Key issues and evidence

Introduction

This section provides an overview of key transport issues pertinent to the HIIA for those who are most like to experience health inequalities. The HIIA assess the likely effects of the strategic policies in the NTS Delivery Plan on protected characteristic groups and people experiencing socio-economic disadvantage or are vulnerable to falling into poverty. This includes:

• People on benefits
• Single parents
• At risk families e.g. young mothers, people experiencing domestic abuse, children at risk of statutory measures
• Looked after children and young people
• Those leaving care settings (including children and young people and those with illness)
• Homeless people
• Carers (including young carers and carers with protected characteristics)
• Those involved in the criminal justice system
• People with low literacy/numeracy
• People misusing substances, and
• Others e.g. veterans and students

Health inequalities can also manifest across different geographical communities including across rural or semi-rural communities, urban communities as well as coastal and island communities and as such the HIIA will examine impacts across a range of areas. Health impacts are also experienced differently by different types of workers including full-time and part-time workers, shift workers and those experiencing ‘in-work’ or working poverty.

Around 24% of Scotland's population live with a long-term physical or mental health condition that limits their daily life. Yet those with long-term limiting illnesses, including disabled people, often experience higher levels of inequality. In areas with a higher level of deprivation, more people live with a limiting condition. In the most deprived areas in Scotland, 33% of adults live with a limiting condition, while 15% of adults lived with a limiting condition in the least deprived areas.

Only about 50% of disabled people of working age are in work compared to 80% of non-disabled people of working age. Employment rates vary greatly according to the type of impairment a person has. People with a mental health condition considered a disability have the lowest employment rate of all impairment categories (21%) and the employment rate for people with learning disabilities is 26%.

There is a tendency for people belonging to protected characteristic groups, particularly young people, older people, disabled people, and certain ethnic minority groups, to experience poorer health and require more frequent access to healthcare than others. In particular, older people make up a higher proportion of patient admissions. This can present issues for older people, particularly in rural areas where the high cost and low availability of public transport can act as a barrier to accessing healthcare.

The Scottish Index of Multiple Deprivation (SIMD) ‘health’ domain measures the risk of premature death and the impairment of quality of life through poor physical or mental health. The domain measures morbidity, disability and premature mortality but not aspects of behaviour or environment that may be predictive of future health deprivation.

According to SIMD, 1,395 Data Zones in Scotland are in the top 20% most deprived parts of the country in this domain. Of these, 23.7% (331) are located within the Glasgow City Local Authority Area. Glasgow combined with North and South Lanarkshire represent 41.6% of the 20% most deprived Data Zones with regards to health.

In the most affluent areas of Scotland, men experience 23.8 more years of good health and women experience 22.6 more years compared to the most deprived areas. The life expectancy of people with learning disabilities is substantially shorter than the Scottish average (Public Health Scotland, 2021).

There is a tendency for people belonging to protected characteristic groups, particularly young people, older people, disabled people, and certain ethnic minority groups, to experience poorer health and require more frequent access to healthcare than others. In particular, older people make up a higher proportion of patient admissions. This can present issues for older people, particularly in rural areas where the high cost and low availability of public transport can act as a barrier to accessing healthcare.

Recent data for Scotland shows ageing in the current population through the growth of the 65+ age bracket (from ~16% in 2000 to ~19% in 2020). While the population over 75 is expected to age exponentially due to the large number of people around age 50 in 2016 who will turn 75 by 2041. It is important to recognise the ageing population of Scotland because older people’s reliance on public transport introduces issues relating to access to services, such as shops, post offices and healthcare centres as well as visiting friends and relatives.

Accessibility issues are more likely to affect older people than other age groups with some older people having limited mobility, hearing or vision impairments, difficulties in understanding information or accessing digital resources and difficulties in alighting to and from transport services or standing for long periods of time. These factors may affect an older person’s ability to safely access and use public transport services. Any changes made to transport services and infrastructure may disproportionately impact this age group, especially those living in rural areas who are particularly vulnerable to social isolation.

2.1 Car ownership and dependency

Some groups are more likely to rely on public transport such as young people, older people, women and people from certain ethnic groups (Transport Scotland 2020a). The availability and costs of bus services is not uniform across Scotland, with levels of provision differing across local authorities and between urban and rural areas (Poverty and Inequality Commission, 2019). Improvements to sustainable travel and public transport options will therefore benefit those who are less likely to have access to a car

For school children, walking is the most common transport mode for travelling to school (44.8% of modal share) which contrasts with working age adults who primarily travel to work by car or van. Secondary school children are more likely to take the bus than get driven to school (See Figure 2-1).

Young people in rural areas are particularly dependent on public transport, particularly for accessing education and training. However, the high cost and low availability of public transport in rural areas is a significant challenge for young people and can act as a barrier to their educational choices and overall progress into employment. For many rural young people, having a driving licence and being able to afford a car is essential. Older people are more likely to use public transport for journeys in comparison to other age groups (Transport Scotland, 2020a) and there has been a 2% increase in the number of people aged 60+ in possession of a concessionary bus pass between 2009 and 2019.

Access to services, such as shops, post offices and healthcare centres as well as visiting friends and relatives can be difficult for older people, particularly in rural areas and island communities. Older people who do not have access to their own car or who have may have lost the right to drive due to eyesight deterioration or other medical problems, are particularly vulnerable to social isolation in rural areas, where services, such as GP surgeries, are too far away to walk, and public transport options are limited. Disabled adults are more likely to use the bus than non-disabled adults (11% of journeys vs 7%) (Transport Scotland, 2020a). In terms of requiring affordable transport options, whilst the National Concessionary Travel Scheme is available to all those who qualify, disabled people are more likely to face transportation cost issues than non-disabled people.

In cases where public transport is not a viable option, Community Transport operators are a crucial service to elderly and disabled populations as they provide a safe, demand responsive and door-to-door service. The benefits of Community Transport journeys include social interactions, which in turn can minimise mental health struggles amongst these protected characteristic groups.

According to the 2011 Census, certain ethnic minority households were most likely to have no car or van available. This includes 51% of African households, 39% of Caribbean or Black households and 36% of Chinese, Chinese Scottish or Chinese British. Other Asian and Arab households did not have access to a car or van. Certain ethnic minority groups are more likely to travel to work by walking or public transport and are also highest amongst those that never cycle for either work or leisure purposes (Transport Scotland, 2020a).

Women are more likely to make multi-stop and multi-purpose trips, combining travel to work with trips for other purposes such as taking children to school, looking after family members or shopping and are more likely to walk, be a passenger in a car or take a bus than men (Sustrans, 2018).

Those living in the 10% most deprived areas are also more likely to walk or catch the bus to travel to work or school (Transport Scotland, 2020a). Being able to access education, employment and training is critical for low income households as a means of escaping poverty, as well as for their general wellbeing (Transport Scotland, 2020b).

Affordable and accessible transport can allow children from low-income households to access education and recreational opportunities and allow parents to balance their parenting with their own educational or employment commitments. Furthermore, recent research by Transport Scotland found that travel costs are also an issue for families with young people pursuing further education. Yearly travel passes are expensive and can represent a significant proportion of most household budgets.

A key aspect of the relationship between income inequality and transport is the way in which socio-economic background can affect individuals’ ability to access public transport. A 2016 report published by Sustrans titled ‘Transport Poverty in Scotland’ found that about 1 million people across Scotland lived in ‘high risk’ zones and were vulnerable to transport poverty (Sustrans, 2016). A high risk of transport poverty was considered to be greatest in regions with (relatively) low income, high car availability and limited access to essential services by public transport.

Most high risk data zones were located in accessible rural areas (30% of all high risk data zones) and accessible small towns (28%). 20% were located in remote rural/very remote rural areas, 13% in remote small towns/very remote small towns, and 9% in large/other urban areas. Figure 2-2 shows the distribution of public transport accessibility across Scotland. Red zones indicate high risk zones while yellow zones are considered to have lowest risk.

This demonstrates that while location and convenience is certainly a factor in transport poverty, the largest issue faced in high risk areas relate largely to high transport costs (fuel and tickets) over accessibility. Transport costs can influence the extent to which various communities use the transport system. For low-income individuals specifically, cost is the most significant transportation-related obstacle. In some areas measures to reduce private car use, in the absence of high-quality alternatives, may lead to disproportionate impacts on lower income groups experiencing forced car ownership (Curl et al, 2018).

The average weekly household expenditure on transportation and vehicles was £68.20 in 2016-18, accounting for around a seventh of total expenditure. Although it has decreased significantly from a high of over 15% in 2012-14, it still accounts for a large amount of people's income (Joseph Rowntree Foundation, 2018).

Cost increases thus disproportionately affect socio-economically disadvantaged groups, contributing to broader societal inequities in opportunity: that is, because of the price and availability of transportation choices, many low-income people may be unable to maintain social relationships or access work or training possibilities that could improve their standard of living.

Research on the impacts of low income found that public transport use was shaped by three key factors: affordability, accessibility and individual household circumstances. All these factors shaped choices and everyday decision making. Cost was cited as a key issue for transport use and behaviour with several examples of public transport costs being unmanageable for families and frequently causing anxiety (Poverty Alliance, 2021).

Furthermore, if households were unable to afford transport, this resulted in long walks for shopping, isolation from support networks, and reduction on household spending including on food, which for some had resulted in food bank usage. Despite careful budget management, inadequacy of income constrained choices around the use of public transport. Where households had entitlement cards for free travel, this removed cost as a barrier; however, other barriers were still an issue in transport use such as poor availability.

2.2 Physical activity

Access to active travel and transport systems that encourage active living and regular physical activity is an important factor in combating obesity as well as having beneficial impacts on mental health and wellbeing. According to the Scottish Health Survey (Scottish Government, 2018) in 2017, 26% of children aged 2-15 were at risk of being overweight, including 13% at risk of obesity. The proportion of children in the healthy weight range decreased by age, from 73% of children aged 2-6 to 64% of children aged 12-15. This pattern was largely driven by girls, for whom prevalence of healthy weight decreased significantly from 77% for those aged 2-6, to 60% for those aged 12-15 (Scottish Government, 2019).

At present in Scotland, older people, women and people from ethnic minority groups are less likely to cycle than younger, white males, while walking as a means of transport is more evenly distributed across the population (Teuton et al, 2020). However, evidence suggests that where uptake of cycling becomes more commonplace and perceptions of safety improve, the uptake of this mode becomes more evenly distributed across societal groups (Aldred et al, 2016).

Cycling amongst disabled people is also lower than those who are not disabled even though 75% of disabled cyclists use their cycle as a mobility aid, with the same proportion finding cycling easier than walking. However, disabled cyclists cite inaccessible cycle infrastructure, cost of non-standard cycles and the inability to cycle in places where a mobility scooter would be allowed as the biggest barriers to cycling (Wheels for Wellbeing, 2008).

For travel to work purposes cycling is most popular amongst those in the highest income brackets (Scottish Household Survey, 2019 Table 7) and the uptake of cycling for commuting purposes is lowest for low incomes groups and those living in the most deprived areas of Scotland. Uptake of cycling is greater in urban areas than in rural parts of Scotland (Transport Scotland, 2020a). This may be due in part to the longer distances required to travel to access services. Investment in walking and cycling may therefore be focused on those in urban areas, unless it is sufficiently integrated with other actions designed to improve multi-modal travel in rural areas.

Amongst elderly populations, active travel is more than physical mobility: mobility, wellbeing and independence are intricately connected with each other. Mobility enables older people to engage in everyday activities that enhance wellbeing, whilst independent living gives older people control over the times and places in which activities are carried out. Thereby, loss of mobility (from age-related disability or the loss of a driving licence) can be viewed as significantly diminishing wellbeing. Loss of mobility not only compromises physical mobility, but adversely affects psychology such as happiness, life-satisfaction and sense of self.

2.3 Safety and security

Safety is a key issue for children with regards to transport. There were 331 child pedestrian casualties recorded in Scotland in 2019, accounting for 44% of all pedestrian casualties of all ages (Transport Scotland, 2020c). In particular children from deprived areas and certain ethnic groups are more at risk. A key aspect to consider is school transport casualty risk. A recent report shows that, for children, the journey home from school in the afternoon has more risks than the journey to school in the morning, especially when walking or cycling (Transport Scotland (2020c). Furthermore, children killed or injured when walking after leaving a bus or a car are often classed as pedestrian casualties.

People living in deprived areas tend to live in more hazardous environments, with greater proximity to high volumes of fast-moving traffic and high levels of on-street parking and, as such, they have higher levels of exposure to road traffic risk (Lucas et al, 2019). There is strong relationship between deprivation and pedestrian casualties. In particular, children and young people from deprived areas were found to be more likely to be involved in traffic injuries, for whom the risk was highest on main roads and on residential roads near shops and leisure services (Christie et al, 2010).

There is a significant causal relationship between increased motorised transport and increased road casualties and deaths: people from deprived neighbourhoods are more likely to be injured or killed as road users and people in the highest socio-economic groups (SEGs 1 & 2) were found to be substantially less at risk of death as car occupants than people in the lower groups (SEGs 4 & 5) (UK Government Office for Science, 2019).

Disability, race, gender reassignment, sexual orientation and religion and belief are the five groups of protected characteristics covered hate crime legislation. Disabled people who experience hate crime may often feel fearful in their own homes, communities and when using public transport Glasgow Community and Safety Services, 2013).

Disabled people are generally slightly less positive about their experiences using public transport than people who were not disabled, although differences were small for most aspects. The area where the difference was highest was whether individuals felt ‘safe and secure on the [bus or train] at night’ (58% of disabled people agreed they felt safe and secure on the bus at night compared to 73% of non-disabled people) (Transport Scotland, 2020a).

Lesbian, gay bisexual and Transgender (LGBT) individuals are more likely than heterosexual individuals to have encountered inappropriate sexual behaviour or hate crime while using public transport and may be concerned about safety and security while travelling. Nearly half of transgender persons in Scotland experienced a transphobic hate crime or incident in the year previous to 2017, according to estimates (However, the total number of charges for hate crimes against transgender people comprises 0.8% of all hate crimes. For many transgender people, concerns about discrimination and harassment are part of their day to day lives, for example more than half of trans people feel uncomfortable using public toilets (Stonewall Scotland, 2017).

Discrimination, harassment or abuse based on racial background or religious identity can create a barrier to travel for ethnic minority groups who are more likely to be subject to hate crimes.

Women’s concerns when traveling on public transport largely relate to gender-based violence and assault, including sexual harassment when travelling. The annual instances of all sexual crimes in Scotland, the victims of which are overwhelmingly women, has risen by 90% since 2007/8 to 2018 (Scottish Government Local Government and Communities Directorate, 2018).

There has been an increase in crime rates across Scotland, in part driven by increased awareness and reporting of sexual crimes, the majority of which are experienced by women. In comparison to males, women are more likely to be very or fairly concerned about sexual assault, and they are also less likely to feel very or fairly safe travelling alone at night (66% compared to 89%).

2.4 Environment impacts and health risk

Environmental impacts of traffic can disproportionately affect certain groups. For example, evidence shows that traffic-related noise is correlated more broadly with lower health-related quality of life in children (Hjortebjerg, D. et al, 2015) and has increased health risks for older people (Halonen. J, 2015). Children and older people are also more vulnerable to the adverse health effects of transport-related emissions compared to the overall population.

Disabled people, including those with weak respiratory systems, or people who suffer health problems more generally associated with weaker lungs may be disproportionately impacted by traffic-related emissions and dust as well as dust and emissions created through construction and maintenance of transport infrastructure (Font et al, 2014).

Pregnant women are more vulnerable to the adverse effects of air pollution including an increasing risk of miscarriage (Leiser et al, 2019) as well as premature births and low birth weights.

The above groups are also more at risk to the environmental, safety and accessibility impacts of construction activities associated with new transport infrastructure or maintenance projects.

Deprived areas are more likely to suffer from poor air quality (DEFRA, 2006). There is also potential for health inequalities widening in these areas due to emissions being concentrated in the most heavily trafficked roads, which are used more by disadvantaged people as places where they live, work and shop (Lucas et al, 2019).

Furthermore, there are social impacts of the road-based transport of hazardous materials, particularly for residents of deprived communities. They are more at risk of exposure to hazardous material spills due to their greater likelihood of residing near a hazardous material route and/or near industrial land uses.

Climate change can compound poverty and deprivation and, in parallel, poverty increases vulnerability to climate impacts. There is also evidence that some adaptation and mitigation policy can deepen inequity. Lower-income groups living in poorer-quality housing in coastal locations are disproportionately affected by coastal flooding, while disadvantaged groups living in deprived urban areas with the least green space are more vulnerable to pluvial flooding (flooding caused by rainfall) and heatwaves (Joseph Rowntree Foundation, 2014).