Glasgow Theses Service http://theses.gla.ac.uk/ theses@gla.ac.uk Daniels, Gordon A. (2014) Underlying influences on health and mortality trends in post-industrial regions of Europe. PhD thesis. http://theses.gla.ac.uk/5697/ Copyright and moral rights for this thesis are retained by the author A copy can be downloaded for personal non-commercial research or study, without prior permission or charge This thesis cannot be reproduced or quoted extensively from without first obtaining permission in writing from the Author The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the Author When referring to this work, full bibliographic details including the author, title, awarding institution and date of the thesis must be given Underlying influences on health and mortality trends in post-industrial regions of Europe Gordon A Daniels: BA, MSc Submitted in fulfilment of the requirements for the Degree of PhD University of Glasgow College of Medical, Veterinary and Life Sciences, Institute of Health and Wellbeing, Public Health research group 2014 2 Abstract This Thesis is part of a wider programme of work being pursued by the Glasgow Centre for Population Health (GCPH) which is examining health outcomes in West Central Scotland and other post-industrial regions throughout Europe. Background Scotland‘s health has been improving since the industrial revolution but its position relative to improving trends within Europe has been deteriorating. This is recent, dating from the period since the Second World War and becoming more problematical over the past three decades. While deprivation is a fundamental determinant of health, in the case of Scotland (and particularly West Central Scotland (WCS)) it does not explain the entire extent of the higher levels of mortality. There is, of course, a well established link between deindustrialisation, deprivation and poor health. However, the unexplained additional mortality in Scotland and WCS (the Scottish Effect) compared to other similar post-industrial regions and the time scale of Scotland‘s worsening relative health status, require further investigation. Other research has examined this question using a range of well established public health principles and methods. This thesis adds to this understanding by providing a comparative analysis of the political and socioeconomic contexts for the observed mortality trends. Setting Post-industrial change is discussed at three levels. These are (i) International regions – Eastern Europe and Western Europe (ii) Countries – Scotland within the UK is compared with two Eastern European (Poland and the Czech Republic) and two Western European (France and Germany) countries. (iii) Regions within countries that have been subject to deindustrialisation. Five post-industrial regions are investigated (West Central Scotland, The Ruhr, Germany, Nord Pas- de-Calais, France, Katowice, Poland and Northern Moravia, Czech Republic). These regions were selected because they are analogous in their experience of deindustrialisation but diverse in their political and socioeconomic histories. 3 Methods The main aim of the thesis is to determine what aspects of the political and socioeconomic context in WCS have diverged from comparable post-industrial regions of Europe and whether these might form the basis of potential explanations for the region‘s poor health record. Two methods were employed. First, a detailed narrative literature review was undertaken to examine political and socioeconomic change in the post-war period at the national level with a particular focus on policy responses to deindustrialisation. Second, case studies were conducted on the five regions listed above. These examined political and socioeconomic changes in each of the five regions in some detail using published data and a variety of literatures as source materials. In this way a rich but diverse picture of economic restructuring as a response to deindustrialisation emerged. Insights from the literature review and case studies were then brought together to formulate some conclusions about why health in WCS has suffered more adverse effects than in the other four regions. Findings This thesis has shown that there was a broad correspondence between life expectancy and the socioeconomic/political success of states in Central East Europe and Western Europe during the 20 th Century. When states prosper and their governments enjoy the confidence of the population, health improves. In all the countries covered in this analysis, deindustrialisation damaged health and slowed improvements in life expectancy (in some cases putting it into reverse). The institutional path dependencies and country-specific factors outlined in this thesis help to explain the divergence in policy responses and subsequent economic development that can be observed in each of the five regions and their parent countries. The five countries and regions have each taken a different approach to deindustrialisation, have varied in the levels of social protection provided and each manifests a very different context. In response to economic restructuring (and associated social costs), policy in WCS (and the UK) has focused primarily on narrow economic growth policies, emphasising employment and physical regeneration, but not social outcomes such as community cohesion and sustainability. 4 Conclusions Detailed comparisons suggest that WCS negotiated deindustrialisation less successfully than the other regions. However, it is important to note that the other regions are not ‗better‘ than WCS on all factors: there is a complex picture to be understood in each region. Rather, what seems to emerge is that there are a series of national and regional factors at work in WCS which have made the aftershock of deindustrialisation particularly severe and may have contributed to poorer health outcomes. 5 Table of Contents Underlying influences on health trends in post-industrial regions of Europe. 17 1. Introduction 17 1.1 The Aftershock of Deindustrialisation 20 1.1.1 How this work differs and what it adds to GCPH? 27 1.2 The determinants of health in populations 28 1.3 Aim and objectives 34 1.4 The structure of the thesis 36 2. Methods 37 2.1 Overview of methods 37 2.2 Rationale for methods 39 2.3 Literature review 40 2.4 Case studies 48 2.5 Final synthesis 54 3. Synthesis of the narrative literature review 56 3.1 CEE 56 3.2 Western Europe 65 3.3 Conclusion 75 3.4 A simple framework for further analysis 77 3.5 Comparable data for the five post-industrial regions 78 3.6 Proxy geographies 78 3.6.1 Silesia/Katowice 79 3.7 Case study structure 80 4. The Ruhrgebiet (Ruhr region), 93 4.1 Deindustrialisation 94 4.1.1 Federal role 96 4.1.2 Regional role 97 4.1.3 Unemployment 104 4.1.4 Employment rates 105 4.1.5 Worklessness 107 4.2 Context 108 4.2.1 Skills and Education 108 4.2.2 Social exclusion 110 4.2.3 Social capital 114 4.2.4 Relative poverty 115 4.2.5 Income inequality 117 4.3 Social protection 118 5. Nord-Pas-de-Calais (NPdC) 120 5.1 Deindustrialisation 122 5.1.1 National response 123 5.1.2 Regional response 124 5.1.3 Unemployment 132 5.1.4 Employment rates 133 5.1.5 Worklessness 134 5.2 Context 134 5.2.1 Skills and Education 135 5.2.2 Social context 137 5.2.3 Social capital 142 5.2.4 Income inequality 143 5.3 Social protection 144 6. Katowice (Upper Silesia) 146 6.1 Deindustrialisation 148 6 6.1.1 National response 151 6.1.2 Regional response 152 6.1.3 Unemployment 157 6.1.4 Employment rates 158 6.1.5 Worklessness 160 6.2 Context 161 6.2.1 Skills and education 163 6.2.2 Social context 164 6.2.3 Social capital 170 6.2.4 Income inequality 172 6.3 Social protection 173 7. Northern Moravia (Moravia-Silesia) 177 7.1 Deindustrialisation 179 7.1.1 Restructuring 181 7.1.2 Political and policy responses 185 7.1.3 Unemployment 189 7.1.4 Employment rates 191 7.1.5 Worklessness 192 7.2 Context 193 7.2.1 Skills and education 195 7.2.2 Social context 196 7.2.3 Social capital 200 7.2.4 Relative poverty 201 7.2.5 Income inequality 202 7.3 Social protection 203 8. West Central Scotland (WCS) 206 8.1 Deindustrialisation 206 8.1.1 National responses 207 8.1.2 Regional dimension 211 8.1.3 Unemployment 216 8.1.4 Employment rates 216 8.1.5 Worklessness 218 8.2 Context 218 8.2.1 Skills and Education 222 8.2.2 Social context 224 8.2.3 Social capital 230 8.2.4 Relative poverty 230 8.2.5 Income inequality 231 8.3 Social protection 231 9. Discussion 234 9.1 Main findings 234 9.1.1 Summary tables 250 9.2 Have the research aims been achieved? 259 9.3 Political decisions have consequences for health – the example of inequalities. 262 9.4 Theoretical consideration 265 9.5 Strengths and limitations 270 9.6 Conclusions 273 9.7 Recommendations 275 9.8 Concluding remarks/reflections 278 Appendix A……………………………………………………………………………………………………….…280 Appendix B………………………………………………………………………………………………………….376 Bibliography……………………………………………………………………………………………………… 386 7 List of Tables Table 2.1: Strengths and Limitations of Systematic and Narrative-Literature review Table 3.1: Post-industrial European regions: country, size, industrial specialisation and employment loss Table 9.1: Characteristics of post-war economic models (1945-1980) Table 9.2: Industrial development of selected regions Table 9.3: Timing and speed of deindustrialisation and national responses Table 9.4: Level of social protection from the state at time of deindustrialisation and privatisation Table 9.5: Regional responses to deindustrialisation Table 9.6: Current economic models i.e. three varieties of capitalism Table 9.7: Current levels and type of social protection Table 9.8: Summary wider determinants of health Table A.1: Social expenditure, 1960-1975, as percentage of GDP in the UK, West Germany and France 8 List of Figures Figure 1.1: West Central Scotland Region Figure 1.2: Male life expectancy for WSC and ten post-industrial regions Figure 1.3: Mortality of working aged men in WCS with European comparators Figure 1.4: Impact of alcohol in WCS among 15 to 44 years old males Figure 1.5: Evans & Stoddart (1990) Model of the Determinants of Health Figure 2.1: Percentage of industrial employment lost in regions selected Figure 3.1: Industrial employment as percentage of civilian labour force for five host countries: 1956-2010 Figure 3.2: Unemployment as a percentage of civilian labour force for five host countries: 1956-2010 Figure 3.3: Unemployed as a percentage of economically active population in host countries for years: 2008 and 2011 Figure 3.4: Percentage of men aged 25-49 not in employment in selected regions: 2001 Figure 3.5: At risk of poverty rates for working age adults not in employment in host countries: 1995-210 Figure 3.6: Income inequality over time in Scotland and host countries: 1984- 2004 Figure 3.7: Percentage of adults aged 25-64 with tertiary level qualifications in selected regions: 2008 Figure 3.8: Percentage of adults aged 25-64 with no or low-level qualifications in selected regions: 2008 Figure 3.9: Percentage of households with children headed by a lone parent in the selected regions: 1999-2002 Figure 3.10: Change over-time in percentage of households with dependent children in selected regions: 1990-2001 Figure 3.11: Percentage of households that are single person households in selected regions: 1999-2002 Figure 3.12: Change over-time in percentage of single person households in selected regions: 1990-2001 Figure 3.13: Percentage of adults aged between the ages of 25 and 64 who were married in selected regions: 2001 9 Figure 3.14: Percentage of adults in selected regions who never attend religious ceremonies except on special occasions: 2002-2008 Figure 3.15: Voter turnout percentage for national parliamentary elections in selected regions: 2005-2007 Figure 3.16: Change over-time for percentage voter turnout in national parliamentary elections in selected regions: 1990-2007 Figure 3.17: Percentage of adult male daily smokers in selected regions: 2002- 2010 Figure 3.18: Percentage of adult female daily smokers in selected regions: 2002- 2010 Figure 3.19: Percentage of adult population not drinking during last year in host countries between 2003 and 2007 Figure 3.20: Percentage of adult population drinking daily in selected host countries between 2003 and 2007 Figure 3.21: Percentage of births to mothers under the age of 20 in selected host countries: 2005-6 Figure 3.22: Occupations of employed population for selected host countries: 2007 Figure 4.1 The Ruhr Region Figure 4.2: Unemployment in SW Scotland and the Ruhr Figure 4.3: Male employment in WCS and the Ruhr Figure 4.4: Female employment in WCS and the Ruhr Figure 4.5: Educational attainment in adults in WCS and The Ruhr Figure 4.6: Excess alcohol consumption in Greater Glasgow and selected cities in The Ruhr Figure 4.7: Relative poverty in South Western Scotland and North-Rhine- Westphalia Figure 4.8: Income inequality in WCS and North-Rhine-Westphalia. Figure 5.1: Nord-Pas-de-Calais Region Figure 5.2: Unemployment in WCS and NPdC [...]... Organisation WCS: West Central Scotland Chapter 1 17 Underlying influences on health trends in postindustrial regions of Europe 1 Introduction This thesis seeks to better understand the health status of the people of West Central Scotland (WCS) in the period following deindustrialisation It will do so by reviewing the political and socioeconomic history of WCS and comparable regions of both Western and Eastern... across all social strata and throughout Scotland However, it is most evident in Glasgow and WCS (Hanlon et al 2005) A second paper The Aftershock of Deindustrialisation: Trends in mortality in Scotland and other parts of post-industrial Europe (Walsh et al 2008, 20094) examined the same issue (Scotland‘s high levels of mortality and the role of deprivation linked to deindustrialisation) from a different... Foundation 1998), is responsible for much of Scotland‘s and WCS‘s poor health What is being questioned is the perception that all of the health outcomes in WCS in recent decades can be explained in terms of the region having suffered more and greater industrial shocks than most other parts of Europe (Devine 2005; Payne 1996) and that this provides a sufficient explanation for observed health and social trends. .. health in Europe s post-industrial regions, in terms of a broad conception of the determinants of health, it will do so from the starting point of post-war economic development onto the period of ‗deindustrialisation‘ and the policy responses that emerged thereafter As the analysis unfolds it will become evident that the thesis uses an awareness of the broader determinants of health (as expressed in the... complex and interacting Consider some reasonably direct pathways of causation: socioeconomic status can influence health directly through the influence of material deprivation in terms of an individuals or populations health status, or via access to services like health care and education The reverse is also true to a small extent: health can influence socioeconomic status due to the effect of health on. .. that explain links between political and socioeconomic change and life expectancy 3 Describe the pattern (timing, rate and nature) of deindustrialisation/privatisation and identify variations to the general pattern 4 Define the typologies of policy response to deindustrialisation/privatisation 5 Define the level of social protection, including welfare provision and broader social protection, available... (socioeconomic factors, environmental factors, health behaviours etc.) in WCS and a subset of the post-industrial regions included in the Aftershock Report (Taulbut et al 2011) While this work added greatly to the texture and detail of the regional comparisons, its most striking finding was that the most marked differences that could be observed were between continental Europe and all the UK regions considered... Scotland and South Poland Figure 6.9: Degree of alcohol consumption in Scotland and South Poland Figure 6.10: Number of adults with no religious affiliation in WCS and Silesia Figure 6.11: Relative poverty in SW Scotland and Silesia Figure 6.12: Income inequality in WCS and Silesia Figure 7.1: Northern Moravia region Figure 7.2: Unemployment in SW Scotland and N.Moravia Figure 7.3: Male employment WCS and. .. collection, public health information and awareness of the determinants of health A large programme of that research relates to increasing understanding regards why WCS‘s health differs from other post-industrial regions GCPH's approach has majored on data-driven epidemiological analyses However, the findings of those analyses show a clear need for the evidence to be viewed in the context of historical,... determinants play a central role So, while the Biomedical Model has its place in medical care, an understanding of population health requires analyses of what are increasingly being called ‗the social determinants of health (e.g Marmot & Wilkinson 1999) The WHO asserts that political and socioeconomic contexts generate structural determinants of health, defined as including: governance, macroeconomic . have contributed to poorer health outcomes. 5 Table of Contents Underlying influences on health trends in post-industrial regions of Europe. 17 1. Introduction. Daniels, Gordon A. (2014) Underlying influences on health and mortality trends in post-industrial regions of Europe. PhD thesis. http://theses.gla.ac.uk/5697/ Copyright and moral. Population Health (GCPH) which is examining health outcomes in West Central Scotland and other post-industrial regions throughout Europe. Background Scotland‘s health has been improving since