healthscotland.com

Health Education Population Survey (HEPS) 1996-2003

Summary

Health education has been a strong and consistent element in the efforts to improve Scotland's health since the early 1990s. Health education, information and communications activities seek to influence people's health-related knowledge and attitudes and to motivate and support the process of behaviour change. The Health Education Population Survey (HEPS) was initiated by HEBS in 1995 to monitor general population trends in Scotland in adults' knowledge, awareness, attitudes and motivation to change with respect to health and health-related behaviours. The survey is conducted by BMRB International in two waves each year (March and September) to form a nationally representative annual sample of 1800 adults aged between 16 and 74 years. The "little and often" monitoring approach of HEPS is intended to complement the other major national surveys, such as the Scottish Health Survey and Scottish Household Survey, which are carried out less frequently and with larger samples.

This report presents an overview of key findings and trends from the HEPS dataset during the first eight years (1996-2003).

For summary purposes, the following symbols are used in the text below:

 

Attitudes to health and reducing the risk of disease

There has been a slight increase in the proportion of people who feel that they can influence their own health (from 76% in 1996 to 79% in 2003), with the increase greatest for those in social grade C1. The proportion believing they could reduce their risk from strokes rose significantly from four in ten in 1996 to over five in ten in 1998 and has remained at the same level since then.

During a period when cancer has overtaken cardiovascular disease as the leading cause of premature death in adult Scots (since 1999), there has been a significant increase in the proportion of adults in Scotland mentioning cancer as the main cause of premature death. At the same time, the proportion of Scottish adults who view coronary heart disease (CHD) as the main cause of premature death has declined significantly. Cancer has consistently been the disease most likely to be viewed as a personal risk, and a significant decrease in the proportion of adults considering CHD a personal risk has widened the gap between the two diseases.

Over eight in ten adults are aware that the risk of CHD can be reduced. From 1996 to 2003 there has been a significant increase in the proportion of those who consider that regular exercise, eating a healthy balance of foods and controlling weight are very important in this respect (from 66% to 77%, from 58% to 65% and from 54% to 61%, respectively). There have also been significant increases in the proportions of those who believe it is possible to reduce the risk of skin and bowel cancer.

The health education message that individuals can influence their own health and reduce their risk of developing certain diseases appears to have gained salience over the past eight years. More people in Scotland are now aware that they can reduce the risk of strokes and more people make the link between diet, exercise and CHD. This may be associated with the media-based health education campaign run by HEBS between 1996 and 2002 about the health risks associated with CHD, cancers and stroke (the Big 3 campaign) which featured core messages on the three diseases and a series of Top Tips ads related to specific actions to reduce the risk. However, there is still room for improvement here, and the messages could be further reinforced in the Scottish Executive's healthyliving campaign (launched in January 2003), building on the progress made over the last decade.

 

Healthy eating

There is substantial evidence of the effectiveness of healthy eating messages in the last eight years. The proportion of people who are aware of the recommended daily consumption of at least five portions of fruit and vegetables rose significantly from 19% in 1996 to 59% in 2003. This increase is very likely to reflect the concerted health education efforts on healthy eating over this period, in particular the promotion of the 5-a-day message. However, four in ten adults are still not aware of the 5-a-day recommendation, which suggests there is still considerable scope for further improvement.

Improvements in motivation to eat more healthily were of only borderline significance over the full eight-year period. From 1996 to 1999, half wanted to eat more healthily or had already tried to make such a change. By 2001 the proportion of respondents contemplating or trying change had risen to almost six in ten and this level was maintained in 2002 and 2003 (this level of motivation is similar to that for physical activity). It will be interesting to see whether the renewed efforts of the Scottish Executive's healthyliving campaign on motivating dietary change manages to restore an upward trend.

The HEPS dataset indicates significant improvements in fruit and vegetable consumption from 1996 to 2003, rising from around one in five consuming the recommended five portions in 1996 to almost three in ten in 2003. The average number of portions consumed per day increased marginally from 2.8 in 1996 to 3.4 in 2003. While three in ten adults in Scotland still do not eat fruit or vegetables daily, and an average of 3.4 portions is still a long way short of the recommended five portions, these are nevertheless indications of significant improvements in the Scottish diet. Furthermore, this trend of dietary improvement is supported by findings from the Scottish Health Survey.

With the levels of knowledge and consumption of fruit and vegetables increasing, and motivation to improve diet relatively high, the indications are that it should be possible to build upon the progress made over the last eight years by improving knowledge and motivation and supporting the process of dietary change.

 

Breastfeeding

Breastfeeding is another aspect of the Scottish diet where there have been significant improvements over the last decade. The Infant Feeding Survey 2000 (Hamlyn et al, 2002) showed a rising trend in breastfeeding initiation rates in Scotland from 55% in 1995 to 63% in 2000. The proportion of babies still being breastfed at 6-8 weeks has risen from 34.6% in 1999 to 36.5% in 2003 (ISD, 2004). During this time health education has been focused on communicating the benefits of breastfeeding for both babies and mothers and providing practical information and support. In addition, health education campaigns have been encouraging a shift in public attitudes to support breastfeeding in public places. The HEPS survey shows that attitudes towards breastfeeding in public are changing and becoming increasingly positive, with shifts in attitudes greatest among the 16-24 age group.

 

Physical activity

Physical activity is one area where there has been no discernible pattern of change in knowledge levels over time. Around one-third are aware of the minimum recommended level of 30 minutes of moderate intensity physical activity per day.

Approximately six in ten adults were contemplating increasing the amount of physical activity they did, or had already tried to change. For those categorised as sedentary, this proportion fell to half. Levels of motivation to take more exercise remained largely unchanged from 1996 to 2003, but more recently there appears to have been a small shift of borderline significance away from those not contemplating change towards those who have tried to change.

In terms of behaviour, approximately three in ten led sedentary lifestyles and four in ten achieved the recommended levels of vigorous or moderate activity. Scottish adults were more likely to walk as part of their daily routine than to undertake more vigorous activity, with six in ten walking at least 30 minutes per day. There is some evidence of an increase in physical activity levels since 2002 but longer-term data are needed to determine whether this will be sustained.

Progress in terms of physical activity is more complex to assess. Knowledge of recommended physical activity levels has been slow to improve, despite concerted health education messages in Scotland since 1996, promoting the health benefits of walking and active living. At the same time motivation is reasonably high and there are some signs that this may be increasing over time. There seems to have been a small increase in physical activity levels in recent years, but three in ten adults are still sedentary and only four in ten achieve the recommended levels of physical activity. However, the majority do attain some degree of active living by walking for 30 minutes a day. There is substantial scope to develop the active living approach further, in particular in relation to walking, and to boost the motivation of those who currently do not take any exercise.

 

Smoking

Compared to other areas of health-related behaviour change, levels of motivation to change are highest among smokers. Half of all current smokers had actually tried to cut down, with a further one in three smokers contemplating change. Only one in five smokers were not contemplating change.

The HEPS data for 2002 and 2003 suggest a possible decline in the proportion of regular smokers (36% in 1996 to 29% in 2003), particularly among the 25-34 and 45-54 age groups, but longer-term data are needed to confirm this. Data on adult smoking trends in Scotland from the Scottish Household Survey also indicate a downward trend between 1999 and 2002, with an apparent decline in smoking among men in deprived areas, but little change among women.

Smoking and health issues have been highly salient in the public arena for many years and knowledge levels on the health risks of smoking are extremely high. Unlike in other areas, smoking is unlikely to be due to a knowledge deficit. Many of those who smoke may see this as a personal choice, while being aware of the health risks. The main thrust of current health education efforts is thus on increasing awareness of the health risks of smoking to others and reducing the acceptability of environmental tobacco smoke. The recent ban on tobacco advertising in the United Kingdom is also intended to contribute toward the normalisation of non-smoking environments as observed in many countries over the past couple of decades. Future HEPS surveys will be monitoring public attitudes to smoking in public places in order to assess whether these efforts are successful. In addition, with high levels of motivation among smokers to cut down or quit, continuing to support those who want to give up smoking remains primary goal for health education.

 

Alcohol

Current recommendations on alcohol consumption combine weekly limits (14/21 units for females/males) and daily benchmarks (2-3 units/3-4 units per day for females/males). The proportion of adults aware of the recommended weekly alcohol limit rose significantly between 1996 and 1997. One in five respondents knew the recommended maximum weekly limit for their sex (rising from one in ten). There has been no further increase in recent years.

Compared to other areas of health-related behaviour change, levels of motivation to change are lowest for reducing alcohol consumption - only a quarter were contemplating cutting down their drinking or had tried to do so already. This rose to over four in ten of those currently exceeding the weekly recommended limits. There was evidence of a recent small increase in levels of motivation, but this was not a significant increase for those exceeding the recommended limits.

The proportions of adults in Scotland exceeding the recommended limits remained stable at around 15% over the eight-year period.

Public understanding of messages concerning the recommended limits for alcohol consumption appears to be problematic for several reasons. The current recommendations combine the previous weekly limit, the more recent daily benchmark and a suggestion of a number of alcohol-free days. This is considerably more complex than the simple 'eat more fruit and vegetables' or 'give up smoking' messages. There is some evidence that the initial attempt in 1995 to introduce the idea of a daily limit of two or three drinks caused some confusion. Not surprisingly, given the press coverage at the time which presented contradictory interpretations and conflicting recommendations, some respondents believed that the recommended weekly limit had been increased. However, by 1997 the confusion had lessened and over half of respondents mentioned the more established weekly limit or less.

A specially designed set of questions was used in the 2002 HEPS survey to assess the salience of daily benchmarks. This showed that there is still relatively low awareness of the more recent guidelines: when asked what they thought the current recommended limits for drinking alcohol were, only 25% of those who knew about measuring alcohol in units mentioned the daily benchmarks, while the majority gave weekly limits. This suggests that effective communication of the daily benchmark approach would need to be relatively simple, perhaps based on the old weekly limits qualified by an 'avoid binge drinking' message. While there is at present no commonly accepted definition of what constitutes binge drinking, the Scottish Executive is currently using over 8/6 units per session as a working guideline (Scottish Executive, 2002b).

The targeting of alcohol consumption messages is another issue that complicates health education in this area. The question is whether it is best to communicate a 'sensible drinking' message to everyone, or specifically to target the heavier drinkers to reduce their consumption. Since the motivation to cut down is not much higher among heavy drinkers compared to drinkers in general, and given the general lack of change over time, there is a case for tailoring health education messages specifically for this group. Such an approach is particularly relevant for young women whose alcohol consumption levels have been rising (ONS, 2000). This is a priority in the current Scottish Alcohol Action Plan to reduce binge drinking (Scottish Executive, 2002b).

 

Mental health

Mental health has been a broad underlying theme of much public communications activity in health education. Stress in the workplace has been a more specific focus of preventative actions. More recent activity centres on the mental health of young people. The HEPS dataset shows no discernible changes over time in levels of stress or potential mental distress. Around a quarter said they had experienced large amounts of stress, and over a third said they had experienced stress they felt was harmful. Three in ten showed signs of potential mental health distress with a GHQ12 score of more than two.

 

Oral health

One of the main aims for health education in the area of oral health is to encourage regular visits to the dentist. The HEPS dataset shows significant increases in the proportion of adults who have visited their dentist in the last year (from 65% in 1996 to 73% in 2003) and who have visited their dentist for a routine check-up in the last six months (from 34% in 1996 to 45% in 2002), as well as in the proportion planning to visit their dentist in the next six months (from 65% in 1996 to 75% in 2002).

 

Sexual health

Health education activities in the area of sexual health are primarily targeting young people via sex education in schools, encouraging condom use and providing information on STIs and HIV and advice and treatment services. The HEPS dataset showed significant positive changes between 1996-1999 and 2001-2003 in attitudes to condom use, but overall there was no change observed in the proportion (14%) who had actually made changes in their sexual behaviour, such as condom use, in order to protect themselves from HIV/AIDS and other sexually transmitted infections.

 

1. Introduction

1.1 Background

The Health Education Population Survey (HEPS) monitors health-related knowledge, attitudes, behaviours and motivations to change among the adult population in Scotland. This report presents an overview of key findings and trends from HEPS data during the first eight years (1996-2003). The survey was first commissioned in 1995 by the Health Education Board for Scotland (HEBS) which was the national health promotion agency in Scotland from 1991-2002 and one of a number of agencies with a role in improving the health of people in Scotland¹. HEBS worked in three main strategic areas:

• communication with the general public to improve awareness, knowledge and motivation regarding key health-related issues
• enabling informed and effective practice among health promotion practitioners and other professionals
• developing policies, strategies and infrastructures, together with other partner agencies and sectors, to support individual and public health improvement

A core element of the work of HEBS, and health promotion generally, is to increase public awareness of health-related risk factors and how to make the lifestyle changes necessary to reduce such risks. Health education, information and communications activities seek to influence people's health-related knowledge and attitudes and to motivate and support the process of behaviour change. The main purpose of the survey is to collect the data required to monitor progress towards achieving this aim with respect to the priority topic areas identified in a series of policy documents on improving Scotland's health (Health Education in Scotland, 1991; Scotland's Health - A Challenge To Us All, 1992; Towards a Healthier Scotland, 1999; Improving Health in Scotland - The Challenge, 2003).

The indicators presented in this report concern knowledge, attitudes, motivation and behaviour/health status among adults in relation to the following topics:

• attitudes towards own health
• causes of mortality and morbidity
• physical activity
• diet
• smoking
• alcohol
• mental health
• oral health
• drug use
• sexual health

¹In April 2003, HEBS was merged with the Public Health Institute of Scotland (PHIS) to form NHS Health Scotland.

While there are some core questions on these topics that were asked at each survey wave, other questions were asked less frequently, or formed part of modules which were only included in particular waves. The questions providing the data presented in this report are listed in Appendix A, and the list of topics covered between 1996 and 2003 is shown in Appendix B.

In addition to providing performance monitoring data for the public communications and educational aspects of health promotion, the information collected by HEPS contributes towards the planning and development of future health promotion initiatives.

The data from HEPS should not be seen in isolation. It is intended to complement other health population surveys, most notably:

• the Scottish Health Survey commissioned by the Scottish Executive Health Department to provide monitoring data on the prevalence of specific health conditions and associated risk factors in the Scottish population
• the Health Education Monitoring Survey (HEMS) commissioned by the Health Education Authority and carried out between 1995 and 1998, collecting similar data for England as that provided by HEPS for Scotland
• the Health in Wales Survey commissioned by the Health Promotion Division of the National Assembly for Wales to track progress towards the achievement of health improvement targets for Wales
• local health and lifestyle surveys carried out periodically by Scottish health boards

Data collected through HEPS are presented for Scotland as a whole with breakdowns by age, sex, socio-economic grade, and deprivation category (DEPCAT). The annual sample size is too small for meaningful analysis at health board level and makes it difficult to draw reliable and statistically significant conclusions for some sub-groups of the population. Boosting the sample to allow more robust statistical analysis by sub-groups and health board regions would entail significant cost increases, and ones that have not been regarded as justifiable relative to the utility of the information. It may be useful to note that the 1995 and 1998 Scottish Health Surveys found relatively little regional variation across a range of indicators when differences associated with age and social class are taken into account (Dong and Erens, 1997; Shaw et al, 2000). These surveys are substantially more heavily resourced than the Health Education Population Survey, as they are intended to monitor progress toward national health targets. The regional differences which were observed are also difficult to interpret without taking into account contextual influences such as economic history and patterns of population migration.

However the HEPS dataset does provide a useful indication of general population trends for adults in Scotland. It can contribute to local planning activity by highlighting topic areas and population groups of particular interest. This in turn may guide more focused needs assessment to inform local service provision. By describing the broader national context within which local activity takes place, national findings can be used as a benchmark against which to assess the local situation in relation to local health promotion needs and developments.

1.2 Methodology

The survey

The survey was commissioned by HEBS in 1995 and is conducted by BMRB International. Fieldwork began in March 1996 and is carried out twice a year (March and September) in mainland Scotland. The survey was suspended for three waves during 1999-2000 while resources were diverted to data analysis activities for the 1996-1999 dataset (Walters, 2000; Phillips et al, 2001). There is thus a gap in data collection for the three survey waves covering September 1999, March 2000 and September 2000.

The survey is administered using computer assisted personal interviewing (CAPI) in respondents' homes, including a self-completion section for more sensitive issues such as mental health, sexual health and drug use. Each survey wave has an achieved sample of approximately 900 people aged 16-74 years. Respondents are selected using a multi-stage clustered random sampling design with the Postal Address File as the primary sampling frame. A 'rolling' sampling procedure allows results to be combined from consecutive waves. The data are weighted to adjust for differing probabilities of selection and response bias with respect to sex and age. Most questions are asked using prompted closed-format response categories, and those asked using unprompted open-format are identified in the text.

Sample size and response rates

This overview report presents key data from all waves of the survey (1996-2003), using combined results for each year from the two waves of the survey conducted in that year. The exception to this is 1999 when only one survey wave was carried out. The results for 1999 should therefore be treated with considerable caution since the much lower base will produce much greater levels of random variation. The number of achieved interviews and response rates with respect to the eligible sample are shown below for each year.

	1996	1997	1998	1999	2000	2001	2002	2003
Achieved interviews	1810	1795	1794	880	-	1757	1742	1720
Response rate	72%	73%	72%	72%	-	71%	72%	72%

Analysis

Annual summary reports were published for each of the first three years (HEBS, 1997a; HEBS, 1999; HEBS, 2000). These provided basic descriptive statistics noting any significant differences between socio-demographic groups for each year's data. This report focuses on changes over time for key variables, both for the whole population and for sub-groups with respect to sex, age, social grade and deprivation (base sizes for sub-groups are given in Appendix C). Differences between years are tested for statistical significance using t-tests for means or hypothesis tests for proportions, as appropriate. Unlike other significance tests, these tests also take into account the estimated design effect due to the sampling procedure (see below for more details). The report describes observed changes and explicitly points out where such a change is statistically significant (p<0.05). Differences should not be considered statistically significant unless it is specifically stated. Any use of the term significant is taken to mean statistically significant, but the use of this term does not imply substantive significance or importance. Changes over time that are significant are indicated by shaded rows in the tables. It should be noted that given the relatively small size of some of these differences, some caution is recommended in interpreting and generalising from this data in the absence of other supporting evidence.

The significance tests have been applied to look for change between two points in time (e.g. between 1996 and 2001). The period of change considered will be specified in the text, and any change will be considered in context. If the apparent change is not supported by trends of change in between the two points in time, or by change being sustained in the longer term, or by evidence of change from other sources, then caution should be used in interpreting the apparent change.

Readers should also exercise caution when considering time trend data over the relatively short period considered in this report. On the whole, changes at a population level occur gradually and underlying trends only become apparent over longer time periods. Apparent changes in the short term may in the long run turn out to be a result of random variation within the population, and predictions based on short-term patterns observed for past data may therefore prove misleading. Long-running time series, such as smoking rates from the General Household Survey, often have 'blips' in the data which can be misleading when taken out of context. Smoking rates in the UK have fluctuated between 27% and 28% since the early 1990s (27% in 2000), but the shift from 27% in 1994 to 28% in 1996 was reported as signalling a possible upward trend (ONS, 1998). The latest report on the General Household Survey notes that upward and downward movements in survey estimates are to be expected due to sampling fluctuations, even when prevalence in the population is not changing (Walker et al, 2001).

It is also not appropriate to attribute observed changes definitively and solely to health promotion activity as many other factors (e.g. macro-economic change, commercial marketing) will influence health-related attitudes and behaviours.

Sample design effects

When using survey data it is important to take the sample design into account. The aspect most likely to affect the precision of the results is clustering, where the sample is selected from a number of geographical areas in order to increase the efficiency of the fieldwork and reduce costs. While clustering does not introduce a bias, it can increase the estimation error of observed prevalences relative to a more dispersed simple random sample, and thus result in a lower level of theoretical precision. The reduction in precision can be measured by calculating the design effect, with larger values representing reduced levels of precision. This is calculated by looking at the variation in responses between sampling points. Taking into account the design effects across a range of questions, an average design effect for the survey can be defined. The variables selected in this case were those deemed most likely to reflect regional variations in health status and behaviour, and therefore the estimated design effect is likely to be larger than the true value.

For this survey, the design effect was 2.3 (the design effect for a simple random sample is 1). This is taken into account when testing for statistical significance by multiplying the standard error assumed for a simple random sample by the design effect, which means that an observed difference needs to be more marked in order to be statistically significant. The estimate of the design effect for HEPS errs on the side of caution, and is relatively large compared with bigger surveys such as the Health Survey for England and the Scottish Health Survey, which tend to have design effects of 1.2 or less. However, it can be considered small relative to school-based surveys where the design effects are larger due to the combination of more clustered sampling, institutional school effects and peer-group influences. As mentioned previously, both the Health Survey for England and the Scottish Health Survey are designed to make a substantial contribution to monitoring progress toward national health targets, and are accordingly very heavily resourced in order to provide data with the additional degree of precision.

Multiple comparisons

When using survey data it is also important to take into account the problem of multiple comparisons. If a large enough number of parameters are measured across time, then some changes will be observed, even if there are no real changes in the population. It is important to check for widespread or sustained change, or to look for evidence of change from other sources, and not to give too much weight to isolated changes. Any apparent changes in the HEPS data are considered in this context.

Self-reported behaviours

It is worth bearing in mind that the behavioural measures are self-reported, rather than observational. This is likely to mean some degree of under-reporting for behaviours such as alcohol consumption or over-reporting for behaviours such as physical activity or consumption of fruit and vegetables.

Classifications used

Age: In general, six age groups are used for analysis (16-24, 25-34, 35-44, 45-54, 55-64, 65-74). These are the standard groups used in presenting survey findings. However, in the absence of clear gradients, or in the case of small base sizes, results may be presented in terms of more aggregated age groups to clarify observed patterns of difference.

Social grade is used as a household-based proxy measure of social class. This classification is based on the normal occupation of the chief income earner in the household, which is categorised into AB (professional, managerial and technical), C1 (skilled non-manual), C2 (skilled manual), D (partly skilled and unskilled) and E (dependent on state and casual workers) (Market Research Society, 1991). The social grade of a retired person with a pension from their job is based on their previous normal occupation. The social grade of widows or widowers receiving a pension from their spouse's job is based on the previous normal occupation of the spouse. For those unemployed for two months or less, social grade is based on their previous occupation - the longer term unemployed are graded as E. The main advantage of this classification system is that it provides a relatively stable population profile over time and all respondents can be assigned a social grade, unlike occupation-based systems such as the Registrar General's Social Class based on Occupation which excludes the long-term unemployed, arguably one of the most materially and socially disadvantaged population groups.

Deprivation: DEPCAT is used as an area-based measure of deprivation and is based on the Carstairs scores derived from Census data. They are a composite measure of four variables: overcrowding, male unemployment, low social class and having no car. The Carstairs scores are used to define seven DEPCAT groups, from 1 (the most affluent) to 7 (the most deprived). Carstairs scores are updated periodically when more up to date Census data are available, or when there are changes to postcode boundaries. The division of the scores into DEPCAT groups was first done in 1981 on a pragmatic basis, using the first Carstairs scores. More recent DEPCAT groups have been achieved by dividing the population (according to the latest Carstairs scores) into seven new DEPCAT groups, each containing the same proportions of the population as those produced in 1981. The latest available DEPCAT scores were used for analysis in this report.

McLoone (2000) notes a number of weaknesses when using DEPCAT as an analysis variable. Since DEPCAT is defined at postcode sector level, an area needs to be relatively homogeneous (i.e. most residents affluent or most deprived) for it to be identified as deprived or affluent (high or low DEPCAT). Any area which is more heterogeneous will be defined as DEPCAT 3, 4 or 5 (groups covering 62% of the Scottish population). However, these postcodes contain deprived households, and it is possible that some of these 'middle' sectors contain more deprived households than those identified as DEPCAT 6 or 7. Furthermore, as postcode sectors are geographically larger in rural areas, this means that DEPCAT is probably a better descriptor of affluence in urban areas (which are likely to be more homogeneous).

Figure 1.1 shows the relationship between social grade and DEPCAT score using the HEPS data from 1996-1999. Whilst there is a clear gradient of social grade across DEPCAT scores, the chart clearly illustrates the lack of homogeneity of the different DEPCAT groups, even at the extremes. For example, when considering results for individuals classified as deprived when using DEPCAT (scores 6 and 7), a reasonable proportion will actually come from relatively affluent ABC1 households.

Fig 1.1: Relationship of social grade to DEPCAT using 1996-99 HEPS data

Base: all respondents 1996-1999

Motivation: Three mutually exclusive categories are used to classify respondents according to their motivation to change health-related behaviours. Those who:

• have tried to change in the past year
• want to change, but have not tried in the past year
• have neither tried nor want to change

Anyone who falls into either of the first two categories would be defined as 'motivated to change'.

 

Tables and figures

When using the tables and figures, the following points should be noted:

• percentages may not add up to 100 due to rounding, or the exclusion of don't know responses where they only represent a small proportion of answers
• percentages are used throughout the report, irrespective of base size - for each percentage given, the number of individuals constituting the base is given in Appendix C and should be taken into account when interpreting the findings
• the base for percentages consists of all respondents (including those for whom data are missing), unless explicitly stated, and the base size in tables is denoted by 'N'

1.3 Report structure

Section 2 gives an overview of recent health trends in Scotland, including comparison with other countries, in order to provide the context for the reported findings. Section 3 provides a discussion of respondents' self-perceived health to provide further context. Section 4 presents data on perceptions of causes of mortality and morbidity, as well as the possibility of reducing the risk of certain diseases. More detailed topic-specific findings on behaviour, knowledge and motivation to change are presented in Sections 5 to 12. Section 13 summarises the main fndings of the report and briefly discusses their implication for health promotion.

Main points

• This report presents data on time trends in health-related knowledge, attitudes, motivations and behaviours in Scotland over the period 1996-2003.
• While the aim of the analysis is to assess the degree of significant change in these indicators over time, the sample size and design mean that it is sometimes difficult to distinguish observed variations due to actual small changes from those due to random sampling error.
• The results from HEPS presented here are considered alongside other data sources, such as other long-running national surveys, in order to provide supporting evidence of observed trends.

2. Scotland's health

While HEPS gives some indication of changes in health-related knowledge, attitudes and behaviour in Scotland over the last eight years, it is important to view these findings in the context of longer-term changes in Scotland's health. As in many other Western European countries, life expectancy is rising and many indicators of health are improving. However, compared to other countries, Scotland today has a poor health record: it is worse than comparable areas in the UK, like the industrial North East of England, and falls some way behind comparable European countries (Hanlon et al, 2001). Since the mid-twentieth century, the rate of health improvement in Scotland has been slower than in other European countries and Scotland has been sliding down the European league table of life expectancy (Leon et al, 2002). Scotland's nearest neighbours in the European health 'league table' are now Slovenia and Portugal (Hanlon et al, 2001). Moreover, within Scotland the rate of health improvement has been faster in the more affluent groups and areas, giving rise to widening health inequalities (Health Scotland, 2004).

To what extent do the conscious planned efforts to improve population health contribute to these trends? Since the nineteenth century when infectious diseases were the major cause of death, advances in medicine (e.g. vaccination, anaesthesia and antiseptics), in science (e.g. pasteurisation of milk) and improvements in housing, water, sanitation and work environments have all made major contributions to improvements in public health. With cardiovascular diseases and cancers as the major causes of premature death in Scotland today, and with many of the associated lifestyle-related risk factors, public health has become a complex, multi-agency task mixing health promotion, protection and prevention, within which there is a constant emphasis given to health education and information. This was re-asserted in the recent Wanless Report, Securing Good Health for the Whole Population (2004), which located primary responsibility for health improvement with individuals making informed choices.

In Scotland, the implementation of actions to improve health has largely been the function of health promotion departments within the 15 local health boards. At national level, the work of the Health Education Board for Scotland (HEBS) included the role of raising health awareness among the public through PR work and national media campaigns, most notably:

• smoking cessation campaign promoting the use of Smokeline by adult smokers who want to quit (commenced 1992 and incorporated into the Big 3 campaign)
• walking campaign to increase public awareness of the health benefits of moderate exercise, especially walking (commenced 1996 and incorporated into the Big 3 campaign)
• the Big 3 and Top Tips campaigns aimed at adults in the 35-55 age range and focused on the main killer diseases in Scotland and what people can do to reduce the risks in terms of quitting smoking, improving diet and increasing physical activity levels (1998-2002)
• parenting campaigns - initially this work focused on specific topics (e.g. drugs, child safety and breastfeeding) and since 2001 has focused on parent-child communication and building confidence
• Think About It campaign is aimed at young people aged 12-17 years and aims to raise awareness of the need to consider health as part of personal decision making around alcohol, smoking, drug use and sexual health and relationships (commenced in 1997)
• supporting special health awareness days/weeks locally on the topics of smoking, breastfeeding, oral health, mental health and HIV/AIDS

The HEBS communications activities have been supplemented by Scottish Executive media campaigns on drugs (Know The Score, commenced 1997), on alcohol (commenced in 2001) and more recently on diet and physical activity (healthyliving campaign, commenced in 2003).

The two key questions to be addressed in this report are:

• To what extent has the recent emphasis on health education had the intended effect of: improving levels of health-related knowledge in the population, helping to change attitudes, and increasing motivation to change towards more health promoting and protective behaviours?
• Is there any evidence that the emphasis on health education may have inadvertently exacerbated health inequalities by accelerating the rate of improvement within the more affluent and educated groups?

2.1 Main causes of mortality

The main causes of death both in Scotland and in the UK as a whole include coronary heart disease (CHD), cancer and cerebrovascular disease (CVD) (principally strokes). CHD, cancer and stroke are among the top priorities for the National Health Service in Scotland, and account for six in ten deaths Cancers account for 26%, CHD for 21% and strokes for 10% of deaths (Registrar General for Scotland, 2002; Information and Statistics Division Scotland, 2001). The figures are very similar for the UK as a whole (cancer 25%, CHD 25% and strokes 11%) (ONS, 1997). Overall the prevalence of self-reported cardiovascular morbidity is similar throughout England and Scotland, but there are some notable differences: Scottish males aged 65-74 years and middle-aged Scottish females (45-64 years) have a higher self-reported prevalence of CVD than their English counterparts (Leon et al, 2002).

Cancer

Cancer overtook cardiovascular disease as the leading cause of premature death in adult Scots in 1999. Tackling cancer is therefore a top priority for the Scottish Executive, as outlined in their recently published cancer strategy document, Cancer in Scotland: Action for Change (Scottish Executive, 2002).

Throughout Europe, survival rates have increased for the majority of adults with cancer over the last 25 years, with many people diagnosed with cancer now living longer. A recent report on Scotland's health in an international context (Leon et al, 2002) showed that Scotland' cancer survival rates tend to be among the worst in Europe for many of the most common adult cancers. For all Scottish males and females aged between 15 and 99 years who were diagnosed with cancer between 1991 and 1995, the overall five-year survival rate was 31.5% for males and 43.1% for females. However the survival rates differed greatly for different malignancies. Lung cancer has the worst five-year survival rate at less than 6% in both males and females, whereas the survival rate was approximately 45% for cancer of the large bowel in both sexes and 75% for cancer of the breast in females. The poorer rates of cancer survival in Scotland for all malignancies in a European context have been partly attributed to Scotland's overall late presentation of cancers which are less responsive to treatment, and to the relatively higher rates of lung cancer, which has a particularly poor prognosis.

Between 1989 and 1998 there was an increase in cancer incidence rates of 7% for men and 12% for women (www.isdscotland.org). The most substantial recent increases have been for the incidence of oral cancer, oesophageal cancer and skin cancers, along with prostate cancer in men and thyroid cancer in women (Scottish Cancer Intelligence Unit, 1998). Incidence of lung cancer has also increased in women while decreasing in men. Indeed, Scottish women have the highest death rates in the world from lung cancer. This reflects changes in smoking behaviour over time - in the past 20 years, smoking rates have decreased more rapidly for men than for women.

The challenge for Scotland is to increase survival as well as stepping up preventative measures to decrease cancer incidence. Since lung cancer is the major killer of males and females, smoking cessation and preventing children and young people from starting to smoke is of key importance.

Coronary heart disease

The mortality rate from coronary heart disease in Scotland rose between the 1950s and 1980s but has since fallen to levels lower than those observed in 1950 (Registrar General for Scotland, 2000). Death rates have always been lower for women than for men, particularly for younger age groups, and the rise and fall has been slightly less marked in women. There is little difference in mortality rates between Scotland and in the UK as a whole. Mortality rates for the UK are just above the European average for men and just below average for women (WHO, 1997).

The decline in mortality rates has been attributed both to the changing incidence levels and to changing case fatality. Studies in the US suggest that declines in CHD mortality have been greater than declines in incidence. Reductions in mortality rates have been attributed both to improved treatment and to changes in the social environment and lifestyles, such as improved diet and declining smoking rates. For example, a study by Capewell et al demonstrated that 51% of postponed or prevented deaths could be explained by changes in risk factors, while treatment explained 40% of the decline in cardiovascular mortality in Scotland between 1975 and 1994 (McPherson et al, 2002).

Stroke

The main causes of death both in Scotland and in the UK as a whole include coronary heart disease (CHD), cancer and cerebrovascular disease (CVD) (principally strokes). CHD, cancer and stroke are among the top priorities for the National Health Service in Scotland, and account for six in ten deaths Cancers account for 26%, CHD for 21% and strokes for 10% of deaths (Registrar General for Scotland, 2002; Information and Statistics Division Scotland, 2001). The figures are very similar for the UK as a whole (cancer 25%, CHD 25% and strokes 11%) (ONS, 1997). Overall the prevalence of self-reported cardiovascular morbidity is similar throughout England and Scotland, but there are some notable differences: Scottish males aged 65-74 years and middle-aged Scottish females (45-64 years) have a higher self-reported prevalence of CVD than their English counterparts (Leon et al, 2002).

2.2 Behavioural risk factors

The three major diseases share a number of behavioural risk factors. Physical inactivity, poor diet, smoking and excessive alcohol consumption have been shown to play a part in modifying the risk of these diseases. These behaviours have seen some degree of change over time, and some behaviours differ in Scotland from elsewhere in the UK. Such behaviours are also associated with social inequity: smoking and poor diet are more prevalent among materially disadvantaged social groups, contributing toward increasing risk of mortality and morbidity. Poverty can result in health damaging behaviours, such as smoking, being used as coping mechanisms, as well as a reduction of resources and choice, such as access to and availability of a healthy balanced diet (Benzeval et al, 1995). In addition, material and social disadvantage can affect health through more indirect psychosocial pathways, thus contributing to the added burden of morbidity and mortality attributable to behavioural factors (Marmot and Wilkinson, 1999).

Physical activity

Levels of physical activity have clear consequences for health. Thirty-seven percent of deaths from coronary heart disease can be attributed to physical inactivity, compared to 19% for smoking, and there are more people who do not take the recommended amount of exercise than there are smokers. In addition, physical activity can lower the levels of cholesterol in the blood-stream, high cholesterol levels being a contributing factor for almost one-half of deaths from CHD (British Heart Foundation, 2002). Physical activity may contribute to health in other ways by enhancing mental and social well-being. While there is little evidence of increasing physical activity levels in the UK over the last ten years, the General Household Survey shows that people living in Scotland are no less likely to take physical activity than people living elsewhere in the UK (ONS, 1998).

Obesity is also a risk factor for CHD, and both diet and physical activity are linked to weight. The Scottish Health Survey data show that in Scotland over half of the adult population were classified as either overweight or obese in 1998 and the prevalence of obesity in Scotland has increased by about 3% between 1995 and 1998 for both men and women (Shaw et al, 2000). Scotland has a lower prevalence of overweight males (43%) compared with England (45%), but a higher prevalence of obesity (20%) compared with England (17%). In the 16-24 year old age group Scottish females were more likely to be overweight or obese (30%) than their English counterparts (26%).

As a result of guidelines on the health benefits of moderate intensity physical activity and 'active living', issued by the American College of Sports Medicine and the Centre for Disease Control (Pate et al, 1995), there have been revisions of health education strategies in this area. These are outlined in The Promotion of Physical Activity in Scotland (HEBS, 1997b) and involve a two-stage approach: those who are not regularly active should spend at least 30 minutes doing moderate intensity physical activity most days of the week (five or more), while those who are regularly active should aim to include three periods per week of vigorous activity lasting at least 20 minutes. In more general terms, the emphasis is on small increases in physical activity at all levels, and on incorporating physical activity into the daily routine in order to make such increases sustainable. The national strategy for physical activity in Scotland, Let's Make Scotland More Active (Scottish Executive, 2002a), highlights the importance of sustainability, and giving incentives to the least active, by encouraging a cumulative approach to increasing physical activity: the most recent guidelines for adults are to build up to at least 30 minutes of moderate activity on most days of the week.

Diet

Healthy eating is of particular relevance given its implications for cardiovascular disease, cancers, obesity and oral health. It has been shown that high consumption of fruit and vegetables has some protective effect against cardiovascular disease (ONS, 1997). Excessive consumption of saturated fats is strongly implicated as a risk factor for CHD and high salt intake is related to raised blood pressure, and hence a risk factor for stroke.

The diet of British people has changed considerably over time, with health implications. Rationing between 1939 and 1953 had a strong influence on the Scottish diet which extended beyond the period of actual rationing. Post-rationing, foods that had been scarce such as butter, eggs, meat, sugar and white bread became much more widely available (ONS, 1997). Changes such as the participation of women in the workforce, increased car ownership, the growth of supermarkets, the use of freezers and microwaves, multicultural restaurants and the availability of convenience food have all had some impact on the British diet since the 1950s. For instance, comparing household food consumption in the UK in 1950 and 1994 shows a decrease in consumption of potatoes, sugar and fresh vegetables, and an increase in the consumption of fruit, fruit juice, cheese and vegetable products (ONS, 1997).

The change in consumption has differed according to social group. After the war, affluent households had the highest consumption of sugars, fat and eggs, but by 1993 their consumption was lowest. There has been a decline in fat consumption in all groups since the 1970s, but this decline is most marked in the higher income group (ONS, 1997). Diet is clearly an area affected by health inequalities. A healthy diet may be perceived as more expensive by those with less money, or requiring more effort to prepare, and it has been suggested that where money is scarce, families buy food which is high in calories and taste appeal, but may be relatively low in nutritional value (Benzeval et al, 1995).

In response to the need to improve Scotland's diet, a multidisciplinary Working Party was charged with the specific task of surveying the Scottish diet and of making recommendations on the improvements required. The Report of the Working Party (1993) mapped a direct relationship between Scotland's poor dietary habits and coronary heart disease, stroke and cancer disease patterns and premature mortality. Based on the Report's recommendations, Eating For Health: A Diet Action Plan for Scotland (The Scottish Office, 1996) was published. A number of key national dietary targets were set for Scotland on the consumption of fruit and vegetables, bread, breakfast cereals, fats, saturated fatty acids, salt and NME sugars, total complex carbohydrates and fish. The targets also included increasing the proportion of mothers breastfeeding their babies for at least the first six weeks of life.

Smoking

Smoking is the most important and preventable cause of premature mortality in developed countries (WHO, 2002). In Scotland an estimated 13,000 people die each year from smoking-related diseases. The UK has one of the highest smoking-related death rates in the world from lung cancer, CHD and chronic obstructive airways disease (Benzeval et al, 1995). Taking diseases that are strongly linked with smoking, such as lung disease, cancer of the lip, oral cavity, pharynx, oesophagus and larynx, the deaths of 16% of men and 9% of women are caused by smoking. If those moderately related to smoking are included this rises to 22% of men and 12% of women. If CHD and other associated conditions are considered, where smoking can contribute to the disease, the proportion of smoking-related deaths rises to 51% for men and 37% for women (ONS, 1997).

Smoking rates have fallen in the UK since 1980, and the UK is among the bottom half of European countries in terms of per capita cigarette consumption. Around a quarter of adults in the UK smoke cigarettes (roughly equal for men and women), which is considerably lower than for most European countries. While smoking behaviour is increasing in many Central and Eastern European countries, in the UK and many other Western European countries smoking prevalence is falling (Harkin et al, 1997).

Table 2.1: Prevalence of cigarette smoking, by sex and country, 1976-2001

%	1976	1986	1996	2001*	N(2001)
All
Scotland	46	36	32	31	1320
England	41	32	28	27	13,286
Wales	41	31	27	27	748
Great Britain	42	33	28	27	15,354
Men
Scotland	50	37	33	32	585
England	45	34	28	28	6,128
Wales	46	33	28	27	342
Great Britain	46	35	29	28	7,055
Women
Scotland	43	35	31	30	735
England	37	31	27	25	7,158
Wales	37	30	27	26	406
Great Britain	38	31	28	26	8,299

Source: 2001 General Household Survey
*data weighted from 1998 onwards

Over the last 25 years, the prevalence of cigarette smoking has fallen considerably in the UK, levelling out from the early 1990s and remaining relatively steady between 27% and 28% (Walker et al, 2001). However, rates in Scotland have remained consistently higher than in England and Wales (Table 2.1). The 1998 Scottish Health Survey reported adult smoking levels at 34% for males and 32% for females. Fewer of those living in Scotland, compared with England, report that they have quit smoking and smokers tend to report heavier daily smoking rates (Shaw et al, 2000). The 2002 Scottish Household Survey reported adult smoking levels at 28% for both men and women.

Corresponding with the general decline in smoking prevalence, there has been a drop in the last 20 years in smoking-related mortality among those under the age of 60. This excludes cancers of the oral cavity, pharynx and larynx which are also closely related to the consumption of alcohol (ONS, 1997). However, smoking has become increasingly concentrated amongst those living in areas of deprivation – the unemployed, lone parents and those living on low incomes. Those in the less well-off groups are more likely both to smoke cigarettes and to smoke more cigarettes per day. According to the 1995 Scottish Health Survey, 55% of those in the unskilled manual group are smokers compared with 15% in the professional group. Smoking rates among young teenagers and pregnant women are particular areas of concern and national targets have been set relating to these.

A UK White Paper called Smoking Kills (HM Government, 1999a) was published in November 1998 and set out a package of measures aimed at reducing smoking. These included proposals for a ban on tobacco advertising and sponsorship, a health education campaign to shift attitudes and change behaviour, measures to reduce smoking in public places, and a new code of practice to protect people from other people’s tobacco smoke at their place of work. The White Paper also set out proposals for NHS smoking cessation services, including NRT, to help those smokers who want to quit. Smoking cessation guidelines for Scotland were provided in A Smoking Cessation Policy for Scotland (Action on Smoking and Health Scotland/HEBS, 1998); these guidelines have been updated in 2004. A review of progress in Scotland with recommendations for future action was published in 2003 (Health Scotland and ASH, 2003).

Alcohol consumption

Alcohol consumption has mixed health effects - adverse in the case of acute intoxication or chronic dependency, and potentially beneficial in the case of moderate levels of consumption (McPherson, et al, 2002). High consumption contributes to raised blood pressure, increasing the risk of CHD and strokes, and is associated with other diseases such as oral cancer, especially in combination with heavy smoking. It is a major cause of liver cirrhosis. A recent research review of alcohol and alcohol-related problems in Scotland (Haw et al, 2004) highlights the rapid increase in alcohol-related morbidity and mortality during the 1990s across all age groups, despite an apparent stabilisation in alcohol consumption at a population level. The review also identifies the relatively high level of breast cancer risk attributable to alcohol consumption. Excessive and 'binge' drinking also increases the risk of accidents and crime. Alcohol-related harm not only affects the individual drinkers but has costs for families, friends and society as a whole.

While the current guidelines for recommended drinking limits are based on daily benchmarks, awareness of these is limited (HEBS, 1997a) and knowledge of sensible drinking limits can only realistically be assessed in terms of weekly alcohol consumption. Current national targets are in relation to recommended maximum limits of 14 units per week for women and 21 units for men. There is no generally agreed definition of 'binge drinking' or a standard way of measuring it. One approach is to use unit-based measures. For example, the Scottish Health Survey measures binge drinkers as those drinking double their daily benchmark or more on their heaviest drinking day in the past week. On the other hand, the General Household Survey uses the consumption of six or more drinks on a single occasion as a proxy measure of binge drinking.

Alcohol problems in Scotland are getting worse. More adults are drinking beyond the recommended limits and children and young people are drinking more than ever before. According to the Scottish Health Survey data for 1995 and 1998, the proportion of men in Scotland exceeding the recommended weekly limit stayed constant at 33%, while for women there was an increase from 13% (1995) to 15% (1998) in the proportion exceeding the weekly recommended limit. Women's alcohol consumption has remained consistently lower than men's.

Patterns of drinking are as relevant to health as the volume of alcohol consumed, binge drinking in particular being especially hazardous (WHO, 2002). Measures of adult alcohol consumption provided by the General Household Survey concentrate on binge drinking behaviours and frequency of drinking rather than just on total alcohol consumption (Tables 2.2 and 2.3). Whilst mean weekly consumption is no higher in Scotland than in England and Wales, and Scottish adults are no more likely than English and Welsh adults to have had a drink in the past week nor to have drunk on six or more days in the last week, they are more likely to have drunk more than 6 (for women) or 8 (for men) units on at least one day in the last week. This suggests that binge drinking behaviour may be more common in Scotland. Comparing the mean alcohol consumption figures from 2001 and 1996 (Tables 2.3 and 2.2) it also appears that alcohol consumption has increased for women in Scotland in the last five years.

Table 2.2: Alcohol consumption, by sex and country, 1996

	Moderate %	High %	Mean units	N
Men	(11-21 units)	(over 21 units)
Scotland	28	25	16.2	657
England	23	27	16.1	6,145
Wales	19	25	15.0	367
Great Britain	23	27	16.0	7,169
Women	(8-14 units)	(over 14 units)
Scotland	16	11	5.5	793
England	16	14	6.3	7,227
Wales	15	16	6.8	476
Great Britain	16	14	6.3	8,496

Source: 1996 General Household Survey

	Drank last week %	Drank 6+ days last week %	Drank more than 6/8 units on at least one day %	Mean units	N
Men
Scotland	77	16	28	16.1	584
England	74	22	21	16.9	6,128
Wales	72	19	20	16.5	342
Great Britain	75	22	21	16.8	7,054
Women
Scotland	57	10	13	6.9	735
England	60	14	9	7.5	7,159
Wales	54	13	11	7.3	405
Great Britain	59	13	10	7.4	8,299

Source: 2001 General Household Survey

The Scottish Health Survey data for 1998 provide a measure of binge drinking in Scotland. Of those who drank alcohol in the past week, 44% of men had consumed eight or more units on their heaviest drinking day, compared to 26% of women who had consumed six or more units on their heaviest drinking day. Twenty percent of men reported being drunk once a week in the past three months, compared to 9% of women. In total, 51% of male drinkers had been drunk at least once in the past three months compared to 31% of women.

In December 2000 the Scottish Executive published a Plan for Action on Alcohol Problems that identified two key priorities: to reduce binge drinking and to reduce harmful drinking by children and young people. The measures identified to tackle these priorities included: changing attitudes to binge drinking through a new national education campaign; a new parents' guide to help parents talk with their children about alcohol; supporting the implementation of the health promoting school concept throughout Scotland; a framework for support and treatment services to assist those who plan and commission services to assess local needs and improve services; continuing efforts to reduce drink driving; promotion of training and responsible practice for those serving and selling alcohol; more support for local alcohol problems co-ordinating groups; improved training for staff in services addressing alcohol problems; a review of licensing laws to look at the effects of licensing on health and public order.

3. Attitudes towards own health

In addition to the behavioural risk factors outlined in the previous chapter, how respondents view their own health provides a further relevant context for health education and promotion. The way people view their own health, and their ability to influence their own health, is likely to have an impact on how responsive they are to health education messages, and to the effort they would be willing to make to improve their health in the longer term. Moreover, self-assessed general health status has been shown to predict mortality independently of other factors and is used in Scotland as a measure of Healthy Life Expectancy along with Limiting Longstanding Illness (ISD, 2004).

3.1 Self-reported general health

Respondents were asked how they would rate their own health.

Table 3.1: Percentage who feel their health is very/fairly good, by age/social grade/DEPCAT

%	1996	1997	1998	1999	2000	2001	2002	2003
All	72	76	77	74	-	76	79	76
Age
16-24	82	78	85	69	-	85	84	89
25-34	76	85	85	91	-	86	90	80
35-44	81	80	83	70	-	84	84	75
45-54	67	78	69	72	-	74	79	77
55-64	60	67	67	69	-	57	74	71
65-74	58	58	63	69	-	57	56	58
Social grade
AB	89	86	86	89	-	90	91	86
C1	80	80	83	90	-	87	84	83
C2	77	77	80	76	-	78	82	76
D	72	73	79	45	-	66	74	70
E	42	55	44	58	-	41	52	51
DEPCAT
1-2	80	83	86	88	-	82	89	86
3-5	74	77	77	73	-	78	80	77
6-7	61	67	64	59	-	67	67	60
Base: all respondents	1810	1795	1794	880	-	1757	1742	1720

Each year, around three quarters of repsondents reported that their health was good (Table 3.1) and fewer than one in ten reported that their health was poor (8% in 2003). This was consistent with the findings of the Scottish Health Survey in 1995 and 1998 (Dorg & Erens, 1997; Shaw et al. 2000). There was no obvious pattern of change over time with no significant change from 1997 to 2003. Without information on previous years it is impossible to say whether the apparently lower figure for 1996 reflects any change in the longer term.

There was no difference by sex, but there were clear differences by social grade and deprivation, with self-reported general heatlh worse among the E group and those living in the most deprived areas. Not surprisingly, there was also an age gradient, with older respondents less likely to feel their health is good. The decline in self-reported health tended to start at the 45-54 age group and was consistently worse amongst those aged 65-74. This is also consistent with the findings of the Scottish Health Survey in 1995 and 1998.

The key gradients by sex and age are illustrated below in Figure 3.1, using the data collected in 2003.

Fig 3.1: Percentage who feel their health is very/fairly good, by age/social grade

Base: all respondents 2003 (1720)

 

3.2 Long-standing illness

For some respondents, self-perceived health is likely to be related to having a long-standing illness or disability. Around one in three respondents reported having some form of long-standing illness or disability. There was no consistent pattern of change over time (Table 3.2).

Table 3.2: Percentage who have a long-standing illness or disability, by age/social grade

%	1996	1997	1998	1999	2000	2001	2002	2003
All	36	31	30	32	-	34	30	32
Age
16-24	18	15	14	32	-	16	18	16
25-34	19	20	17	14	-	22	22	22
35-44	29	24	24	22	-	28	18	33
45-54	44	34	39	33	-	37	33	34
55-64	56	52	46	52	-	57	42	44
65-74	65	55	55	55	-	58	58	54
Social grade
AB	32	25	25	23	-	21	27	24
C1	30	30	25	21	-	25	26	25
C2	26	25	28	34	-	32	26	28
D	30	34	26	47	-	39	31	39
E	64	51	54	44	-	67	50	59
Base: all respondents	1810	1795	1794	880	-	1757	1742	1720

Whilst there was no difference by sex, there was a clear age gradient. As for self-perceived health, the increase in long-standing illness tended to sharpen amongst the 45-54 age group and long-standing illness is consistently higher for the oldest respondents. Long-standing illness was also more likely amongst respondents in the E social grade, although there was no clear pattern of difference between any of the higher social grades. There was no clear pattern of difference by DEPCAT.

These key gradients by sex and age are illustrated below in Figure 3.2, using the data collected in 2003.

Figure 3.2 Percentage who have a long-standing illness or disability by age/social grade

Base: all respondents 2003(1720)

 

3.3 Ability to influence own health

In addition to consideration of self-perceived health measures. It is equally important to consider how much control people feel they have over their own health since the perceived ability to influence one's health is likely to have some impact on future changes in health behaviours, and ultimately on longterm health. In order for any specific health promotion activity to have an impact, it is fundamentally important that people believe that they will be able to influence their own health in order for them to be willing to take on board and act on the message. Indeed, encouraging people to believe that they can influence their health, and the health of their children, has been a central message of many health education campaigns in Scotland. In 1996, 76% believed that they could do something to make their own life healthier; by 2002 this had risen to 80% (Table 3.3). This difference is only of borderline significance and longer-term tracking would be useful to give further evidence of this apparent trend.

Table 3.3: Percentage who believe they can do something to make their own life healthier, by self-perceived health/age/social grade

%	1996	1997	1998	1999	2000	2001	2002	2003
All	76	76	77	78	-	79	80	79
Self-perceived health
Good	79	79	80	80	-	84	84	82
Fair	76	72	73	74	-	70	70	71
Poor	47	52	62	52	-	45	43	64
Age
16-24	86	85	90	92	-	91	90	83
25-34	84	85	88	92	-	93	88	91
35-44	81	87	84	87	-	85	91	86
45-54	79	81	77	79	-	79	80	80
55-64	67	57	68	61	-	58	72	69
65-74	43	45	43	37	-	50	44	49
Social grade
AB	88	82	86	85	-	85	83	84
C1	79	76	81	83	-	88	86	83
C2	80	81	77	75	-	80	79	81
D	73	74	75	79	-	68	76	71
E	59	59	62	63	-	58	67	65
Base: all respondents	1810	1765	1794	880	-	1757	1742	1720

Significant changes (p<0.05)

As for the other measures there were patterns of difference by both age and social grade. The vast majority of those in the youngest age groups believe they can influence their own health. This starts to fall in the 45-54 age group and was significantly lower each year for those aged 65-74. This reflects quite closely the pattern seen for long-standing illness. Those in the highest social grade (AB) tended to be most likely to feel they coul:d influence their own health, while social grade E respondents and those living in the most deprived areas were least likely to feel they could influence their own health. The proportion of C1 respondents believing they can influence their own health has increased over time so that there is now no difference between AB and C1 respondents. There has, however, been no consistent change over time for those in the lower social grades, nor were there any consistent time trends by DEPCAT.

The key gradients by sex and age are illustrated below in Figure 3.3, using the data collected in 2003.

Fig 3.3 Percentage who believe they can do something to make their own life healthier, by age/social grade

Base: all respondents 2003 (1720)

Those who felt their health was poor were considerably less likely to feel they could do something to make their own life healthier than those who considered their health to be good or fair. As discussed in Section 3.1 there is a strong correlation between self-perceived health, and age, social grade and deprivation. It is interesting, therefore, that there is a much greater difference in self-perceived control over health by age than by social grade.

Main points

• The majority of people felt that their health was good, although around
• a third reported a long-standing illness or disability and this has not changed over time.
• Most people felt that they could influence their own health and the number appears to have increased slightly over the last eight years. The increase has been greatest for those in social grade C1.
• Those in the lowest social grades and, in particular, older people were least likely to think their health was good, most likely to report a longstanding illness and least likely to feel they have any influence over their own health. This suggests that those groups most in need of improvements to their health are also likely to be those who are least open to health education messages because they don't believe they can influence their own health.

 

4. Perceptions of mortality, morbidity and risk

One of the main aims of health promotion is to ensure that people are aware of the major risks to their health and the means of achieving good health. For example, between 1996 and 2002 HEBS ran a public awareness-raising media campaign about the health risks associated with coronary heart disease, cancers and stroke (the Big 3 campaign) which featured core messages on the three diseases and a series of Top Tips ads related to specific actions to reduce the risk. This is now the focus of the Scottish Executive's healthyliving campaign, launched in 2003. A range of indicators was used in HEPS to assess knowledge levels in relation to the major causes of mortality and morbidity in Scotland as well as perceptions of personal risk and the preventability of ill-health.

 

4.1 Main cause of premature death

Respondents were asked in an open question what they thought was the main cause of premature death for people in Scotland (Figure 4.1).

Fig 4.1: Time trends in perceived main cause of death in Scotland, 1996-2003

Base: all respondents

Across all eight years covered by the survey, the majority regarded CHD as the main cause of premature death in Scotland. The salience of cancer has increased in recent years: the proportion mentioning cancer as the main cause of death in Scotland rose significantly between 1996 and 2003, while the proportion who identified CHD fell significantly from 1996 to 2001-3. Very few mentioned stroke at any time.

 

4.2 Perceptions of risk and preventability

The perception that CHD was a risk to personal health fell significantly over the eight years. The perceived risk from other diseases showed less clear trends with more fluctuation year on year. Although CHD is clearly regarded as the main cause of death among Scottish adults, more respondents felt personally at risk from cancer (Table 4.1).

Table 4.1: Perceived risk to own health

%	1996	1997	1998	1999	2000	2001	2002	2003
Cancer	66	64	66	66	-	61	63	69
CHD	61	54	52	56	-	49	50	53
Stroke	41	40	41	47	-	44	41	48
Mental illness/ depression	14	15	16	18	-	16	16	20
HIV/AIDS	5	5	4	3	-	5	3	3
Base: all respondents	1810	1795	1794	880	-	1757	1742	1720

Significant changes (p<0.05)

In terms of specific cancers, breast cancer was perceived as the greatest risk (around half of women), followed by lung cancer (around a third of all respondents). Smokers were more likely to feel at risk from lung cancer than other respondents, with three-quarters of regular smokers saying lung cancer was a risk to their personal health (Table 4.2). Men who smoked were more likely to feel at risk from lung cancer than women who smoked. While women were likely to be slightly lighter smokers than men, this does not explain the difference in perceptions - women who smoked heavily were less likely than men who smoked heavily to feel at risk from lung cancer.

Table 4.2: Perceived risk to own health from lung cancer, by sex (regular smokers)

%	1996	1997	1998	1999	2000	2001	2002	2003
All	76	76	77	77	-	72	76	78
Women	69	70	71	72	-	73	70	72
Men	84	83	83	80	-	72	83	84
Base: regular smokers	658	588	566	308	-	563	512	530

There was a difference in the perceived risk of breast cancer to women according to age. Women under 35 were most likely to believe they were at risk, with women aged 65 or over much less likely to believe they were at risk (Table 4.3). There was no evidence of consistent patterns of change over time.

Table 4.3: Perceived risk to own health from breast cancer, by age (women only)

%	1996	1997	1998	1999	2000	2001	2002	2003
All women	45	43	45	48	-	52	41	52
Age
16-24	57	54	51	61	-	68	61	64
25-34	57	53	58	42	-	67	46	65
35-44	46	54	49	46	-	53	39	54
45-54	43	42	54	69	-	52	45	48
55-64	41	23	31	38	-	34	30	47
65-74	20	18	18	28	-	25	21	23
Base: all women	925	954	916	449	-	894	886	992

Looking more closely at perceived risk of CHD by risk behaviours (Table 4.4), whilst it would appear that smokers are more likely to believe they are at risk than non-smokers, there are no similar consistent differences according to daily fruit and vegetable consumption or whether or not people meet the recommended physical activity levels.

Table 4.4: Perceived risk to own health from CHD, by smokers/not meeting recommended physical activity levels/not eating fruit and vegetables daily

%	1996	1997	1998	1999	2000	2001	2002	2003
All	61	54	52	56	-	49	50	53
Smoking	<