not possible to obtain comparable district-level data on car access, a proxy measure is analysed here: cars per 100 people. Figure 20 presents this measure for the WCS local

authorities and Ruhr kreise. In all but three of the WCS local authorities, the number of cars per capita was lower than that recorded for any Ruhr kreise. Variation between kreise was also not as wide as between WCS local authorities.

Figure 20

Cars per 100 people, West of Scotland Local Authorities & Ruhr Area Kreise: 2001 Sources: GRO(S), Federal Statistical Office

20 Number of cars per 100 total population 10

r e n e e e m ne r r r ty uh Ci R usen am er che shire shire shi r Essen Hagen H r k k e Bottrop ha H onshir ewshire erclydeon Bochum t Duisburg Ayrshi r Ayrshi v t Dortmund enki h h In -Ruhr-Kreis Kreis Unna bar s t lasgow Kreis Wesel Oberhausen or G un East AyrshireRenf N Gel Sout uth Lanar Dunbar t D o orth Lanar s Reckling N st Ennepe ülheim an d East Renfrewshire S ei Eas M Kr We Area

3.4 Home ownership

Lack of home ownership has been used as a measure of relative disadvantage in many studies of health and deprivation in the UK. However, as with car ownership, there are clear difficulties in making cross-country comparisons of such an indicator. Any differences may reflect cultural attitudes towards home ownership and the policy environment (e.g. ‘Right to Buy’xi in the UK) as much as levels of prosperity.

xi Introduced in 1980, the Right-to-Buy scheme gave tenants of council housing in the UK the right to buy the home they lived in. From March 2011, those renting social housing for the first time in Scotland or those returning to rent social housing no longer have the right to buy.

Figure 21 shows that owner-occupation is much more common in WCS than in the Ruhr: in 2001, nearly three-quarters of households in the German region did not own their own home, while in WCS this figure was much lower, at four in 10.

Figure 21

Percentage of households not owning their own home, West Central Scotland and Ruhr area: 1999-2002 Sources: GRO (S) Census of Population; Urban Audit

100

80 73.5

Percentage 40.1 40

0 Ruhr area West Central Scotland Ruhr area West Central Scotland

This divide in owner-occupation rate widened between 1991 and 2001. In the Ruhr, the percentage not owning their own home remained relatively stable but in WCS it decreased from 53.1% to 40.1% (Figure 22).

Figure 22

Percentage of people not owning their own home, West Central Scotland and the Ruhr area: 1989-93 to 1999-02 Sources: Urban Audit; GRO (S) Censuses of Population

100

90 Ruhr area West Central Scotland 80 75.4 73.5

60 53.1 50

Percentage 40.1 40

0 1989-93 1999-2002

3.5 Perceived adequacy of income

As discussed in the main report, survey data can be compared to assess regional differences in perceived adequacy of income at the household level. The question asked in both the European Social Survey (ESS) and the Scottish Social Attitudes Survey (SSAS) is whether people “find it difficult to manage on household income nowadays”xii. Some care must be taken in comparing these results, given small sample sizes and the use of North-Rhine-Westphalia as a proxy for the Ruhr area. Nonetheless, the percentage reporting they found it difficult to manage was not significantly different in the two regions: 11% of the WCS sample in the SSAS compared to 14% of the ESS sample for North-Rhine-Westphalia (Figure 23).

xii ESS data are taken from Rounds 1-4 of the survey which cover the years 2002, 2004, 2006, and 2008. However, reported values for this question for the selected region do not vary significantly between rounds. Note also that ESS data are available for all Scotland (but not WCS), and the figure for this question is close to that for WCS taken from the SSAS: 12.8%.

Figure 23

Percentage of adults finding it difficult to manage on household income nowadays: c. 2002-08 Sources: European Social Survey Rounds 1-4; Scottish Social Attitudes Survey 2007

14.4

15 11.4 Percentage 10

0 North-Rhine-Westphalia West Central Scotland Sample sizes: North-Rhine-Westphalia=1854; WCS=534.

3.6 Family affluence

The Family Affluence Scale is calculated from young people’s responses to four questions in the WHO-collaborative Health Behaviour in School-aged Children survey (HBSC)5. The questions relate to: family ownership of a car; ownership of computers; whether the young person has their own bedroom; and number of family holidays in the year prior to the survey. A composite score is derived from the answers to these questions and, from this, families can be assessed as being of low, middle or high levels of affluence6. The main report presents data for five regions of interest for this study. Here we compare the percentage of 11-15 year olds living in ‘high’ and ‘low’ affluence families in North-Rhine-Westphalia (used here as proxy for the Ruhr area) and WCS.

Figure 24 shows that: children living in North-Rhine-Westphalia were less likely to live in ‘low affluence’ families than those in WCS (14.1% vs. 18.3%); conversely, children living in WCS were less likely to live

in ‘high affluence’ families than those in North-Rhine-Westphalia (46.3% vs. 40.3%).

Figure 24

Percentage of 11-15 year olds with 'low' and 'high' levels of family affluence, West Central Scotland and North-Rhine-Westphalia: 2006 Source: 2006 Health Behaviour in School Aged Children

50 46.3

40.3

Percentage 18.3 20

14.1

0 North-Rhine-Westphalia West Central Scotland North-Rhine-Westphalia West Central Scotland Low family affluence High family affluence Sample sizes: North-Rhine-Westphalia=5642; WCS=2547.

3.7 Relative poverty and inequality

In the European Union, poverty is usually measured in relative terms: that is, showing income levels relative to national income standards. The most common indicator used is the percentage of people living in households with an income less than 60% of median national income. Lemmi et al (2003)7 have published methods and data that can be used to estimate relative poverty rates for a large number of NUTS IIxiii regions, averaged for the period 1994-2001. These were used to estimate poverty rates for North-Rhine-Westphalia (used here as a proxy for the Ruhr area) and South Western Scotland (used as a proxy for WCS). Again, some caution should be used in

xiii Nomenclatures of Units for Territorial Statistics (NUTS) are the standard geographies used by the European Union to divide countries into regions and sub-regions. NUTS II regions have populations between 800,000 and 3m.

interpreting these results, given that levels of poverty in the core Ruhr area are higher than those in NRW State8.

Figure 25 shows that relative poverty was substantially lower in North-Rhine-Westphalia than in South Western Scotland (11.0% vs. 18.9%). This is likely to be driven by much lower rates of poverty among children and pensioners in Germany than in Scotland.9

In the main report, we show that income inequality in Scotland (as measured by the Gini coefficient) was higher than levels seen in Germany. However, at a regional level, income inequality in WCS was only marginally higher in North-Rhine-Westphalia (0.296 vs. 0.289, Figure 26).

Figure 25

Percentage of population living in relative poverty (60% of median national income), 1994-2001 average Sources: Lemmi et al (2003), based on ECHP; GCPH calculations

20 18.9

11.0 Percentage 10

0 North-Rhine-Westphalia South Western Scotland

Sample sizes: 2164 (North-Rhine Westphalia); 1279 (South Western Scotland).

Figure 26

Income inequality in West Central Scotland and North-Rhine-Westphalia: 2003-04 Sources: Luxemburg Income Study; Scottish Household Survey

0.50

0.40

0.289 0.298 0.30

GINI Coefficient 0.20

0.10

0.00 North-Rhine-Westphalia West Central Scotland

Sample sizes: 2379 (North-Rhine Westphalia); 11030 (West Central Scotland).

Summary: Prosperity and poverty

 Current levels of unemployment are higher and current employment rates lower, in the Ruhr area compared to WCS.  Relative to WCS, male employment rates in the Ruhr were slightly higher in the 1980s, similar in the 1990s and slightly lower in the 2000s, while female employment rates have remained consistently lower in the German region.  Car ownership was lower, but home ownership higher, in WCS compared to the Ruhr. However, clearly these differences may reflect cultural as much as socio-economic differences in the two regions.  According to comparable survey data, the percentage of adults finding it difficult to manage on their household income nowadays was similar in WCS and North-Rhine-Westphalia.  Family affluence may be lower in WCS. Survey data show that compared to North-Rhine-Westphalia, WCS had a lower percentage of children aged 11-15 living in ‘high affluence’ families and a higher proportion living in ‘low affluence’ families.  WCS has much higher rates levels of relative poverty compared to North-Rhine-Westphalia, though income inequality is very similar in both regions.  It is difficult to conclude that differences in socio-economic factors alone can account for WCS’s poorer health outcomes compared to the Ruhr.

4.0 Population

Understanding the composition of the population, and how it has changed over time, may provide insights into factors driving population health. This section explores aspects of population in the two regions: overall trends; population size; population structure and density are presented here. Time trends and data for each district (Ruhr kreise and WCS local authorities) are presented where available. The most recent available data are shown.

4.1 Population change

Population change over time can be accounted for by the birth rate, death rate, immigration and emigration. Figure 27 shows how the total population changed over the 12 year period from 1996-2008 for WCS and the Ruhr area. Both regions experienced a decrease in population over this period, but it was relatively more pronounced in the Ruhr area than in WCS (Figure 27).

Figure 27

Population of the Ruhr area and West Central Scotland: 1995-2008 Sources: Federal Statistics Office; GRO (S)

6000

-237,400 (-4.4%)

5000

4000

3000

-42,300 (-2.0%) Population ('000s)Population 2000

1000

0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Ruhr area West Central Scotland

Population change between 1995 and 2008 (as a percentage of the 1995 population), was also calculated for each kreise in the Ruhr and local authority in WCS, to examine variation within the regions.

Figure 28 presents results for the WCS local authorities. Most of WCS local authorities experienced net population loss over the period from 1995 to 2008. East Renfrewshire, South Lanarkshire and North Lanarkshire saw modest increases in their populations. The Inverclyde population, at the worst end of the scale, decreased by almost 9% between 1995 and 2008.

Figure 28

Percentage change in population, West Central Scotland Local Authorities: 1995-2008 *As a percentage of 1995 population Source: GRO(S) 10

1.9 1.7 0.6

e e e e e e r ir ty r r hir i shi Ci hi h ksh rclyde rk -1.4 ow ons e a ar -1.7 g ews rtons h Ayrshire an t -2.3 as bart a Inv L Gl n Renfrewshir h Lan th Nor East Ayrshire Renfr u st ut r South Ayrshire D -3.3 t Dunb Percentage change population in No st s Ea So -3.8 e Ea W -5 -4.7 -5.1

-8.9 -10 Area

The change in population also varied across the Ruhr area (Figure 29). With the exception of Wesel (which saw a small increase in its population), all the kreise lost population between 1995 and 2008. The most striking population loss over the period was seen in Gelsenkirchen: its population fell by 29,101 between 1995 and 2008, representing a net loss of 10% of the total 1995 population.

Figure 29

Percentage change in population, Ruhr Area Kreise: 1995-2008 *As a percentage of 1995 population Source: Federal Statistical Office 4

2 1.4

n g n nd en r -0.5 u s eis se ge usen Kr a Unna m a - Es Herne Hamm Bottrop rt hau r H rh g Bochum -2 eis -1.4 Do e der Ruhr Duisbu Kr Ruh n Kreis Wesel Ob - Gelsenkirchen -2.4 -2.4 Recklin epe eis Enn -4 Kr Mülheim a -3.9 -4.0 -4.6 -4.7 -5.4 -6 -5.7 Percentage change population in -7.2 -8 -7.7

-10 -9.4 -10.0

-12 Area

4.2 Migration

Net migration is shown for a 12 year period (1995-2007) to minimise the effect of short-term fluctuations on the overall movement of populations. To ensure comparisons between areas are valid, net migration between these dates is expressed per 1000 people resident in each area in 1995.

Between 1995 and 2007, there was net emigration of 23,000 people from WCS: almost 11 people per 1000 total population. There is a contrasting pattern in Scotland, which saw net immigration of almost 95,000 people to Scotland: an increase of 19 people per 1000 of the total (1995) population of Scotland. Variation between the local authorities was marked, with net immigration of 29 people per 1000 population in South Ayrshire and net emigration of 57 people per 1000 population in Inverclyde (Figure 30).

Figure 30

Net Migration 1995-2007, per 1000 people in each area in 1995, West Central Scotland Local Authorities Source: GRO(S)

40 29

19 20

7 2 0

e e e e y e e ir r ir ir it r ir hire hi hire -6 hi s sh s sh sh C shire r k r k w sh n rclyde -11 ws on Ay ar rews Ay ar go re ve h f h Ayr t n -20t an t an as -16 nf barto I L r L e bart n th Ren No Eas th Gl R Sou st r Dun Sou Ea No st Du West-31 Ea -40 -36

-47 Net migration per (1995) 1000 total population

-60 -57

-80 Area

Between 1995 and 2007, the Ruhr lost over 15,000 people or almost three people per 1000 population. This is in sharp contrast to Germany as a whole, which saw net-immigration of 25 people per 1000 people over the same period106. Substantial disparity among the Ruhr area kreise is evident in Figure 31, below. The range of net migration from 1995-2007 was from 44 immigrants per 1000 population in Wesel, to 64 emigrants per 1000 population in Hagen (Figure 31).

Figure 31

Net Migration 1995-2007, per 1000 people in each area in 1995, Ruhr Area Kreise Source: Federal Statistical Office

44 40

24 19 20 15 10 6 4 0 0

l p n -2 n e n n nd e m -3 -4 n sen se urg ge ttro Ruhr u hu u b Wese tm -Kreis Es Her is Bo er r r Hamm Ha s d Boc ei eis Unna Do Du enkirche -20 Kr -Ruh s Kr Oberhaus cklingha -18 im an Gel nepe Re ülhe En M Kreis -40 -40

Net migration per (1995) 1000 total population -49 -60 -64

-80 Area

Figure 32

Net Migration 1995-2007, per 1000 people resident in each area in 1995, West Central Scotland Local Authorities & Ruhr Area Kreise Sources: GRO(S), Federal Statistical Office

44 40 29 24 19 19 20 15 10 7 6 4 2 0 -2 -3 -4 -6 -11 -16 -18 -31 -36 -40 -47 -49 -57 -64 0

l p a r e s n n e g n n o nd i e m ne ir ire tr hire u hir m um se hire r ur lyde t Unn s Ruh s h s Wese r w Es He nsh irche rc Hage Bo is e Ha rk o e de ortm r Boc a gow City rewsh Duisb rt v eis D f h Ayrshire t Ayrshire s enk In -20 Kre n -Ruhr-Kre t s nf s Kr a e Oberhaus nba h Lanark Ren Ea h Lan Gla Re South Ayrshire t t Nor t Du Gel eim t lh Nor Sou ü Eas Ennep Eas M Kreis Recklinghausen West Dunbartonshire -40 Net migration per 1000 total population (1995) total population 1000 per migration Net

-60

-80 Area

4.3 Population density

WCS is a predominantly urban environment, and as such had a considerably higher population density in 2008 (316 people per square kilometre) than that of Scotland as a whole (66 people per km2). This varied from 91 people per km2 in South Ayrshire, to 3329 in Glasgow City, although all local authorities except the city had less than 700 persons per km2.

The Ruhr was far more densely populated than WCS, with 1173 persons per km2, in a range from 453 in Wesel to 3247 in Herne. Although North Rhine-Westphalia is an urban state with 526 persons per km2, Germany on the whole had far more people per area (230 per km2 in 2007) than Scotland 2. Figure 33 below shows population densities for the Ruhr area kreise and WCS local authorities in 2008. Population density was highest in the cities of Glasgow and Herne.

Figure 33

Population Density, West Central Scotland Local Authorities & Ruhr Area Kreise: 2008 Sources: GRO(S), Federal Statistical Office

3500

3000

2500

2000

1500 Persons per sq km 1000

500

re re re re re a is n hr g ty i i i i i e e rop ur h h t hen hum sen rsh sh Unn t agen Ru c c u k rkshire Hamm r-Kr H ir Essen Herne Ay ar erclyde tons Bo Bo rha t nv rewsh eis der Duisb nk an I ar nf ana Ruh inghaus Dortmund e sgow Ci L b L Kr kl an s a Kreis Wesel e- Obe Gl Eas North Ayrshireth Renfrewshire Re th p South Ayrshire t DunbartonsDun r Gel o Rec N s Sou Eas Enne East ei West Kr Mülheim Area

4.4 Population structure and dependency ratio

Figure 34 shows the population structure for each WCS local authority, dividing the 2007 population into three age groups: children (under 15), working-age adults (15-64), and pensionable adults (65+). As would be expected of a large city, Glasgow City local authority had the largest proportion of working-age adults (70%) in WCS, but there was not substantial variation across the region. The proportion of pensionable adults ranged from 14% in Glasgow City to 20% in South Ayrshire; the proportion of children ranged from 15% in South Ayrshire and Glasgow City to 19% in East Renfrewshire.

Figure 34

Population Structures, West Central Scotland Local Authorities: 2007 Source: GRO(S)

100%

90%

80%

70%

60% 65+ 50% 15-64 <15 40%

30%

Proportion of population (%) total 20%

10%

e e e e nd r r ty ir ire re a hi hire hi Ci hi s s clyd rsh rsh s yr ws w rkshire rk er a A v Ay Ay na l Scotl t sgo In nfrewshire a rth e La SCOTLAND Gl o Eas Renfre N R h st South ut st Dunbarton North Lan st Centra Ea So e Ea W Area

Variation between Ruhr area kreise was less than in WCS (Figure 35). Of note, however, is the greater proportion of the population that were over 65 – ranging from 19% in Hamm to 24% in Mulheim an der Ruhr – when compared to local authorities in WCS. Proportions of 15-64 year-olds ranged from 63% in Mulheim an der Ruhr and Hagen to 67% in Bochum. Children generally made up less of the population in the Ruhr (14%) than in WCS (17%).

Figure 35

Population Structures, Ruhr Area Kreise: 2007 Source: Federal Statistical Office

100%

90%

80%

70%

60% 65+ 50% 15-64 <15 40%

30% Proportion (%) of total population 20%

10%

a n r d n n e e hen sel eis ar burg Ruh c hum e Kr NRW is Esse ausen tmun Herne aus - hr u er h Bottrop r Hage Hamm h r d nkir Boc Ru D e Do eis W ng n li Ruh Kreis Unna a Ober ls Kr k - Ge eim Rec nepe lh s ü ei En M Kr Area

The dependency ratio is defined by Last (2001) as “the proportion of children and old people in a population in comparison to all others i.e. the proportion of economically inactive to economically active”11. This is calculated by dividing the working-age (15-64) population by the sum of children and pensionable adults, expressed as a percentage. This of course does not take into account the number of people aged 15-64 who are economically inactive due to ill health, care responsibilities, or lack of employment opportunities. The trend in OECD countries, and in particular Germany, is that of an ageing population (and, therefore, an increasing dependency ratio). The consequential increase in the dependency ratio has been a concern to policy makers in Germany in recent years12.

Figure 36 shows trends in the dependency ratios for both regions between 1995 and 2007. In 2007, the dependency ratio was marginally higher in the Ruhr area than in West Central Scotland. This is a reversal of the position seen in the mid-1990s and was driven by a fall in the dependency ratio in WCS and a rising dependency ratio in the German region.

Figure 36

Trends in the Dependency Ratio, West Central Scotland and the Ruhr area: 1995-2007 Sources: calculated from GRO (S) and Federal Statistics Office data 70

60 53 53 52 52 53 53 52 52 52 51 51 52 52 50 51 50 50 50 50 49 48 48 49 49 50 49 49

20 Dependency ratio ((population <15+ population 65+)/population aged 15-64)*100 10

0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Ruhr area West Central Scotland

Figure 37 shows the range of dependency ratios across the Ruhr area kreise and WCS local authorities. In the Ruhr area, dependency ratios in the kreise varied from 49 in Bochum (where there was the smallest proportion of children) to 58 in Hagen (where there was a relatively large proportion of pensioners). In WCS local authorities, the 2007 dependency ratios ranged from 42 in Glasgow City (where there was a high proportion of working-age people) to 56 in East Renfrewshire (where there was a high proportion of children).

Figure 37

Dependency Ratios, West Central Scotland Local Authorities & Ruhr Area Kreise: 2007 Sources: Calculated from GRO(S) & Federal Statistical Office data 60

20 65+)/population 15-64)*100

10 Dependency population ratio+ ((population <15

y e e g n it r m ir hr C hi yde und nna hen shire cl U am ssen sbur age ochum Wesel Herne H E yrshire H B ew arkshireAyrs ortm Bottroprhausen s Ayrshire tonsh ui A gow nver ei D der Ru as an I D be th ar senkirc h l Kreis Kr an G Renfr East O or el Renfrewshire th Lanarkshire N G Sout m or Dunb N hei South L Ennepe-Ruhr-Kreis East ül East West Dunbartonshire Kreis Recklinghausen M Area

4.5 Fertility rates

The birth rate (live births per 1000 people) and the fertility rate (live births per 1000 women aged 15-44) complement the mortality rate in understanding population change. Both were calculated but here we show only the fertility rate since it is a more precise and comparable measure (Figure 38). The fertility rate for Scotland (and WCS) in 2008 was 57 per 1000 women aged 15-44. There was only slight difference between local authorities, in a range from 62 per 1000 in North Lanarkshire to 52 per 1000 in East Dunbartonshire.

Figure 38 also shows recent trends in the fertility rate for WCS and the Ruhr area. In 2008, the fertility rate in WCS (57 per 1000) was higher than that recorded for the Ruhr area (44 per 1000). The regional gap in fertility rates also widened between 2003 and 2008. The upward trend in WCS was mirrored by each of the local authorities, and was particularly steep in South Lanarkshire, Renfrewshire and West Dunbartonshire. However, the trends of individual kreise of the Ruhr were not uniform. While most kreise had

very moderate increases or decreases over the five year period, fertility rates increased in Recklinghausen (from 42 per 1000 in 2003 to 53 per 1000 in 2008) and decreased in Hagen (from 48 to 44 per 1000).

Figure 38

Trends in the Fertility Rates, West Central Scotland & Ruhr Area: 2003-2008 Sources: Calculated from GRO(S) & Federal Statistical Office data

60 West Central Scotland 56.5 Ruhr area 55 54.2 52.3 51.2 51.4

50 49.1

45 42.4 42.6 43.7 41.2 41.9 40.5 40 Number of live births per 1000 women 15-44 35

30 2003 2004 2005 2006 2007 2008 Year

Figure 39 shows the range of fertility rates across the WCS local authorities and Ruhr area kreise. Except for Recklinghausen, none of the Ruhr kreise had a fertility rate as high as any of WCS local authorities.

Figure 39

Fertility Rates, West Central Scotland Local Authorities & Ruhr Area Kreise: 2008 Sources: Calculated from GRO(S) & Federal Statistical Office data

Number of livewomen births per 1000 15-44 10

e e e e e e e r r r r r r ity ir m nd ne op en hi lyde C u uhr tr c shi shire am agen chen Unna er esel Kreis kshi nsh H tm H r Essen H ot W onshi yrshi ew uisburg s B haus arkshire rewshi Ayrs A Ayr r rto der R D ei is Bochum Inver h Dor r e enf t linghausenlasgow senki K ber Ruhr- Lanar Lan orth enf an el O Kr th h R East G N Sou eck Dunba m G epe- or R N out s hei S East R i ast ül Enn re E West Dunbart K M Area

Summary: Population

 Both West Central Scotland and the Ruhr area saw their populations decrease between 1995 and 2008, though the scale of change was slightly higher in the German region (-4.4% vs. - 2.0%).  Population density is higher in the Ruhr (1173 persons per km2) than WCS (316 people per km2).  Both regions experienced net emigration between 1995 and 2007. Rates in WCS were much higher than in the Ruhr (11 per 1000 compared to three people per 1000 population).  The dependency ratio was slightly higher in the Ruhr (53) than in WCS (49).  Fertility rates were higher in WCS than in the Ruhr in 2008, and remained consistently higher than the German region between 2003 and 2008.

5.0 Social environment

Social factors – such as education and the support available to people from family, community or state – can play a role in creating, preserving or destroying health. This section reviews selected aspects of the social environment in the Ruhr and WCS to see if key differences exist that can begin to explain the poorer health outcomes in the Scottish region. Comparisons include: educational attainment, vulnerable households and selected aspects of social capital (religious participation and voter turnout).

5.1 Education

Educational attainment is associated with clear differences in health, but making international comparisons of education is not straightforward. The International Standard Classification of Education (ISCED)xiv framework has been used in the past to overcome this challenge. The main report presents two indicators based on ISCED – the percentage of adults with no or low level qualifications (ISCED Level 0-2) and the percentage with tertiary (post-secondary) level qualifications. It shows that North-Rhine Westphalia (used here as a proxy for the Ruhr), had a lower proportion of adults aged 25-64 qualified to tertiary level but also a lower proportion with low or no qualifications, compared with South Western Scotland (used here as a proxy for West Central Scotland). In this section, we attempt to use more precise geographies to compare educational attainment in the Ruhr and WCS directly.

xiv International Standard Classification of Education, November 1997. Available at: http://www.unesco.org/education/information/nfsunesco/doc/isced_1997.htm.

Figure 40 shows the distribution of working-age adults in the Ruhr area and WCS by the highest level of ISCED qualification attainedxv. Both regions have a similar level of working-age adults with the lowest level of attainment. The differences are in the percentage of working-age adults with intermediate level qualifications (much higher in the Ruhr area: 56% vs. 35%) and those with higher-level qualifications (much higher in WCS: 35% vs. 13%).

Figure 40

Percentage of working-age adults by ISCED educational attainment: 2003-06 Sources: Annual Population Survey January-December 2005; Urban Audit 2003-06 60 55.8

40 35.2 35.2

31.0 29.6 30 Percentage

13.2

0 ISCED 0-2 ISCED 3-4 ISCED 5-6

Ruhr area West Central Scotland

xv Three levels of qualification were examined: low or no qualifications (ISCED 0-2), intermediate (upper secondary school qualifications, ISCED 3-4) and higher-level (tertiary level qualifications, ISCED 5-6). UK qualifications were mapped to ISCED levels as follows: no qualifications & NVQ Level 1=ISCED 0-2; NVQ Level 2, 3 and Trade apprenticeships=ISCED 3-4; and NVQ 4+ and other qualifications=ISCED Level 5-6.

5.2 Lone parent households

This indicator shows the proportion of households with dependent children headed by a lone parent. This is a slightly narrower measure than that used in the main report, where the measure used was households with children regardless of whether those children were dependentxvi. It is clear, though, that the percentage of lone parent households is similar in both regions (26.9% vs. 28.5%, Figure 41).

Figure 41

Percentage of households with dependent children headed by a lone parent, West Central Scotland and the Ruhr area: 2001 Sources: Urban Audit; GRO (S) Census of Population 2001

30 28.5 26.9

20 Percentage

0 Ruhr area West Central Scotland

During the 1990s, the percentage of lone parent households increased in both regions, but the growth of lone parent households occurred at a faster pace in WCS. While the concentration of lone parent households was five percentage points higher in the German region at the start of the 1990s, the gap had been closed by the end of the decade (Figure 42).

xvi The percentages were 31.1% (WCS) and 32.3% (The Ruhr area, estimated from Urban Audit and Federal Statistics Office data).

Figure 42

Percentage of households with dependent children headed by a lone parent, West Central Scotland and the Ruhr area: 1991 to 2001 Sources: Urban Audit; GRO (S) Census of Population 2001

30 28.5 26.9 25 23.6 Ruhr area West Central Scotland 20 18.6

Percentage 15

0 1991 2001

5.3 Single person households

This analysis looks at the percentage of single person households in the Ruhr and WCS. In 2001-02, the percentage of single-person households was slightly higher in the Ruhr than in WCS (36.8% vs. 33.8%, Figure 43).

Figure 43

Percentage of single-person households, West Central Scotland and the Ruhr area: 2001 Sources: Urban Audit; GRO (S) Census of Population 2001

40 36.8 33.8 35

20 Percentage

0 Ruhr area West Central Scotland

As with lone parent households, the percentage of single-person households in both regions increased in the 1990s, but again there is evidence that the rate of increase was faster in WCS. The Scottish region narrowed the gap with the Ruhr in terms of single-person households over the decade (Figure 44).

Figure 44

Percentage of single-person households, West Central Scotland and the Ruhr area: 1989-91 to 1999-02 Sources: Urban Audit; GRO (S) Census of Population 2001

Ruhr area 25 West Central Scotland

20 Percentage

0 1991 2001

The growth in single-person households reflects a long-term trend. As discussed by Palmer (2006) 13, this raises a number of areas of potential concern:

 Single-person households may not have the same capacity to adjust to sudden changes in financial circumstances (e.g. loss of a job), increasing the risks to individuals.  Rising proportions of people living alone may result in increasing inequality, social isolation and poverty.

More recent data allow us to analyse this indicator at a sub-regional level. In Scotland, the average proportion of households occupied by a single person in 2007-08 was 33%. Across the WCS local authority areas (excluding Glasgow City) the figures range from 26% in East Dunbartonshire to 34% in West Dunbartonshire. Glasgow City stands apart from the other districts with 41% of households occupied by a single person, 15 percentage points more than in East Dunbartonshire (Figure 45).

Figure 45

Single Person Households, West Central Scotland Local Authorities: 2007/08 Source: Scottish Household Survey

45 41.0 40

35 34.0 34.0 34.0 33.0 31.0 31.0 30 29.0 29.0 28.0 26.0 25

Percentage 20

e e e e e e e y ire ir r r r t h hi hi hi s shire s s s hire Ci ksh kshir onshir yr ons t ew ar Ayr ar Ayr rew rt h h Inverclyd bar enfr t Lan asgow R East A Renf Gl un th Lan Nor h Sout st or st D N Ea Sout est Dunba Ea W Area

In the Ruhr there is also a difference of 15 percentage points across the kreise: Wesel has 30.3% single person households while Essen has 44.8%. The overall state average proportion of single person households was 37%; this is similar to the German average of 39%17 (Figure 46).

Figure 46

Single Person Households, Ruhr Area Kreise: 2007 Source: IT.NRW 50

44.3 44.8 45 41.1 41.9 40.1 38.8 38.9 40 37.3 37.4 35.8 33.0 33.3 33.8 34.7 35 30.3 30

20 Percentage

el m g n n rop en t he hum Ham Hagen Herne Esse s Wes Bot haus Boc ei reis Unna Duisbur Dortmund K -Ruhr-Kreis Kr Ober e Gelsenkirc

Ennep Kreis Recklinghausen Mülheim an der Ruhr Area

It can be seen from Figure 47 that, in general, the proportions of single person households in the Ruhr kreise were greater than those of WCS local authorities.

Figure 47

Percentage of single-person households: 2007-08 West Central Scotland local authorities and and Ruhr districts Source: Scottish Household Survey 2007-08; IT.NRW 60

30 Percentage 20

e e e e e n g y n r r r en op de r r r ne it hi hi sel hi tr y hi C und s e t cl Ruhr er chen Unna H ir tm Esse ons yr W s yrshire Bo er ons Hamm hausen Hage k t s i A t r hr-Kreisder Bochum A ei e nv u Duisbu Dor E. N. Ayrs Kr S. inghaus I be nbar Kr Lanarkshire kl O lasgow lsen u Renfrewshi G e D N. Lanarkshire S. ec m an G E. Renfrewshire R . Dunbar ei E. lh eis W Ennepe-Rü Kr M

5.4 Marital status

This indicator is calculated from 2001 Census data published by Eurostat. It shows the percentage of adults aged 25-64 who were legally married (including those who were separated). As shown in Figure 48, the percentage of adults in this age group defined as legally married in both regions was marginally higher in the Ruhr than in WCS (66% vs. 63%, Figure 48).

Figure 48

Percentage of adults aged 25-64 who were married, West Central Scotland and the Ruhr area: 2001 Source: Eurostat 100

70 66.4 63.0 60

50 Percentage 40

0 Ruhr area West Central Scotland

The Heinz-Nixdorf Recall Study cohort allows us to compare marital status for older middle-aged residents (aged 45-74) in the three cities of the Ruhr and Glasgow City (Figure 49).

Figure 49

Adults aged 45-74 year-olds by marital status, Mulheim, Bochum & Essen (Ruhr) 2000-2003 and Glasgow City 2001 Sources: Heinz-Nixdorf Recall Study data; GRO (S) Census of Population

100

75 80

70 58 60

Percentage 40

20 13 12 13 9 7 10 4 6 4 0 Mulheim, Glasgow City Mulheim, Glasgow City Mulheim, Glasgow City Mulheim, Glasgow City Mulheim, Glasgow City Bochum & Bochum & Bochum & Bochum & Bochum & Essen (Ruhr) Essen (Ruhr) Essen (Ruhr) Essen (Ruhr) Essen (Ruhr) Single Married (including legally Cohabiting Divorced Widowed separated) Sample sizes: HNRS 2000-03 (three cities) – 4802 adults.

Glasgow City residents in this age group were substantially less likely to be married (58% vs. 75%) or cohabiting (4% vs. 9%) and substantially more likely to be divorced, single or widowed compared to their counterparts in the three Ruhr cities.

5.5 Social capital: religious affiliation

Religious affiliation appears to be higher in the German region than WCS. Survey data show that half the adult population of WCS reported that they never attended religious ceremonies except on special occasions, significantly higher than the figure reported for North-Rhine Westphalia (used here as a proxy for the Ruhr area) (Figure 50).

Figure 50

Percentage of adults who never attend religious ceremonies except on special occasions: c. 2002-08 Sources: European Social Survey Rounds 1-4; Scottish Social Attitudes Survey 2007

60 52.7

40 30.6

Percentage 30

0 North-Rhine-Westphalia West Central Scotland Sample sizes: North-Rhine Westphalia=1863, West Central Scotland=444 adults.

5.6 Social capital: voter turnout

Our last indicator of the social environment in the two regions is voter turnout, used as a crude proxy for social capital. Voter turnout in Scotland is calculated by dividing the number of people who voted in an UK election by the electorate (i.e. those registered and entitled to vote). The Federal Statistical Office of Germany calculates voter turnout by dividing the number of people who voted by the total population over 18 years. This discrepancy may underestimate the difference between the two regions: since the registered electorate will be smaller in number than the total population aged 18 years or over, German voter turnout may appear less than if the electorate were the rate denominator.

Note also here that voter turnout in Scotland is measured (and, therefore, here presented) by constituency, rather than local authority.

In 2005, voter turnout at parliamentary elections in North-Rhine Westphalia (used here as a proxy for the Ruhr area) was much higher than for WCS: 78.3% vs. 58.3%. Furthermore, although turnout in WCS has fallen over time, rates in the German region remained largely unchanged, increasing the gap between the regions over time (Figure 51).

Figure 51

Voter turnout at national parliamentary elections, West Central Scotland and North- Rhine Westphalia: 1990-92 to 2005 Sources: UK Electoral Commission; Federal Statistics Office

100 North-Rhine-Westphalia 90 West Central Scotland 83.9 78.7 80.3 80 78.3 75.4 70.2 70

56.5 60 58.3

50 Percentage 40

0 1990-92 1997-98 2001-02 2005

An analysis of the sub-regional data in both regions for 2005 highlights two clear differences: first that there is a much greater variation in voter turnout across the WCS constituencies compared to what is seen in the Ruhr area; and second, that voter turnout was consistently higher in all of the Ruhr kreise compared to the WCS constituencies. This is despite the denominator for the German data being larger (the total population aged 18 years and over); the real difference may be expected to be even greater. These data are shown in Figure 52.

Figure 52

2005 UK General Election and 2005 Bundestag Elections, National Elections 2005 West Central Scotland UKPCs and Ruhr districts Sources: www.ukpolitical.info, Federal Statistical Office

100

Percentage 40

l s a n n n e n h o h t e n h t h t h t l i n ck an c t w s s st ra rop se e rn ast rt g o u o es u e rt e ast t tt hum se s E o a rr ll o Ea Ruhr Kre Un c u us mund h Sout Wes rclyd ti W W No W E en r- r- s a E a HammHe Hagert re re East N n n h w th e h Bo i Bo h rh uisburgkircheni i re ma umn re ve i w S th w o C d is Weseu e g e D n h i s ire i rk o o o g or w e in Do e s e C In ilt d Wishaor g s N Kr l ls n L sg n a o Kr Ob wsh nd m a N w pe-R ck rto d ewsh rth andd KiA w Gl o im-an- e Ge a re a ock & Loudon Ha Gl o Glas ow Sout g lasg e n b fr Ayrshire Central No a g g s n ick rn h d s s G lh n is Re Renfrewsh rr re t n ryston and Bellshilla Airdrie anda Shotts a E e u en an unbartonsh i y h Gl D v h n a Gl Gl Mü Kr d R a Ca D ils e n th nd Ren r, Kilma K nark andl Hamilton East a a y Ayrs , rg Motherwell a y ld La e ey a enfe A u h isl , Str sl a e ut d ai rn R Pa ri P e ilb mb Coatbridge, C st K Cu a E

Summary: Social environment

 Among working-age adults, WCS and the Ruhr have a similar proportion of adults with a low level of educational attainment. The Ruhr has a much higher proportion of adults with intermediate level qualifications, while WCS has a much higher proportion with high level qualifications.  The percentage of single-person households is marginally higher in the Ruhr than WCS, while both regions have a relatively high percentage of lone-parent households.  In relation to marital status, the percentage of adults aged 25-64 who were married was marginally higher in the Ruhr than in WCS. Among older middle-aged adults, the percentage that were married was far higher, and the percentage who were single or divorced lower, in three key Ruhr cities compared to Glasgow City.  Two proxy measures of social capital were analysed. Adults in North-Rhine-Westphalia (used as a proxy for the Ruhr) were significantly less likely than those in WCS to report they never attended religious ceremonies except for special occasions. Voter turnout was also consistently higher in North-Rhine-Westphalia compared to WCS. This was also true at a sub-regional level, with voter turnout in Ruhr kreise higher than in almost every West Central Scotland constituency.  Overall, comparisons of social determinants in the two regions of health present a mixed picture. The messages on educational attainment are ambivalent and the two regions have a similar level of vulnerable (lone parent and single person) households. On the other hand, marriage rates among the middle-aged are higher in the Ruhr and some measures of social capital may be rather stronger in the German region relative to WCS.

6.0 Physical environment

This section briefly discusses aspects of the physical environment for WCS compared to the Ruhr. Data limitations mean the analyses here are confined to: measures of climate; recorded levels of crime per capita; and perceived neighbourhood safety.

6.1 Climate

Climate, and more specifically lower levels of Vitamin D resulting from less sunshine, has been suggested as one reason for Scotland’s enduring poor health status14. Lower levels of Vitamin D have been linked with a range of diseases, including a number of different forms of cancer. In 2005 Glasgow (the largest city in West Central Scotland) received less sunshine (‘daily irradiation’) than Dortmund (the largest city in the Ruhr) in 10 out of the 12 months of the yearxvii (Figure 53).

Figure 53

Monthly daily average irradiation, Glasgow (West Central Scotland) and Dortmund (Ruhr area): 2005 Source: Solar Radiation Data (SoDA)

7000

Glasgow Dortmund

6000

5000

4000

3000

Mean irradiation of daily (Wh/m2) 2000

1000

0 January February March April May June July August September October November December

xvii Unfortunately, data are only available for 2005. Using one year’s data may of course present a skewed picture, and it would be preferable to show data average over several years were such information available.

However, it is difficult to draw any firm conclusions about the impact of this without a dedicated study which could compare not only levels of Vitamin D deficiency (Hypovitaminosis D) among the two populations, but which could also control for the effects of a whole range of confounding factors (diet, socio-economic status, family history etc.). As such a study does not exist, we must remain cautious in interpreting any climate related data for the regions.

6.2 Recorded Crime

Our second measure of the physical environment is recorded crime. The total number of crimes recorded by the police per head of population is presented here for each district, region and state/country.

In 2006 WCS police recorded, on average, a higher number of crimes per capita than did all Scottish forces; 88 per 1000 and 82 per 1000, respectively. There was wide variation between the local authorities in a range from 44 per 1000 in East Dunbartonshire to 131 per 1000 in Glasgow City (Figure 54).

Figure 54

Total Crime Rates per Capita, West Central Scotland Local Authorities: 2006 Source: Scottish Government

140 131

120

100 100 88 81 78 78 80 69 65 66 60 49 44 40 Total crime rate per 1000 population 20

e e e ir r ire re r ity hi hi s sh shire s shire C yr tonsh ew ew fr ark Ayr r A rtonshi gow st Inverclyde bar en Lan a las R E Renf G un South Ayrshire h North D st ut Dunba st Ea So North Lanarkshire st Ea We Area

In NRW state there were 83 recorded crimes per 1000 in 2006; in the Ruhr area overall, there were 94 per 1000. Crime rates in the kreise ranged from 37 per 1000 in Ennepe-Ruhr-Kreis to 109 per 1000 in Bochum (Figure 55).

Figure 55

Total Crime Rates per Capita, Ruhr Area Kreise: 2006 Sources: State Criminal Office NRW, Federal Criminal Police Office

140

120 109 106 108 100 101 100 93 93 95 86 82 78 79 79 80

60 53

37 40 Total crime rate per 1000 population 20

r n n g op ne uh tr und Kreis age che usen - Unna Essen r Her a tm er R Bot Hamm H hausen d g Bochum reis enki Duisbur Dor K s e-Ruhr an Kreis Wesel Oberh Gel nep lheim En Mü Kreis Recklin Area

The number of crimes per capita in the Ruhr and WCS regions was quite similar: 94 per 1000 and 88 per 1000, respectively. We should, however, be cautious about making comparisons purely on the basis of recorded crime in the two regions, given potential differences in recording practices between the two regions. For example, in Germany multiple offences against the same victim or without a victim are counted as one offence and multiple offences against different victims are counted as two offences15, while in Scotland all the offences are counted, regardless of the number of victims16.

6.3 Perceived neighbourhood safety

We can contrast these administrative data on recorded crime with subjective, survey-based measures of neighbourhood safety. The first indicator compares the percentage of adults who felt safe or very safe walking alone after dark in North-Rhine-Westphalia (used as a proxy for the Ruhr area) and WCS (Figure 56). Perceptions of neighbourhood safety did not vary significantly between these two regions.

Figure 56

Percentage of adults who feel very or fairly safe walking alone in their local neighbourhood after dark, West Central Scotland and North-Rhine-Westphalia: c. 2002- 2008 Sources: European Social Survey Rounds 1-4; Scottish Household Survey 2007/08

100

80 73.2 70.6

50 Percentage 40

0 North-Rhine-Westphalia West Central Scotland Sample sizes: North-Rhine-Westphalia=1854; WCS=6692.

The second source of data is taken from Urban Audit 2009 and compares the percentage of adult residents of Dortmund and Glasgow City who always felt safe in their neighbourhood (Figure 57). The percentage of adults reporting this was the case in Glasgow (69.5%) was much lower than in Dortmund (88.3%).

The final piece of evidence on this comes from the Heinz-Nixdorf Recall Study and Greater Glasgow Health and Well-being Survey 2008 (Figure 58). Older working-age adults in Glasgow City were significantly less likely to report feeling safe in their local neighbourhood after dark than their peers in Bochum, Essen and Mulheim-an-der-Ruhr. The gap was particularly noticeable for women (59.6% vs. 94.3%).

Figure 57

Percentage of adults who always felt safe in their neighbourhood: 2009 Source: Urban Audit

100

90 88.3

69.5 70

50 Percentage 40

0 Dortmund (Ruhr area) Glasgow (West Central Scotland)

Sample sizes: Dortmund=505; Glasgow=500.

Figure 58

Percentage of adults aged 45-74 who agree they feel safe in their local area after dark, Mulheim, Bochum & Essen (Ruhr) 2000-2003 and Glasgow City 2008 Source: Heinz-Nixdorf Recall Study; Greater Glasgow Health and Wellbeing Survey 2008

100

50 Percentage 40

0 Mulheim, Bochum & Essen (Ruhr Glasgow City Mulheim, Bochum & Essen (Ruhr Glasgow City area) area) Men Women Sample sizes: HNRS 2000-03 (three cities) – 2385 men and 2416 women; Greater Glasgow Health and Well-being Survey (Glasgow City) – 523 men and 677 women.

Summary: Physical environment

 In 2005, Glasgow received less daily solar irradiation (sunshine) on average than Dortmund (largest city in the Ruhr) for 10 out of 12 months of the year  Levels of recorded crimes per capita were fairly similar in the Ruhr area and WCS: 94 per 1000 and 88 per 1000 respectively. Some caution should be attached to comparisons of these data, though, due to international differences in how crimes are recorded.  Reported levels of (subjective) neighbourhood safety in WCS were similar to those in North-Rhine-Westphalia. However, residents of Glasgow City were less likely to report feeling safe in their local neighbourhood than their counterparts in the largest cities of the Ruhr, with the difference especially marked for women.

7.0 Health behaviours

Data on health-related behaviours are presented here for smoking prevalence, alcohol consumption, body mass index and physical activity. All data have been collected via health surveys.

7.1 Smoking

Smoking status described here is self-reported via survey for both German and Scottish data. Figures 59 compares adult smoking rates in WCS and North-Rhine-Westphalia (used here as a proxy for the Ruhr area) in 2003-05. Male smoking rates were almost identical in the two regions. However, female smoking rates were significantly higher in WCS than in the German region.

Figure 59

Percentage of adults who were daily smokers: 2003-05 Sources: German Microcensus; Scottish Household Survey

29.8 29.9 28.4 30

25 21.6

Percentage 15

0 North-Rhine-Westphalia West Central Scotland North-Rhine-Westphalia West Central Scotland Men Women Samples sizes: North-Rhine Westphalia – 2283 men and 2591 women; West Central Scotland – 4685 men and 6498 women.

In Scotland, 27% of adult respondents to the Scottish Household Survey were smokers in 2003-04. There was wide variation in WCS, with only 18% of smoking adults in East Dunbartonshire while 35% were smokers in East Ayrshire (Figure 60).

Figure 60

Smoking Prevalence, West Central Scotland Local Authorities, 2003/04 Source: Scottish Household Survey

35 35 33 31 31 30 30 29 29

25 25 25 24 21 20 18

Proportion of respondents who smoke (%) 5

e re re ity re hi hi s sgow shi clyde s la on rewshir Ayr t ver Ayr h In bartonshire ter G lasgow C ort G un Renf N East uth Lanarkshire rea South Ayrshire Dunbar t D o s G North Lanarkshire a East Renfrewshire S est E W Area

Smoking prevalence among adults in North Rhine-Westphalia was estimated at 29% by a 2005 health survey. Variation between kreise was less than that observed in WCS local authorities: across the Ruhr kreise, rates ranged from 28% of adults in Mulheim an der Ruhr to 35% of adults in Gelsenkirchen (Figure 61).

Figure 61

Smoking Prevalence, Ruhr Area Kreise: 2005 Source: LIGA.NRW

35 34 34 35 33 32 32 31 31 31 31 31 31 29 30 28 28

Proportion of respondents who smoke (%) 5

r h n a n m n nn hum und U c m rche r Ru Esse Herne o Bottrop Hage t Ham i de B eis Duisburg Dor Kr lsenk Kreis Wesel Oberhausen e G

Ennepe-Ruhr-Kreis Mülheim an Kreis Recklinghausen Area

Those districts with the smallest proportions of reported smokers are in WCS, and those with the highest are mostly in the Ruhr (Figure 62). However, in the majority of districts from both regions at least 25% of the adult population were estimated to be smokers.

Figure 62

Smoking Prevalance, West Central Scotland Local Authorities & Ruhr Area Kreise Sources: Scottish Household Survey 2003/04; LIGA.NRW 2005

10 Proportion of respondents who smoke (%) 5

e e n n a e e d n ire re el e en ir r ire hi hir um s hi gen h un shir Ruhr es clyde sh s n r Esse Unn Herne k tm w City irche er Bottrop hau Ha Hamm o rews Ayrshired Boch ar f eis W Duisburg ng Ayr rtons Dor enk anarksh S. N. Ayrs Inve Kreis E. a s L Kr Oberhaus kli Lan unbarto Ren c Glasg D S. im an epe-Ruhr-Kreis e N. Gel E. Renfrewshire n R E. s ülhe En W. Dunb M Krei

Smoking rates can also be compared for older working-age adults (aged 45-74), in the more urbanised sub-regions of Greater Glasgow and Mulheim, Bochum and Essen (Figure 63 – Figure 65). The results show that for this age group, Greater Glasgow had a higher proportion of current smokers, a lower percentage of male ex- smokers and a lower percentage of females who never smoked. As discussed in the main report, this suggests that not only are current smoking rates higher for the middle-aged in Greater Glasgow compared to the Ruhr area, they were also higher historically for women in the Scottish region.

Figure 63

Percentage of adults aged 45-74 who smoked regularly/occasionally: 2000-2003 Mulheim, Bochum & Essen (Ruhr) 2000-2003 and Greater Glasgow 2003 Source: Heinz-Nixdorf Recall Study data; Scottish Health Survey 2003

35.2 32.7 40

30 25.7

21.3

Percentage 20

0 Mulheim, Bochum & Essen (Ruhr Greater Glasgow Mulheim, Bochum & Essen (Ruhr Greater Glasgow area) area) Men Women

Sample sizes: HNRS 2000-03 (three cities) – 2388 men and 2416 women; Scottish Health Survey 2003 (Greater Glasgow) – 241 men and 317 women.

Figure 64

Percentage of adults aged 45-74 who used to smoke: 2000-2003 Mulheim, Bochum & Essen (Ruhr) 2000-2003 and Greater Glasgow 2003 Source: Heinz-Nixdorf Recall Study data; Scottish Health Survey 2003

100

60 46.3 50 35.5

Percentage 40

23.3 30 23.1

0 Mulheim, Bochum & Essen (Ruhr Greater Glasgow Mulheim, Bochum & Essen (Ruhr Greater Glasgow area) area) Men Women

Sample sizes: HNRS 2000-03 (three cities) – 2388 men and 2416 women; Scottish Health Survey 2003 (Greater Glasgow) – 241 men and 317 women.

Figure 65

Percentage of adults aged 45-74 who had never smoked: 2000-2003 Mulheim, Bochum & Essen (Ruhr) 2000-2003 and Greater Glasgow 2003 Source: Heinz-Nixdorf Recall Study data; Scottish Health Survey 2003

100

70 55.7 60

50 41.5

Percentage 31.8 40 28.0 30

0 Mulheim, Bochum & Essen (Ruhr Greater Glasgow Mulheim, Bochum & Essen (Ruhr Greater Glasgow area) area) Men Women

Sample sizes: HNRS 2000-03 (three cities) – 2388 men and 2416 women; Scottish Health Survey 2003 (Greater Glasgow) – 241 men and 317 women.

7.2 Alcohol consumption

Using data from the Heinz-Nixdorf Recall Study, we can compare reported levels of alcohol consumption in the two regions for adults aged 45-74 (Figure 66). This shows that older working-age adults in Greater Glasgow were substantially more likely to report that they exceeded the recommended weekly limits for alcohol consumption (21 units for men, 14 units for women) than those in the Ruhr cities.

Figure 66

Percentage of adults aged 45-74 exceeding 21/14 units of alcohol a week, c. 2003 Mulheim, Bochum & Essen (Ruhr) 2000-2003 and Greater Glasgow 2003 Source: Heinz-Nixdorf Recall Study data; Scottish Health Survey 2003 (unrevised estimates) 50

40 30.2

30 Percentage 20 13.8 12.6

2.4

0 Mulheim, Bochum & Essen (Ruhr Greater Glasgow Mulheim, Bochum & Essen (Ruhr Greater Glasgow area) area) Men Women

Sample sizes: HNRS 2000-03 (three cities) –1797 men and 1728 women; Scottish Health Survey 2003 (Greater Glasgow) – 241 men and 314 women.

7.3 Body mass index

Body mass index (BMI) is a convenient and widely used measure of obesity/overweight in a population. It is calculated by the following equation: weight in kilograms divided by height in metres squared (kg/m2). Overweight is defined as a BMI between 25 and 30; obese is defined as a BMI over 30. This section presents data on BMI in the two regions.

The Heinz-Nixdorf Recall Study and Scottish Health Survey allow us to compare obesity levels among adults aged 45-74 in three cities of the Ruhr and Greater Glasgow. As shown in Figure 67 (below), levels of obesity did not vary significantly for this age group by region.

Figure 67

Percentage of 45-74 year-olds classed as obese (BMI >= 30), Mulheim, Bochum & Essen (Ruhr) 2000-2003 and Greater Glasgow 2003 Source: Heinz-Nixdorf Recall Study data; Scottish Health Survey 2003

32.4 40 29.2

28.5 26.7 30

Percentage 20

0 Mulheim, Bochum & Essen (Ruhr Greater Glasgow Mulheim, Bochum & Essen (Ruhr Greater Glasgow area) area) Men Women Sample sizes: HNRS 2000-03 (three cities) –2381 men and 2404 women; Scottish Health Survey 2003 (Greater Glasgow) – 213 men and 261 women.

Self-reported data on BMI by age and sex were also available for the adult population (aged 18+) at the state/country level from the national telephone health survey conducted by the Robert Koch Institutexviii.

The proportion of individuals who were estimated to be overweight or obese in NRW state in 2005 was 65%. The range among the kreise varied from 66% in Bochum to 77% in Oberhausen (Figure 68). Figure 69 shows these data separated by the proportion of the population that is estimated to be overweight and those that are

xviii Note that these estimates are likely to understate the ‘true’ level of obesity in the population: as discussed in the main report, self-report tends to underestimate weight and overestimate height.

obese. The proportion of obese people ranged from 13% in Bochum to 19% in Oberhausen.

Figure 68

Percentage of adults (aged 18+) overweight or obese, Ruhr Area Kreise: 2005 Source: LIGA.NRW

100

80 77 73 75.1 75.9 70.9 71.1 72.6 72.6 70 67 67.3 67.9 65.5 65.6 66 66.1 60

Percentage 40

l n n g en hum che c Essen r Ruhr mund ir Herne o t Hage haus Bottrop Hamm B is Wese de Dor ng Duisbur eis Unna Ruhr-Kreis senk i Kr Kre - kl Oberhausen Gel ec s R Ennepe ei Mülheim an Kr Area

Figure 69

Percentage of adults (aged 18+) overweight or obese, Ruhr Area Kreise: 2005 Source: LIGA.NRW 100

Obese 90 Overweight 80

70 17.7 18.7 15.6 15.3 17.4 16.1 14.9 18.4 14.3 60 12.7 13.5 13.8 13.8 14.0 14.1

Percentage 40

30 56.2 57.0 57.3 57.7 58.2 58.3 52.8 52.1 52.2 52.3 53.0 53.2 53.6 54.8 54.6 20

n n a e eis m esel r nn hum che U ttrop Ess W r Ruhr Hagen ir o Herne Ham Boc e ortmund B eis D Duisburg eis r -Ruhr-K Kr K elsenk Oberhausen G is Recklinghausen Ennepe e Mülheim an d Kr Area

In NRW in 2003 there were a higher proportion of overweight or obese males than females: 67% of males and 53% of females. Equivalent data for Scotland were not available, but the proportion of males aged 16-64 who were estimated to be overweight or obese was 64%; the proportion of females aged 16-64 who were estimated to be overweight or obese was 57%.

Summary: Health behaviours

 Male smoking rates are similar in the two regions, but female smoking rates are considerably higher in WCS.  Self-reported alcohol consumption suggest that adults in Greater Glasgow are much more likely than those in the three Ruhr cities to exceed recommended weekly drinking limits.  Survey data suggest that levels of obesity among older working- age residents of Greater Glasgow and cities in the Ruhr are similar.

8.0 Child and maternal health

In this penultimate section, child and maternal health indicators are analysed. The indicators considered include: births to women under the age of 18; low birth weight babies; and terminations of pregnancy. These data were collected through reports by the health care systems in each country.

8.1 Births to mothers under the age of 18

Comparable data were available for the Ruhr and WCS on the number of live births to mothers under the age of 18. Figures shown here are expressed as the rate per 1000 females aged 15-17. In 2008, the rate of births to mothers < 18 was far higher in WCS (15.5 per 1000) than in the Ruhr area (5.1 per 1000). Figure 70 shows that this gap widened slightly between 2003 and 2008: while the rate of births to mothers < 18 fell slightly in the Ruhr area, it remained unchanged in the Scottish region.

Figure 70

Birth rate to mothers < 18, West Central Scotland & Ruhr Area: 2003-2008 Source: GRO (S); IT.NRW

Ruhr area West Central Scotland

15.3 15.4 15.4 15.5 14.7 14.5 15

6.1 6.3 5.7 5.1 5.2 5.0 5 Number of mothers <18 per 1000 females 15-17

0 2003 2004 2005 2006 2007 2008 Year

Figure 71 compares birth rates to mothers under the age of 18 across the WCS local authorities and Ruhr area kreise. With the exception of East Dunbartonshire and East Renfrewshire, every one of the WCS local authorities had a birth rate to teenage mothers higher than that observed for the Ruhr districts. Despite being similar in population size, Glasgow City had a teenage birth rate almost three times that recorded in Dortmund City (17.6 per 1000 versus 5.9 per 1000).

Figure 71

Mothers < 18 per 1000 females aged 15-17: 2008 West Central Scotland Local Authorities and Ruhr districts Source: GRO(S), IT.NRW 25

20.7 19.0 20.1 20 17.6 16.8 17.3 15.0 15 13.9 12.5

10 7.9 7.1 7.1 7.5 6.2 5.6 5.9 6.0 6.0 5.1 5.1 5.1 5 4.5 3.6 3.7 3.8 2.6 Number of mothers < 18 per 1000 females 15-17

l a s n e e e e ty e se ei m ir n ir r ire e sen gen m he h hire hire hir Unn c sh s s rshi clyde W -Kr Es Ha tmund Ha ir Her rk r ns Bochum Bottrop rhausenton ews a Ay e o eis frewshire Duisburgnk e r r Ayr narksh gow Ci nv Ruhr linghausen Dor nf E. S. as I Kreis Kr - k La N. Ayrshire Ob nba Re Gl nbart pe Gelse S. Lan N. E. Ren Du Du E. Enne W. Kreis Rec Mülheim an der Ruhr

8.2 Low birth weight babies

Low birth weight data refer to all babies born under 2.5kg, and this is expressed as a rate per 1000 all live births. In 2008, the rate of low- birth-weight babies per 1000 live births in WCS was 73.8 per 1000 live births, slightly lower than the rate for the Ruhr (79.8 per 1000). At the beginning of the 1990s, the rate of low birth-weight babies was lower in the Ruhr area than in WCS. However, rising rates in the German region meant that it had overtaken levels seen in WCS by the middle of the 2000s (Figure 72).

Figure 72

Trends in Low Birth Weight Babies, West Central Scotland & Ruhr area: 1991-2008 Sources: ISD Scotland, LIGA.NRW

100 West Central Scotland 90 Ruhr area

20 Low weight babies (<2.5kg) per 1000 live births live 1000 per (<2.5kg) babies weight Low

0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year

Sub-regional data on low birth-weight babies is shown for both regions in Figure 73. Within WCS, the rate of low birth-weight babies ranged from 61 per 1000 in East Dunbartonshire to 81 per 1000 in Renfrewshire The range was wider in the Ruhr: from 69 per 1000 in Ennepe-Ruhr-Kreise to 93 per 1000 in Hagen.

Figure 73

Low Birthweight Babies, West Central Scotland Local Authorities and Ruhr kreise: 2008 Source: ISD Scotland; LIGA.NRW

140

120

100 93 93 86 83 85 85 80 81 81 81 78 79 80 80 80 74 75 71 71 73 73 68 69 69 63 61 61 60

20 Low weight babies (<2.5kg) per 1000 births live

e e e e s a r e n e n p ir ir i m r de en nd e en el o en e hi se y s s shir h sh shir hu Ruh l h u r r k -Kr Unn c m aus Herne s Hamm Es er kirc h hau Bottr Hag Ay Ay ar hr Boc i . d. rews gow City v rewshir r rtonshire n e narkshiref s Duisburg f en a th Ru a n In s Dort ling u La Kr e l k Kreis We East Ayrshire Gla Ren Obe North pe- R Ge So e st North L South Enn Mülheim a Ea East Dunb Area eis Rec West Dunbartons Kr

8.3 Termination of pregnancy

Termination of pregnancy is legal (and free through the NHS) in Scotland. It can be performed to avoid injury to the physical or mental health of the woman or her existing child(ren) up to 24 weeks gestation, and to save the woman’s life, prevent grave injury to the woman, or if the child is likely to be severely handicapped at any time during the pregnancy. Over 90% of terminations are carried out within 12 weeks gestation (first trimester)17. The situation is quite different in Germany, where termination of pregnancy is illegal, but not punishable up to 12 weeks gestation if the woman attends counselling designed to discourage termination at least three days before the procedure is carried out. These terminations are not covered by medical insurance unless the woman has an income below a certain level. After the first trimester medical abortion is legal if there is a medical reason such as harm to the woman from continued pregnancy, or a severely deformed foetus18.

With these legal aspects in mind, it is not surprising that the rate of terminations in NRW state (used as a proxy for the Ruhr) was considerably lower than in WCS. In 2007 there were seven terminations per 1000 women aged 15-44 in NRW, just over half the rate in WCS (12.3 per 1000 women aged 15-44). While the rate of terminations in NRW state remained level over the period 2002-07, in WCS there was a rate increase every year during the same period. This trend divergence can be seen in Figure 74.

Figure 74

Trends in Terminations of Pregnancy, North Rhine-Westphalia and West Central Scotland: 2002-2007 Sources: ISD Scotland, Federal Statistical Office

West Central Scotland 12.1 12.3 12 North-Rhine-Westphalia 11.1 10.6 9.9 10.0 10

8 7.4 7.2 7.2 7.1 7.1 7.0

4 Rate of terminations per 1000 women 15-44 2

0 2002 2003 2004 2005 2006 2007 Year

Summary: Child and maternal health

 Rates of births to teenage mothers were far higher in WCS than in the Ruhr. The difference is even more marked at district level: in 2008 the rate of births to teenage mothers was three times higher in Glasgow city than in Dortmund, a city of comparable size.  The Ruhr area had a higher rate of low birth-weight babies than WCS in 2008. This is in contrast to the early 1990s, when the reverse was the case. This reversal was driven by steady increases in the proportion of underweight babies born in the German region in the last 18 years.  Termination of pregnancy rates among women aged 15-44 were much higher in WCS than in North-Rhine Westphalia in 2007. Rates also rose year-on-year between 2002 and 2007, in contrast to the German region where they remained level. However, these differences may be partly accounted for by the stricter conditions and potentially higher costs attached to obtaining a termination of pregnancy in Germany, as well as cultural differences.

9.0 Conclusions

This case study has compared a range of routinely available indicators of health and its determinants in the Ruhr area of Germany and WCS, in an attempt to answer two research questions:

In relation to the first question, this remains unproven. Compared to the Ruhr area, WCS has lower current levels of unemployment and higher levels of employment for men and women. There is also evidence that labour market opportunities (measured by the unemployment and employment rates) have improved relative to the German region over time. Although WCS compares less favourably to the North-Rhine Westphalia (used here as a proxy for the Ruhr) in terms of relative poverty and family affluence, levels of income inequality and the perceived adequacy of household income are similar in the two regions.

In relation to the second question, a number of interesting differences between the regions have been shown. For example, the evidence on self-reported measures of health is at odds with objective measures of health: despite life expectancy being higher in the Ruhr than WCS, adults in the German region are less likely to rate their health as good, and in general report lower levels of life satisfaction compared to their counterparts in WCS. This ‘disconnect’ between subjective and objective measures of health is also discussed in the main report, with an ‘over-estimation’ of health status appearing to be a feature of the Scottish, as well the WCS, population.

The overall picture for social determinants and aspects of health is ambivalent. The Ruhr and WCS have similar concentrations of households that might be thought of as ‘vulnerable’ (lone parent, single person). However, marriage rates and indicators of social capital (regular attendance at religious ceremonies; voter turnout) do appear to be higher in the Ruhr area compared to WCS. We might speculate that adults in the German region might have access to alternative support networks, which might act to protect their health in some way, though exploring this is clearly beyond the scope of this project.

Some differences are also evident in relation to child and maternal health, for example the much lower rate of teenage pregnancies and pregnancy terminations in the Ruhr area compared to WCS. Variation was observed in relation to aspects of the physical environment (climate) and some aspects of health behaviours. Levels of sunlight reaching the ground are lower in the WCS compared to the Ruhr area. While male smoking rates are similar in the two regions, other aspects support a more familiar narrative: female smoking rates and reported levels of alcohol consumption are much higher in WCS than in the Ruhr.

Figure 75 presents an at-a-glance summary of key indicators presented within the case study. It is a (very crude) attempt to summarise the extent to which health and its determinants (or at least data on health and its determinants that are available from routine data sources) differs between these two post-industrial regions: WCS and the Ruhr area. It illustrates domains where WCS is ‘better’ than the Ruhr (self-rated health, labour market participation, tertiary education); those for which WCS is ‘worse’ (life expectancy, female smoking, alcohol consumption, relative poverty and some aspects of social capital and child and maternal health) and those where the regions are very similar (vulnerable households, income inequality and perceived adequacy of income).

As with the main report and the other three case studies, these analyses have identified some important differences between the Scottish and West German post-industrial regions. However, it is difficult to quantify their impact on health outcomes, or on the rate of improvement in health outcomes. Nonetheless, these results add to the evidence that economic issues alone do not appear to be the principal issue. Further research is required, focussing not on routine administrative data, but based on the collation of new data to test specific hypotheses – and this is now being undertaken as part of a programme of work focussing on the key WCS city, Glasgow, and its most comparable post-industrial cities in the UK, Liverpool and Manchester. The results of that research will be complete in 2012.

Figure 75 Selected indicators for WCS compared to the Ruhr area

Is WCS worse than, similar to, or better than the Ruhr?

Domain Indicator WCS vs. the RuhrWCS The RuhrMeasure Region Time Period

Life expectancy - males 72.8 75.1 yrs WCS 2003-05

Life expectancy - females 78.3 80.7 yrs WCS 2003-05

Health & Function Adults aged 45-74 in good/v. good health 59.0 51.0 % GG 2000-03

Females aged 45-74 in good/v. good health 57.0 44.0 % GG 2000-03

Mean life satisfaction (0-10) 7.3 6.8 Av. GG & C 2008

Male employment rate 72.0 67.0 % WCS 2008

Female employment rate 64.0 54.0 % WCS 2008 Prosperity & poverty Unemployment rate 5.8 10.9 % WCS 2008

Perceived adequacy of income * 11.4 14.4 % WCS 2002-08

Population living in relative poverty * 18.9 11.0 % S.W. Scot 1994-01 Inequalities Income inequality * 0.30 0.29 Gini WCS 2003-04

Education: tertiary (level 5/6) qualifications, working age 35.2 13.0 % WCS 2003-06

Education: no/low (

Lone parent households 33.8 36.8 % WCS 2001-03

Social Environment Single person households 33.8 36.8 % WCS 2001-03

Adults (25-64) who are married 63.0 66.4 % WCS 2001

Social capital - not reg. attend. church * 52.7 30.6 % WCS 2002-08

Social capital - voter turnout * 58.3 78.3 % WCS 2005

Climate - average annual irradiance 2805 3019 w G 2005 Physical Environment Crimes per capita 88.0 94.0 Cr1 WCS 2006.0

Male smoking prevalence * 29.9 29.8 % WCS 2003-05

Female smoking prevalence * 28.4 21.6 % WCS 2003-05

Male obesity (45-74) 29.2 26.7 % GG 2000-03 Behaviour Female obesity (45-74) 32.4 28.5 % GG 2000-03

Males (45-74) drinking > 21 units a week 30.2 13.6 % GG 2000-03

Females (45-74) drinking > 14 units a week 12.6 2.4 % GG 2000-03

Births to teenage mothers (< 18) 15.5 5.1 Cr2 WCS 2008

Child & Maternal Low birth-weight babies 73.8 79.8 Cr3 WCS 2008

Terminations of pregancies * 12.3 7.0 Cr4 WCS 2007 * NRW used as proxy for the Ruhr area. Note: For survey data, 95% confidence intervals (and Chi-square test for proportions) used to determine if difference significant.

References

1 Walsh D, Taulbut M and Hanlon P. The Aftershock of Deindustrialisation. Glasgow: GCPH; 2008. 2 Office for National Statistics. How exactly is unemployment measured? London: ONS, 2010. 3 Eurostat. Unemployment rate by gender - Total: European Commission, 2010. Available at: http://epp.eurostat.ec.europa.eu/tgm/table.do?tab=table&init=1&lang uage=en&pcode=tsiem110&plug. 4 Andersen JG and Jensen JB. Chapter 2. Employment and Unemployment in European countries, 1970-2000. In Andersen JG, Clasen J, van Oorschot W and Halversen (eds) Europe's New State of Welfare: Unemployment, Employment Policies and Citizenship. Bristol: Policy Press, 2002. 5 Currie C, Nic Gabhainn S, Godeau E, Roberts C, Smith R, Currie D, Pickett W, Richter M, Morgan A and Barnekow V (eds.) Inequalities in young people's health: HBSC international report from the 2005/06 Survey. Health Policy for Children and Adolescents, No. 5. Copenhagen: WHO Regional Office for Europe, 2008. 6 Currie C, Levin K and Todd J. Health Behaviour in School-aged Children: World Health Organization Collaborative Cross-National Study (HBSC): findings from the 2006 HBSC survey in Scotland. Edinburgh: Child and Adolescent Health Research Unit, The University of Edinburgh, 2008. 7 Lemmi A, Betti G, Mulas A, Natilli M, Neri L, Salvati N and Verma V. Regional Indicators to reflect social exclusion and poverty VT/2003/43. Final Report. Brussels: European Commission, 2003. 8 Paritatische Forschungsstelle. Armutatlas: Nordrhein-Westfalen. Available at: http://www.forschung.paritaet.org/index.php?eID=tx_nawsecuredl&u= 0&file=fileadmin/SUBDOMAINS/forschung/armutsatlas/download/Ar mutsatlas_NRW.pdf&t=1305718746&hash=de92612b3b0df13c25f3c 243af06838b.

9 The Poverty Site. Low income by household type. Available at: http://www.poverty.org.uk/e01c/index.shtml. 10 Federal Statistical Office of Germany. Migration between Germany and foreign countries 1991 to 2007. Bonn: Federal Statistical Office of Germany Bonn, 2010. 11 Last JM. Dependency Ratio. In Last JM (eds) A Dictionary of Epidemiology. 4th edition. Oxford: Oxford University Press, 2001. 12 Hoehn C. Policy Responses to Population Ageing and Population Decline in Germany. New York: Population Division, Department of Economic and Social Affairs, United Nations Secretariat, 2000. 13 Palmer G. Briefing on the growth in one person households: Trends, causes and issues arising. York: Joseph Rowntree Foundation, 2006. 14 Gillie O. Scotland’s health deficit: An explanation and a plan. Health Research Forum Occasional Reports: No 3. London: Health Research Forum, 2008. 15 Aebi MF, Aromaa K, Aubusson de Cavarlay B, Barclay G, Gruszczyñska B, von Hofer H, Hysi V, Jehle J-M, Killias M, Smit P and Tavares C. European Sourcebook of Crime and Criminal Justice Statistics — 2006, 3rd edition. Den Haag, Boom Juridische uitgevers. Reeks Onderzoek en beleid, nr. 241; 2006. 16 Scottish Government. Recorded Crime In Scotland, 2006/07. Statistical Bulletin Criminal Justice Series CrJ/2007/8. Edinburgh: Scottish Government, 2007. 17 ISD Scotland. Sexual Health: Abortions. Scotland: ISD Scotland,2010. Available at http://www.isdscotland.org/isd/1918.html#Tables. 18 Angloinfo. Termination of Pregnancy and Abortion in Germany. Angloinfo, 2010. Available at http://www.angloinfo.com/countries/germany/abortion.asp.

Appendix 1: Definitions and sources of data presented in the case study

Table/Figure Description Source Notes No. Figure 1a. Map showing location of Ruhr area Map produced using boundaries provided within North Rhine-Westphalia and with ESRI ArcGIS 9 software. Germany Figure 1b. More detailed map of the Ruhr area Map produced using boundaries provided with ESRI ArcGIS 9 software. Figure 2 Map of West Central Scotland local Map produced using EDINA UKBORDERS authorities with the support of ESRC/JISC © Crown copyright. Figure 3 Bar chart showing ranked population General Register Office for Scotland (WCS) A German ‘kreis’ is a district or of 11 West Central Scotland local and Federal Statistics Office (Ruhr). county; kreise is the plural. authorities and 15 Ruhr area kreise, 2008. Figure 4 Line chart showing male life General Register Office for Scotland (WCS) expectancy in Ruhr area vs. Germany and NRW LIGA (Ruhr area), plus ScotPHO and WCS vs. Scotland between 1991- Health for All Database. 93 and 2003-05. Figure 5 Line chart showing female life General Register Office for Scotland (WCS) expectancy in Ruhr area vs. Germany and NRW LIGA (Ruhr area), plus ScotPHO and WCS vs. Scotland between 1991- Health for All Database. 93 and 2003-05. Figure 6 Bar chart showing ranked male life NRW LIGA (Ruhr area). expectancy at birth, 15 Ruhr area kreise, 2006-08.

Figure 7 Bar chart showing ranked male life General Register Office for Scotland (WCS) expectancy at birth, for 11 West and NRW LIGA (Ruhr area). Central Scotland local authorities and 15 Ruhr area kreise, 2006-08. Figure 8 Bar chart showing ranked female life General Register Office for Scotland (WCS) expectancy at birth, for 11 West and NRW LIGA (Ruhr area). Central Scotland local authorities and 15 Ruhr area kreise, 2006-08. Figure 9 Percentage of adults aged 45-74 who Heinz Nixdorf Recall Study (Mulheim, rate their general health as good or Bochum & Essen) and Scottish Health very good, by gender, Mulheim, Survey 2003 (Greater Glasgow). Bochum & Essen (2000-03) and Greater Glasgow (2003). Figure 10 Bar chart showing mean life German Socio-Economic Panel (SOEP) for satisfaction scores for adults aged the Ruhr area (2008) and Scottish Health 15+/16+, by gender, Greater Glasgow Survey 2008 for Greater Glasgow & Clyde. & Clyde Health Board area (2008) and Ruhr area (2008). Figure 11 Percentage of adults aged 45-74 Heinz Nixdorf Recall Study (Mulheim, reporting that they have been Bochum & Essen) and Scottish Health diagnosed by a doctor (or equivalent) Survey 2003 (Greater Glasgow). with high blood pressure, by gender, Mulheim, Bochum & Essen (2000-03) and Greater Glasgow (2003).

Figure 12 Percentage of adults aged 45-74 Heinz Nixdorf Recall Study (Mulheim, reporting that they have been Bochum & Essen) and Scottish Health diagnosed by a doctor (or equivalent) Survey 2003 (Greater Glasgow). with diabetes, by gender, Mulheim, Bochum & Essen (2000-03) and Greater Glasgow (2003).

Figure 13 Bar chart showing ranked ILO Annual Population Survey. unemployment rates, for 11 WCS local authorities, 2007. Figure 14 Bar chart showing ranked ILO Eurostat. unemployment rates, for 15 Ruhr area kreise, 2007. Figure 15 Bar chart showing ranked ILO Annual Population Survey (WCS) and unemployment rates, for 11 WCS local Eurostat (Ruhe area). authorities and 15 Ruhr area kreise, 2007. Figure 16 Line chart showing standardised Overman and Puga (S.W Scotland, 1986-96) trends in unemployment rates (as Esch and Langer (Ruhr area, 1985-00, percentage of economically active selected years. adults), South Western Scotland and Eurostat (S.W Scotland, 1986-08) the Ruhr area. Federal Statistics Office (Ruhr area, 2005 & 08).

Figure 17 Crude male employment rate=All West Central Scotland males in employment/all males aged Population data 15-64, except for 1986-1991 WCS Mid- year population estimates, GROS. when rates directly calculated from Employment data Labour Force Survey. 1995-2003: total in employment (Labour Force Survey); 2005 (Annual Population Survey) Ruhr area Population data 1980-2005: North-Rhine Westphalia Institute for Work and Health (LIGA) Employment data 1979-2005: employees in employment (Regionalverband Ruhr) Figure 18 Crude female employment rate=All See above females in employment/all males aged 15-64.

Figure 19 Bar chart showing percentage of German Socio-Economic Panel (SOEP) for households with no access to a car, the Ruhr area (2001-03) and GRO (S) Ruhr area (2001-03) and WCS (2001). Census of Population (2001). Figure 20 Cars per Capita: Total number of cars Federal Statistical Office of Germany; Total number of cars divided by the divided by the population expressed German Institute for Economic Research, population expressed as a as a percentage. World Bank (WDI) for German data. percentage. Figure 21 Bar chart showing percentage of Urban Audit 1999-02 for the Ruhrgebeit LUZ, households not owning their own via Eurostat, and GRO (S) Census of home, Ruhr area (1999-02) and WCS Population (2001). (2001).

100

Figure 22 Line chart showing percentage of Urban Audit 1991 and 2001 for the households not owning their own Ruhrgebeit LUZ, via Eurostat, and GRO (S) home, Ruhr area (1991-01) and WCS Census of Population 1991 and 2001. (1991-01). Figure 23 Bar chart showing percentage of European Social Survey Rounds 1-4 adults aged 15+/16+ reporting that (2002/03 to 2008/09) for North-Rhine- they found it difficult to manage on Westphalia. Scottish Social Attitudes Survey their household income nowadays , 2007 for West Central Scotland. West Central Scotland 2007) and North-Rhine-Westphalia (2002-08 average). Figure 24 Bar chart showing percentage of HBSC data calculated and supplied by For more detail on the family children aged 11-15 living in high and University of Bielefeld (North-Rhine- affluence scale, see: low affluence households, West Westphalia) and University of Edinburgh Boyce et al. The Family Affluence Central Scotland and North-Rhine- (West Central Scotland). Scale as a Measure of National Westphalia region: 2006. Wealth: Validation of an Adolescent Self-Report Measure. Social Indicators Research (2006) 78: 473–487.

Figure 25 Percentage of population living in Lemmi et al. Regional Indicators to reflect South Western Scotland used as relative poverty (< 60% of median social exclusion and poverty VT/2003/43. proxy for West Central Scotland. national income), South Western Final Report. Original source is the European NUTS II Relative poverty rates Scotland and North-Rhine-Westphalia. Community Household Panel, pooled data calculated by national figure (Table from 1994-01 inclusive. A.2) by figures in Table A.3 and Table A.5 where appropriate: the relevant variable is HCR_c.

101

Figure 26 Gini coefficient for household Luxemburg Income Study 2004 (North-Rhine- incomes, West Central Scotland and Westphalia). North-Rhine-Westphalia. Scottish Household Survey 2003-04 (WCS).

Figure 27 Absolute population change per 1000 GRO (S) Mid-year population estimates and people compared to previous year, Federal Statistics Office. West Central Scotland and North- Rhine-Westphalia: 1996-08. Figure 28 Ranked change in population 1995- GRO (S) Mid-year population estimates. 08, as a percentage of 1995 population, for 11 West Central Scotland local authorities. Figure 29 Ranked change in population 1995- Federal Statistics Office. 08, as a percentage of 1995 population, for 15 Ruhr area kreise. Figure 30 Ranked net migration 1995-07, as a GRO (S) Mid-year population estimates. percentage of 1995 population, for 11 West Central Scotland local authorities. Figure 31 Ranked net migration 1995-2007, as a Federal Statistics Office. percentage of 1995 population, for 15 Ruhr area kreise. Figure 32 Ranked net migration 1995-2007, as a General Register Office for Scotland (WCS) percentage of 1995 population, for 15 and Federal Statistics Office (Ruhr). Ruhr area kreise and 11 WCS local authorities.

102

Figure 33 Bar chart showing ranked population General Register Office for Scotland (WCS) density (persons per square km) for and Federal Statistics Office (Ruhr). 11 West Central Scotland local authorities and 15 Ruhr area kreise: 2008. Figure 34 Stacked bar chart showing population General Register Office for Scotland (WCS). distribution by three groups (<15, 15- 64 and 65+) for 11 West Central Scotland local authorities: 2007. Figure 35 Stacked bar chart showing population Federal Statistics Office (Ruhr). distribution by three groups (<15, 15- 64 and 65+) for 15 Ruhr area kreise: 2007. Figure 36 Line chart showing dependency ratio General Register Office for Scotland (WCS) for WCS and Ruhr area, 2003-2007. and Federal Statistics Office (Ruhr). Dependency ratio = (65 + and Under 15)/(Population aged 15-64). Figure 37 Bar chart showing ranked dependency See above. ratio for 11 West Central Scotland local authorities and 15 Ruhr area kreise: 2007. Figure 38 Line chart showing fertility rate for General Register Office for Scotland (WCS) WCS and Ruhr area, 2003-2008. Rate and Federal Statistics Office (Ruhr). shown is all births/female population aged 15-44 in each region.

103

Figure 39 Bar chart showing ranked dependency See above. ratio for 11 West Central Scotland local authorities and 15 Ruhr area kreise: 2008.

Figure 40 Bar chart showing percentage of Urban Audit 2003-06 for the Ruhrgebeit LUZ, Age bands 16-64 for the Ruhr area, working-age adults by highest banded via Eurostat (Ruhr area). 16-64 for West Central Scotland. ISCED education attainment level Annual Population Survey January-December achieved: ISCED 0-2, 3-4 and 5-6. 2005 (West Central Scotland). Scottish data mapped to ISCED as follows: No qualifications & NVQ 1: ISCED Level 0-2 NVQ Level 2,3 & Trade apprenticeships: ISCED 3-4. NVQ 4+ and other: ISCED 5-6.

104

Figure 41 Bar chart showing percentage of Urban Audit 1999-02 for the Ruhrgebeit LUZ, Scottish definition=all lone parents households with dependent children via Eurostat (Ruhr area). with dependent children/all families headed by a lone parent for WCS and GRO (S) Census of Population 2001 (WCS). with dependent children. Ruhr area 1999-02. In WCS, a dependent child is a person aged 0 – 15 in a household (whether or not in a family) or aged 16 – 18, in full-time education and living in a family with his or her parent(s). German definition=all lone parents households with at least one child under 18 years old/all households with at least one adult and at least one children under 18.

Figure 42 Line chart showing percentage of Urban Audit 1989-91 and 1999-02 for the See above. households with dependent children Ruhrgebeit LUZ, via Eurostat (Ruhr area). headed by a lone parent for WCS and GRO (S) Census of Population 1991 and Ruhr area 1989-91 to 1999-02. 2001 (WCS).

Figure 43 Bar chart showing percentage of Urban Audit 1999-02 for the Ruhrgebeit LUZ, All single person households/all single person households for WCS via Eurostat (Ruhr area). households. and Ruhr area 1999-02. GRO (S) Census of Population 2001 (WCS). Figure 44 Line chart showing percentage of Urban Audit 1989-91 and 1999-02 for the See above. single person households for WCS Ruhrgebeit LUZ, via Eurostat (Ruhr area). and Ruhr area 1989-91 to 1999-02. GRO (S) Census of Population 1991 and 2001 (WCS).

105

Figure 45 Bar chart showing ranked percentage Scottish Household Survey 2007-08. of single person households, for 11 WCS local authorities, 2007-08. Figure 46 Bar chart showing ranked percentage IT.NRW. of single person households, for 15 Ruhr area kreise, 2007. Figure 47 Bar chart showing ranked percentage Scottish Household Survey 2007-08, of single person households, for 11 IT.NRW. West Central Scotland local authorities and 15 Ruhr area kreise: 2007-08. Figure 48 Bar chart showing percentage of Eurostat: original sourced from GRO (S) Scottish data on Eurostat combines adults aged 25-64 who were married Census of Population 2001 (WCS) and legally separated and married data (inc. legally separated) for WCS and German Microcensus (Ruhr area). into single ‘married’ category. Ruhr area 2001-02. Figure 49 Percentage of adults aged 45-74 Heinz Nixdorf Recall Study (Mulheim, reporting that they are (a) married, Bochum & Essen) and Scottish Health including separated and (b) divorced Survey 2003 (Greater Glasgow). or single, Mulheim, Bochum & Essen (2000-03) and Greater Glasgow (2003). Figure 50 Bar chart showing percentage of European Social Survey Rounds 1-4 (2002- adults aged 15+/16+ who never attend 03 to 2008-09) for North-Rhine-Westphalia. church/religious ceremonies except for Scottish Social Attitudes Survey 2007 for special occasions, by gender, West West Central Scotland. Central Scotland (2007) and North- Rhine-Westphalia (2002-08 average).

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Figure 51 Line chart showing voter turnout at UK Electoral Commission (West Central Parliamentary Election years were: German and UK parliamentary Scotland). 1992, 1997, 2001 and 2005 for UK elections, West Central Scotland and Federal Statistics Office (North-Rhine 1990, 1998, 2002 and 2005 for North-Rhine-Westphalia. 1990-92, Westphalia). Germany. 1997-98, 2001-02 and 2005-07.

Figure 52 Bar chart showing ranked voter See above. turnout at German and UK parliamentary elections, for 11 West Central Scotland UK parliamentary constituencies and 15 Ruhr area kreise: 2005. Figure 53 Bar chart showing monthly mean daily Solar Radiation Data: http://www.soda- Irradiation is the power received per irradiation, Dortmund and Glasgow is.com/eng/services/services_radiation_free_ area, measured in watt-hours per city, by month, January-December eng.php square metre (Wh/m2). Note that 2005. solar radiation is also lower during the crucial months of May-September. Figure 54 Bar chart showing number of crimes Scottish Government recorded by the police expressed as a rate per 1000 total population by 11 West Central Scotland local authorities. Figure 55 Bar chart showing number of crimes State criminal office NRW, Federal Criminal registered by the police expressed as Police Office. a rate per 1000 total population by 15 Ruhr area kreise.

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Figure 56 Bar chart showing percentage of European Social Survey Rounds 1-4 adults aged 15+/16+ who feel (2002/03 to 2008/09) for North-Rhine- very/fairly safe walking alone in their Westphalia. Scottish Household Survey neighbourhood after dark, by gender, 2007-08 (West Central Scotland). Scottish Household Survey (2007-08) and North-Rhine Westphalia (2002-08 average). Figure 57 Bar chart showing percentage of Urban Audit 2009 Perception Study. adults aged 15+ who always felt safe in their neighbourhood within Glasgow City and Dortmund. Figure 58 Bar chart showing percentage of Heinz Nixdorf Recall Study (Mulheim, adults aged 45-74 reporting that they Bochum & Essen) and Greater Glasgow felt safe/very safe in their local Health and Wellbeing Survey 2008 (Greater neighbourhood after dark, Mulheim, Glasgow). Bochum & Essen (2000-03) and Greater Glasgow (2008). Figure 59 Bar chart showing percentage of Scottish Household Survey (2003-04). Age bands 15+ for North-Rhine- adults aged 15+/16+ who were daily North-Rhine Westphalia (2005). Westphalia, 16+ for West Central smokers, by gender, North-Rhine Scotland. Westphalia (2005) and West Central Scotland (2003-04). Figure 60 Bar chart showing ranked percentage Scottish Household Survey (2003-04). Age band 16+. of adults aged 16+ who were daily smokers, by 11 West Central Scotland local authorities: 2003-04.

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Figure 61 Bar chart showing ranked percentage LIGA.NRW (2005) Age band 18+. of adults aged 18+ who were daily smokers, by 15 Ruhr area kreise: 2005. Figure 62 Bar chart showing ranked percentage See above. See above of adults aged 16+/18+ who were daily smokers, by 11 West Central Scotland local authorities and 15 Ruhr area kreise: 2005. Figure 63 Bar chart showing percentage of Heinz Nixdorf Recall Study (Mulheim, adults aged 45-74 reporting that they Bochum & Essen) and Scottish Health smoked regularly/occasionally, by Survey 2003 (Greater Glasgow). gender, Mulheim, Bochum & Essen (2000-03) and Greater Glasgow (2003). Figure 64 Bar chart showing percentage of Heinz Nixdorf Recall Study (Mulheim, adults aged 45-74 reporting that they Bochum & Essen) and Scottish Health used to smoke, by gender, Mulheim, Survey 2003 (Greater Glasgow). Bochum & Essen (2000-03) and Greater Glasgow (2003). Figure 65 Bar chart showing percentage of Heinz Nixdorf Recall Study (Mulheim, adults aged 45-74 reporting that they Bochum & Essen) and Scottish Health had never smoked, by gender, Survey 2003 (Greater Glasgow). Mulheim, Bochum & Essen (2000-03) and Greater Glasgow (2003).

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Figure 66 Bar chart showing percentage of Heinz Nixdorf Recall Study (Mulheim, adults aged 45-74 exceeding 21/14 Bochum & Essen) and Scottish Health units of alcohol a week, by gender, Survey 2003 (Greater Glasgow). Mulheim, Bochum & Essen (2000-03) and Greater Glasgow (2003). Figure 67 Bar chart showing percentage of Heinz Nixdorf Recall Study (Mulheim, Objectively measured height and adults aged 45-74 classified as obese, Bochum & Essen) and Scottish Health weight to calculate BMI (25-30 by gender, Mulheim, Bochum & Essen Survey 2003 (Greater Glasgow). overweight, >30 obese); expressed as (2000-03) and Greater Glasgow percentage of all respondents. (2003). Figure 68 Bar chart showing ranked percentage LIGA.NRW. of adults (aged 18) who were overweight or obese, by 15 Ruhr area kreise: 2005. Figure 69 Bar chart showing ranked percentage LIGA.NRW. of adults (aged 18) who were obese/overweight (showing breakdown), by 15 Ruhr area kreise: 2005. Figure 70 Line chart showing births to mothers General Register Office for Scotland (WCS) under the age of 18 as a percentage and IT.NRW (the Ruhr). of all live births, West Central Scotland and the Ruhr area: 2003-08.

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Figure 71 Bar chart showing ranked percentage General Register Office for Scotland (WCS) of births to mothers under the age of and IT.NRW (the Ruhr). 18 as a percentage of all live births, by 11 West Central Scotland local authorities and 15 Ruhr area kreise: 2005. Figure 72 Line chart showing percentage of low General Register Office for Scotland (WCS) Live births <2.5kg expressed as a rate birth rate babies, West Central and IT.NRW (the Ruhr). per live births (inc. all gestations and Scotland and the Ruhr: 1991-08. single/multiple births). Live births <2.5kg expressed as a rate per live births. Excludes home births or births at non-NHS hospitals. Figure 73 Bar chart showing ranked percentage General Register Office for Scotland (WCS) of low birth rate babies, by 11 West and IT.NRW (the Ruhr). Central Scotland local authorities and 15 Ruhr area kreise: 2005. Figure 74 Line chart showing trends in ISD Scotland (West Central Scotland). Number of terminations expressed as termination of pregnancy rates, West Federal Statistical Office of Germany, a rate per 1000 women aged 15-44. Central Scotland and North-Rhine prepared by LIGA.NRW (North-Rhine Therapeutic abortions notified in Westphalia: 2002-07. Westphalia). accordance with the Abortion Act 1967 expressed as a rate per 1000 women aged 15-44.

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Merseyside

Nord-Pas-de-Calais

Northern Ireland North Moravia

Ruhr Saxony

Saxony-Anhalt

Swansea & South Silesia Wales Coalfields

Wallonia West Central Scotland

Glasgow Centre for Population Health www.gcph.co.uk