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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
Regular	69	59	59	61	-	52	52	57
Non/occasional	56	51	49	54	-	48	48	51
Meeting recommended physical activity levels
Not meeting levels	65	55	54	52	-	54	52	52
Meeting levels	58	53	51	59	-	47	49	53
Eating fruit and vegetables daily
Not daily	63	52	54	57	-	47	43	50
Daily	59	55	51	56	-	50	53	53
Base: all respondents	1810	1795	1794	880	-	1757	1742	1720

Significant changes (p<0.05)

Most respondents felt they could reduce the risk of getting cancer, CHD and AIDS/HIV (Table 4.5). Fewer felt anything could be done to reduce the risk of a stroke, despite relatively simple measures that can be taken to reduce blood pressure. However, the latter proportion rose significantly from 40% in 1996 to 52% by 1998 and has remained at a similar level since.

Table 4.5: Percentage believing they can reduce the risk of disease

%	1996	1997	1998	1999	2000	2001	2002	2003
Cancer	91	94	94	93	-	92	94	94
CHD	80	81	80	76	-	83	82	80
HIV/AIDS	81	81	82	74	-	81	79	80
Stroke	40	48	52	48	-	51	51	55
Mental illness/ depression	20	23	23	19	-	26	26	26
Base: all respondents	1810	1795	1794	880	-	1757	1742	1720

Significant changes (p<0.05)

While the majority of respondents felt the risk of cancer could be reduced, this varied for different types of cancer (Table 4.6). Most felt something could be done to prevent the onset of lung cancer (over eight in ten) and skin cancer (around three in four). On the other hand, fewer felt anything could be done to prevent bowel (or colorectal) cancer (around a third) or breast cancer (around a quarter).

Table 4.6: Percentage believing they can reduce the risk of skin, bowel and breast cancer

%	1996	1997	1998	1999	2000	2001	2002	2003
Skin cancer	67	74	73	73	-	72	77	77
Bowel cancer	23	33	34	31	-	34	37	36
Breast cancer	23	30	25	29	-	29	26	25
Base: all respondents	1810	1795	1794	880	-	1757	1742	1720

Significant changes (p<0.05)

There were significant increases in perceptions of the preventability of both bowel and skin cancer between 1996 and 1997, and there is some evidence that these increases may have continued over the longer term. Both of these topics have been the focus of media attention over the years, and this is likely to have contributed to the observed shifts in perception. This is of particular note in the case of bowel cancer, where there has been considerable publicity given to the medical evidence regarding the association between diet and the disease.

Despite this increased awareness over time, there has been a consistent social grade gradient. Those in social grades DE were least likely to believe that something could be done to reduce the risk of skin cancer (66% cf. 87% of ABs in 2003) or bowel cancer (29% cf. 53% of ABs in 2003). In the same way, those in the lowest social grades (DE) were less likely to believe that the risk of CHD could be reduced (74% cf. 89% of ABs in 2003). This is in keeping with the finding that those in the lower social grades were less likely to feel they could influence their own health (see Section 3.3).

4.3 Risk factors for coronary heart disease

Respondents were asked how important they thought various actions were in reducing the risk of CHD (Table 4.7). Each action was classified as very important, fairly important or not very important.

Table 4.7: Factors considered very important in reducing risk of coronary heart disease

%	1996	1997	1998	1999	2000	2001	2002	2003
Quitting/cutting down smoking	78	80	82	84	-	83	80	80
Taking regular exercise	66	70	72	72	-	76	78	77
Eating a healthy balance of foods	58	63	62	62	-	67	66	65
Controlling weight	54	57	56	57	-	61	63	61
Reducing stress	54	53	51	51	-	49	51	51
Eating lots of fruit and vegetables	50	56	58	56	-	56	57	53
Stopping/cutting down alcohol consumption	42	42	44	44	-	44	42	43
Regular checks on blood pressure	45	44	42	45	-	43	43	44
Regular cholesterol checks	40	40	38	43	-	40	39	40
Base: all respondents	1810	1795	1794	880	-	1757	1742	1720

Significant changes (p<0.05)

Respondents tended to identify the three factors generally regarded as most important - cutting down smoking, regular exercise and eating a healthy balance of foods. Over half mentioned controlling weight, reducing stress and eating lots of fruit and vegetables. The proportion identifying the following three risk factors showed consistent and significant increases over time:

• regular exercise
• eating a healthy balance of foods
• controlling weight

The proportion identifying quitting/cutting down smoking as a CHD risk factor is much higher. Whilst this appeared to show a rising trend between 1996 and 1999, this increase was not sustained in more recent years, and was not significantly higher in 2003 than it was in 1996.

It appears that the health benefits of exercise, healthy eating and weight management are becoming more salient among the Scottish population. However, while the proportion mentioning eating lots of fruit and vegetables increased from 1996 to 1998, data from future years are needed to confirm whether the apparent decline observed in the period 2001-2003 is the beginning of a downward trend or the result of random fluctuation in the data.

Main points

• While coronary heart disease was seen as the main cause of premature death by most respondents, the numbers declined significantly between 1996 and 2003, as did the proportion of respondents considering CHD as a personal risk.
• Cancer was seen as a greater risk to respondents' personal health than CHD and there was a significant increase in the proportions mentioning cancer as the main cause of premature death.
• There were significant increases in the proportions believing it was possible to reduce the risk of stroke, skin and bowel cancer.
• Those in the lower social grades were least likely to believe it was possible to reduce the risk of a number of diseases including CHD, skin cancer and bowel cancer.
• There were significant increases in awareness levels regarding the importance of regular exercise, healthy eating and weight control in reducing the risk of CHD.

5. Physical activity

Physical activity is an important protective factor against coronary heart disease and a number of other diseases. It is also associated with mental and social well-being. The current two-stage approach in Scotland is based on guidelines highlighting the health benefits of moderate intensity physical activity, or 'active living' (Scottish Executive 2002a; HEBS, 1997b) and is described in Section 2.2. The 'active living' message aims to maximise public health gain by targeting those who are sedentary, and thus at most risk from coronary heart disease. This group is likely to be less responsive to the traditional exercise guidelines involving three 20-minute sessions of vigorous exercise per week, and would therefore benefit from more achievable targets in relation to moderate physical activity. Health education campaigns to introduce the health benefits of moderate intensity physical activity have focused on brisk walking and were first introduced in Scotland in 1996.

Three indicators were used to assess behaviour in relation to physical activity: the first was a measure of physical inactivity, while the two other indicators assessed opportunity for and levels of physical activity. Being sedentary, or physically inactive, is considered to be a risk factor for coronary heart disease, and thus is defined as a risk behaviour for the purposes of this report.

5.1 Risk behaviour

Sedentary behaviour is calculated on the basis of reported levels of physical activity in an average week, as described in Section 5.3. The data indicates that there is a sizeable target group for the first stage of the current approach to promoting physical activity (Table 5.1), since around a third of the Scottish adult population can be classified as sedentary (no 20-minute sessions of vigorous activity and no 30-minute sessions of moderate activity per week).

It should be noted, however, that this classification is likely to result in an overestimation of the number of sedentary people, as it includes those who are active at both moderate and vigorous levels, but do not fulfil the current recommendations for either of these intensities. For instance, those who take two sessions of vigorous physical activity plus three sessions of moderate physical activity would be classed as sedentary because they do not reach three sessions of vigorous physical activity or five sessions of moderate physical activity. These questions used to derive levels of sedentary behaviour were only asked of half of respondents in 2002 as a new WHO measure of physical activity was being trialled with the other half of respondents. The apparent fall in the number of sedentary adults in 2002/2003 is of borderline significance; longer-term data are needed to determine whether these apparently lower levels in 2002 and 2003 will be sustained. Otherwise, there is no consistent pattern of change over time except that the proportion of sedentary respondents aged 25-34 has declined significantly.

There is no consistent marked sex difference in the percentage of respondents who are sedentary, although women were more likely to be sedentary than men. There is, however, a clear age gradient, with older people being more likely to be sedentary. Those in the lower social grades were more likely to be sedentary, particularly in the E group. There is generally a similar pattern by DEPCAT with those in the more deprived areas most likely to be sedentary, although this was not the case in 2002 - a finding which may be related to the smaller sample size.

Table 5.1: Percentage who are sedentary, by sex/age/social grade/DEPCAT

%	1996	1997	1998	1999	2000	2001	2002	2003
All	35	34	35	34	-	35	29	30
Sex
Men	34	28	33	27	-	35	26	26
Women	35	39	37	40	-	36	31	34
Age
16-24	21	23	28	17	-	20	16	17
25-34	36	31	26	26	-	25	20	22
35-44	28	28	23	27	-	31	26	29
45-54	40	29	36	39	-	41	21	30
55-64	38	46	53	48	-	48	46	38
65-74	51	56	58	59	-	56	54	55
Social grade
AB	28	30	24	20	-	27	21	19
C1	29	31	27	29	-	27	24	23
C2	33	33	34	35	-	31	30	32
D	39	35	36	32	-	44	31	37
E	47	49	68	56	-	63	51	51
DEPCAT
1-2	30	29	25	25	-	27	23	20
3-5	35	32	33	33	-	31	31	30
6-7	38	43	54	47	-	49	25	42
Base: all respondents, half sample in 2002	1810	1795	1794	880	-	1757	877	1720

Significant changes (p<0.05)

The key gradients by age, social grade and DEPCAT are illustrated in Figure 5.1 using the 2003 data.

Fig 5.1: Percentage who are sedentary, by age/social grade/DEPCAT, 2003

Base: all respondents 2003 (1720)

 

5.2 Active living

The amount of time respondents spend walking as part of their daily routine was used as one indicator of physical activity. This measure does not include leisure time walking or any indication of intensity of exercise, and is used to assess opportunity and inclination for 'active living' type exercise.

Around six in ten respondents reported walking at least 30 minutes on an average day (Table 5.2). Unlike sedentary behaviour, there was little consistent difference by age, although those aged 16-24 were slightly more likely to walk at least 30 minutes a day than older respondents - possibly due to younger respondents walking to school or college. The percentage walking at least 30 minutes a day was consistently slightly lower for women than for men.

Table 5.2: Percentage walking at least 30 minutes per day, by sex/social grade/DEPCAT

%	1996	1997	1998	1999	2000	2001	2002	2003
All	63	64	63	56	-	64	61	59
Sex
Men	65	67	68	56	-	69	64	62
Women	61	60	59	55	-	60	59	57
Social grade
AB	50	60	56	48	-	54	46	56
C1	63	58	60	52	-	61	64	57
C2	69	65	68	69	-	72	66	60
D	72	74	72	55	-	65	65	67
E	57	69	65	57	-	68	63	57
DEPCAT
1-2	64	58	57	52	-	60	57	56
3-5	61	66	64	57	-	62	61	60
6-7	68	62	68	58	-	71	68	61
Base: all respondents, half sample in 2002	1810	1795	1794	880	-	1757	877	1720

There was also an inverse correlation with social grade. Those in the highest social grades were least likely to have walked 30 minutes a day, rising for those in the C2D social grades, but generally falling again slightly for those in the E grade. The relatively high level of walking for the lower social grades may in part be explained by lack of access to amenities and transport, notably 'inverse care' patterns of provision where areas with relatively poor public transport systems are also those with low levels of car ownership. In addition, findings from the Scottish Household Survey show that those in the lower socio-economic groups tend to walk more as part of travelling to work (Scottish Executive, 2002c). Relatedly, proximity to the home may be an important factor in seeking employment when access to transport is problematic, thus restricting employment prospects (Bailey et al, 1999). These issues raise a question regarding the extent to which walking patterns can be considered to be an indicator of a healthier lifestyle rather than an outcome of relative deprivation for some sectors of the population. The gradient by DEPCAT supports this finding. Since lack of car ownership is one of the factors making up the DEPCAT measure, it is perhaps not surprising that those in the least affluent postcode sectors tend to be more likely to walk at least 30 minutes per day than those in the most affluent areas.

5.3 Protective behaviour

The current recommended levels of activity in terms of health benefits and protection against coronary heart disease are five or more moderate sessions, or three or more vigorous sessions, per week. These measures of physical activity are therefore based on the intensity, frequency and duration of sessions taken. Respondents are asked a series of questions on the types of physical activity they do in an average week. The number of 30-minute sessions of moderate activity or 20-minute sessions of vigorous activity is used to derive a summary activity level, and those achieving the recommended levels for moderate or vigorous activity are classified as regular exercisers (the questions on physical activity can be found in Appendix A and the method used to derive the summary activity level is described in Appendix D). As explained in Section 5.1, in 2002 only half of respondents were asked these questions.

Table 5.3 Percentage achieving recommended levels of physical activity, by sex/age/social grade/DEPCAT

%	1996	1997	1998	1999	2000	2001	2002	2003
All	36	39	36	39	-	36	42	43
Sex
Men	41	50	41	46	-	43	50	49
Women	31	29	31	32	-	30	36	37
Age
16-24	52	44	41	39	-	46	59	57
25-34	39	47	44	58	-	49	57	53
35-44	40	44	49	40	-	44	38	40
45-54	28	42	31	34	-	32	40	46
55-64	30	27	23	31	-	22	32	31
65-74	24	19	17	20	-	11	21	23
Social grade
AB	35	36	42	44	-	36	41	45
C1	38	41	37	47	-	38	45	45
C2	39	43	39	42	-	46	47	50
D	38	46	39	51	-	33	42	40
E	30	25	18	32	-	19	28	29
DEPCAT
1-2	38	39	40	49	-	45	45	47
3-5	37	41	37	35	-	37	42	44
6-7	34	32	26	38	-	30	43	37
Base: all respondents, half sample in 2002	1810	1795	1794	880	-	1757	877	1720

Significant changes (p<0.05)

In 1996 just over a third of respondents attained the recommended levels of moderate or vigorous activity, and there was a slight increase over the eight-year period of the survey (Table 5.3). The observed results are very similar to those from the 1998 Scottish Health Survey (Shaw et al, 2000). Men were more active than women on the whole. Those in social grade E are least likely to be regular exercisers. There appear to be generally increasing trends for those in the ABC1C2 social grades. Except in 2002, those in the least affluent DEPCAT areas were less likely to achieve the recommended levels of activity than those in more affluent areas.

In most years of the study, levels of physical activity were fairly similar for those aged 44 and under, but start to decline for older respondents. This is in contrast to levels of daily walking where older respondents were generally as likely to walk for at least 30 minutes a day as younger respondents. It is difficult to find any patterns of change over time by age, as the results fluctuate somewhat year on year.

Figure 5.2 illustrates the overall trends in the three measures of physical activity discussed in this section.

Fig 5.2: Trends in physical activity, 1996-2003

Base: all respondents

 

5.4 Knowledge

The knowledge indicator for physical activity used in HEPS to date is geared towards the old health education messages that emphasised the health benefits of accumulating at least 30 minutes of moderate intensity physical activity per day. Since 2003, however, the message has been revised to a frequency of at least five days a week and this is the measure that should be tracked in future survey waves. This report is, however, concerned with knowledge of the message that would have been current at the time of fieldwork. Respondents were asked how many minutes per day of moderate activity, such as brisk walking or heavy gardening, were required in order to keep healthy. Knowledge of the recommended levels was not particularly widespread as approximately a third of respondents gave the correct answer of around 30 minutes per day (Table 5.4). Around half thought that they needed to do more than 30 minutes (most saying at least an hour), and it is possible that such beliefs might represent a disincentive to take up moderate activity. In addition, there appears to be a shift over time, from respondents underestimating the recommended levels to overestimating them.

Table 5.4: Knowledge of recommended levels for moderate activity

%	1996	1997	1998	1999	2000	2001	2002	2003
All
25 minutes or less	16	21	12	18	-	12	11	11
26-30 minutes	30	35	34	36	-	30	35	32
Over 30 minutes	47	40	49	43	-	53	51	56
Sedentary
25 minutes or less	14	34	12	17	-	16	11	15
26-30 minutes	30	30	33	39	-	29	42	31
Over 30 minutes	45	29	47	39	-	49	44	51
Base: all respondents	1810	1795	1794	880	-	1757	1742	1720
Base: all sedentary	632	606	700	329	-	586	544	509

Significant changes (p<0.05)

Respondents classified as sedentary were no less likely to be aware of the recommended levels. There was, however, a difference in knowledge by social grade (Table 5.5). Just as those in the lower social grades were more likely to be sedentary and less likely to achieve the recommended levels of physical activity, they were also least likely to be aware of the recommended levels of moderate activity. The pattern for DEPCAT is less clear, but in general terms, those living in the more deprived areas were least likely to be aware of the recommended levels of moderate activity.

Table 5.5: Percentage who know that 26-30 minutes of moderate activity weekly, recommended by social grade/DEPCAT

%	1996	1997	1998	1999	2000	2001	2002	2003
All	30	35	34	36	-	30	35	32
Social grade
AB	40	37	45	48	-	37	43	34
C1	31	42	35	34	-	34	34	35
C2	33	30	31	39	-	29	36	30
DE	24	28	30	31	-	22	31	29
DEPCAT
1-2	27	42	43	35	-	34	39	38
3-5	30	35	35	39	-	29	35	31
6-7	33	29	22	28	-	28	32	28
Base: all respondents, half sample in 2002	1810	1795	1794	880	-	1757	877	1720

5.5 Motivation

In general, over half of respondents had tried or wanted to increase their levels of physical activity, although motivation is lower for those who are sedentary (Table 5.6). Over the eight years there does not appear to have been any consistent change in motivation. More recently there appears to have been a shift from those not contemplating change towards those who have tried to increase their activity levels, although this change is only of borderline significance, and this was not the case for sedentary respondents.

Table 5.6: Motivation to increase activity levels

%	1996	1997	1998	1999	2000	2001	2002	2003
All
Not contemplating	44	44	51	48	-	42	39	38
Would like to	18	16	16	17	-	20	19	18
Have tried	37	40	33	35	-	38	42	44
Sedentary
Not contemplating	56	52	66	53	-	50	49	53
Would like to	21	18	16	22	-	25	23	19
Have tried	23	30	19	25	-	25	28	28
Base: all respondents	1810	1795	1794	880	-	1757	1742	1720
Base: all sedentary	632	606	700	329	-	586	544	509

Significant changes (p<0.05)

The changes over time in motivation to increase physical activity are illustrated in Figure 5.3. This shows clearly the move away from those who are not contemplating change, towards those who have tried to change, or would like to change, since 1999.

Fig 5.3: Trends in motivation to increase physical activity (tried to or would like to change), 1996-2003

Base: all respondents

Main points

• Younger respondents were least likely to have a sedentary lifestyle, as were those from higher socio-economic groups.
• There is some indication of a slight decrease over time in sedentary behaviour, and a corresponding increase in protective behaviour. This increase is restricted to those in the higher social grades.
• Around one third are aware of the minimum recommended levels of moderate intensity physical activity; there has been no change in these knowledge levels.
• Those in the lower social grades were more likely to be sedentary and less likely to be aware of the recommended levels of moderate activity. However, they were most likely to walk more than 30 minutes on an average day, possibly out of necessity rather than as a health-related choice.
• Men were more likely than women to achieve the recommended levels of physical activity, as were the under 45s compared with older respondents.
• Levels of motivation to take more exercise remained largely unchanged from 1996 to 2003, but there appears to be a small shift more recently away from those not contemplating change towards those who have tried to change.

 

6. Diet

Healthy eating is of particular relevance to health promotion given its implications for cardiovascular disease‚ cancers‚ oral health and the rising levels of childhood obesity. It has also been shown that high consumption of fruit and vegetables is associated with reduced risks of cardiovascular disease and certain cancers (National Forum for Coronary Heart Disease Prevention‚ 1995; World Cancer Research Fund/American Institute for Cancer Research‚ 1997). The current dietary target for fruit and vegetables is to increase the current average intake to at least 400g (five portions) per day by the year 2005 (SODoH‚ 1996). There has been a high level of concerted health education activity across all sectors in Scotland‚ focused on the 5-a-day message during the survey period.

For the purposes of this survey‚ eating fruit and vegetables daily is used as a proxy indicator of a generally healthy diet‚ since good nutrition has been found to be particularly strongly correlated with a high consumption of fruit and vegetables (Blaxter‚ 1990). Additional analyses of the HEPS data shows that respondents consuming fruit and vegetables daily had a healthier diet in terms of eating more complex carbohydrate and fish and less sugar and high-fat foods than other respondents‚ and were more likely to have tried to change their diet in the past year to improve their health.

 

6.1 Risk behaviour

There has been a significant reduction in dietary risk behaviour over time with improvement in daily fruit and vegetable consumption during the 1996-2003 survey period. In 1996‚ over four in ten respondents did not eat fruit or vegetables daily‚ compared to around three in ten in 2002-2003 (Table 6.1).

This trend is supported by findings from the Scottish Health Survey that showed significant increases in the proportions of respondents eating fresh fruit daily between 1995 and 1998 (Shaw et al‚ 2000). Daily consumption has increased for both men and women and for all social grades since 1996‚ but has not increased for those living in more deprived areas. Men have been consistently less likely to eat fruit and vegetables daily‚ as have those in social grades C2DE and those living in the more deprived areas (DEPCAT 6-7).

The likelihood of daily fruit and vegetable consumption increases with age; younger respondents were least likely to eat fruit and vegetables daily. There have been significant increases in daily fruit and vegetable consumption for most age groups since 1996‚ with the exception of those aged 16-24. Over four in ten of this age group still did not consume fruit and vegetables daily in 2003.

Table 6.1: Percentage not eating fruit and vegetables daily, by sex/age/social grade/DEPCAT

%	1996	1997	1998	1999	2000	2001	2002	2003
All	43	36	39	37	–	33	31	31
Sex
Men	48	41	44	39	–	39	40	37
Women	39	31	34	35	–	28	23	25
Age
16-24	44	46	47	57	–	37	44	42
25-34	51	38	52	41	–	35	36	34
35-44	49	35	33	32	–	34	32	30
45-54	41	36	36	34	–	32	27	26
55-64	28	31	33	31	–	32	22	26
65-74	41	25	24	25	–	28	23	25
Social grade
ABC1	35	26	31	26	–	21	25	23
C2DE	49	45	46	47	–	44	37	38
DEPCAT
1-2	39	27	26	24	–	24	20	20
3-5	43	35	40	39	–	38	31	31
6-7	47	45	50	48	–	50	45	43
Base: all respondents	1810	1795	1794	880	–	1757	1742	1720

Significant changes (p<0.05)

This means there is a growing divergence in patterns of daily fruit and vegetable consumption between those living in affluent and deprived areas and between young people (16-24) and older age groups. This is clearly illustrated in Figure 6.1 below.

Figure 6.1: Percentage not eating fruit and vegetables daily by DEPCAT 1996-2003

Base: all respondents

 

6.2 Protective behaviour

In line with the Scottish dietary targets‚ a key health recommendation over the past few years has been to eat at least five portions of fruit and vegetables a day. When asked how many portions they had eaten the previous day‚ around one in five had consumed the recommended amount in 1996 rising significantly to almost three in ten in 2003 (Table 6.2). This trend of dietary improvement is supported by findings from the Scottish Health Survey (Shaw et al‚ 2000). However‚ Figure 6.2 shows results from the National Food Survey that indicate a decrease in the average consumption of fruit and vegetables per person per week in Scotland between 1997 and 2000 (DEFRA‚ 2001).

Figure 6.2: Consumption of fruit and vegetables in Scotland‚ 1997-2000‚ National Food Survey (grams per person per week)

As shown in Table 6.2‚ women and respondents in social grades AB were more likely than men and those in the lower social grades to have consumed the recommended amount of fruit and vegetables. The percentage of women and those in social grades AB eating the recommended amount increased significantly over the eight years. The evidence for an increase for those in the lower social grades is less clear‚ although the 2003 data suggest a possible increase more recently. Further years’ data are needed to determine if this constitutes a genuine upward trend.

Table 6.2: Percentage eating at least five portions daily by sex/age/social grade/ DEPCAT

%	1996	1997	1998	1999	2000	2001	2002	2003
All	18	21	22	24	–	23	28	29
Sex
Men	14	17	16	22	–	16	21	21
Women	22	25	28	27	–	29	36	36
Age
16-24	12	15	15	9	–	15	15	19
25-34	12	20	17	20	–	23	26	28
35-44	19	17	22	33	–	23	30	27
45-54	22	24	25	28	–	26	32	34
55-64	27	28	27	35	–	20	35	34
65-74	22	25	29	24	–	34	30	31
Social grade
AB	27	23	35	44	–	35	41	47
C1	21	27	26	25	–	32	29	28
C2	18	17	15	20	–	15	20	28
DE	13	17	14	18	–	13	25	20
DEPCAT
1-2	27	27	30	28	–	28	40	41
3-5	17	20	20	25	–	26	27	27
6-7	15	18	16	18	–	12	19	20
Base: all respondents	1810	1795	1794	880	–	1757	1742	1720

Significant changes (p<0.05)

There is a clear gradient by DEPCAT with those in the more deprived areas least likely to eat five portions or more a day. It is difficult to discern any clear pattern of change over time although there does appear to have been an increase over time for those in the most affluent areas. This is illustrated in Figure 6.3.

Fig 6.3: Percentage eating at least five portions daily‚ by DEPCAT

Base: all respondents

There was a relatively consistent age gradient for fruit and vegetable consumption (Table 6.2)‚ with the percentage consuming the recommended daily amount increasing with age. As for daily fruit consumption‚ there has been a significant increase over time in the percentage eating five portions of fruit and vegetables daily for most age groups‚ with the probable exception of those aged 16-24. The increase is less marked for those aged 55-64 but people in this age group were amongst those most likely to achieve the recommended limits almost every year.

While consideration of the proportion of people consuming the recommended amount is useful in terms of measuring progress toward the current dietary targets‚ this does not provide much information on the behaviour of those who are not consuming the recommended amount. The mean number of portions eaten is approximately three per day (Table 6.3). Average consumption is higher for women than men. There is a clear social grade gradient‚ with consumption being highest for AB respondents. There is a similar gradient by DEPCAT. Consumption of fruit and vegetables also increases with age. There appear to be increasing trends across time‚ with the exception of those aged 16-24. However‚ the increase is small and average consumption is still well short of the target.

Table 6.3: Mean number of portions of fruit and vegetables consumed per day‚ by sex/age/social grade/DEPCAT

%	1996	1997	1998	1999	2000	2001	2002	2003
All	2.8	3.0	2.9	3.1	–	3.1	3.3	3.4
Sex
Men	2.5	2.7	2.5	2.8	–	2.7	2.8	2.9
Women	3.1	3.3	3.3	3.3	–	3.4	3.8	3.8
Age
16-24	2.6	2.5	2.4	2.2	–	2.5	2.4	2.7
25-34	2.2	2.6	2.5	2.8	–	3.0	3.3	3.1
35-44	2.9	2.9	3.1	3.3	–	3.1	3.5	3.4
45-54	3.3	3.2	3.3	3.4	–	3.4	3.6	3.7
55-64	3.3	3.6	3.1	3.5	–	3.0	3.8	3.7
65-74	2.9	3.4	3.7	3.4	–	3.8	3.5	3.6
Social grade
AB	3.6	3.5	3.8	4.4	–	3.9	4.1	4.4
C1	3.2	3.3	3.2	3.1	–	3.5	3.5	3.4
C2	2.8	2.5	2.6	2.7	–	2.7	2.9	3.1
D	2.3	2.7	2.3	2.6	–	2.8	3.1	2.9
E	2.2	2.4	2.5	2.7	–	2.2	2.9	2.8
DEPCAT
1-2	3.5	3.5	3.6	3.5	–	3.5	3.9	4.1
3-5	2.7	3.0	2.8	3.0	–	3.3	3.3	3.3
6-7	2.5	2.6	2.5	2.7	–	2.3	2.8	2.7
Base: all respondents	1810	1795	1794	880	–	1757	1742	1720

Changes over time in terms of fruit and vegetable consumption are illustrated in Figure 6.4. This shows clearly the decrease in those not eating vegetables daily‚ and the associated increase in the proportion eating five or more portions a day.

Fig 6.4: Time trends in fruit and vegetable consumption‚ 1996-2003

Base: all respondents

 

6.3 Knowledge

There has been a significant increase in the percentage who‚ when asked how many portions of fruit and vegetables they should eat per day‚ gave an answer of five or more (Table 6.4).

%	1996	1997	1998	1999	2000	2001	2002	2003
All	19	29	36	35	–	42	50	59
Fruit and vegetable consumption
Daily	26	37	46	43	–	52	58	68
Non-daily	10	14	21	21	–	22	32	39
Sex					–
Men	13	18	23	25	–	28	38	48
Women	26	39	48	45	–	56	62	70
Social grade
AB	33	35	48	58	–	60	60	76
C1	24	39	43	42	–	49	58	67
C2	15	20	34	27	–	39	45	53
DE	13	21	24	22	–	27	38	47
DEPCAT
1-2	26	38	53	45	–	52	62	76
3-5	18	28	33	33	–	45	50	60
6-7	17	24	26	27	–	28	38	38
Base: all respondents	1810	1795	1794	880	–	1757	1742	1720

Significant changes (p<0.05)

Knowledge levels have risen from two in ten in 1996 to six in ten in 2003. In line with the 5-a-day message‚ the majority of respondents cited the exact amount of five portions per day (59% in 2003).

Those who do not currently consume fruit and vegetables daily are notably less likely to be aware that they should be eating at least five portions a day. However‚ even among this group‚ awareness rose significantly between 1996 and 2003. As would be expected‚ knowledge levels were lower amongst those groups who were less likely to eat fruit and vegetables daily (e.g. those in the lower social grades and those in less affluent DEPCAT areas) but the difference between men and women was greater than could be explained by their differences in consumption. It is possible that‚ at least for some men‚ the family menu is set by their (female) partner and thus they may eat fruit and vegetables daily without being aware of the recommendations. There is no consistent pattern of difference by age‚ but those aged 65-74 tended to be less likely to be aware of the recommended levels.

 

6.4 Motivation

There appears to be a small change‚ of borderline significance‚ towards increasing motivation to eat more healthily. Until 1999‚ around half had either tried to eat more healthily or would like to do so‚ whereas from 2001 this increased to around six in ten (Table 6.5).

Table 6.5: Motivation to eat more healthily

%	1996	1997	1998	1999	2000	2001	2002	2003
All
Not contemplating	47	47	49	50	–	42	42	40
Would like to	11	11	11	8	–	10	14	10
Have tried	42	43	41	42	–	48	45	51
Not eating fruit and vegetables daily
Not contemplating	49	46	49	45	–	46	34	46
Would like to	13	15	13	14	–	13	22	16
Have tried	38	39	37	42	–	41	44	40
Base: all respondents	1810	1795	1794	880	–	1757	1742	1720
Base: all not daily	732	939	700	329	–	586	544	509

Significant changes (p<0.05)

For those who did not eat fruit and vegetables daily‚ their motivation to eat more healthily stayed at much the same level until 2002 when it rose to 66%. In 2003 motivation levels fell off again and returned to former levels amongst this key target group. Further data are needed to determine any longer-term patterns.

Figure 6.5 illustrates the clear change over time in both knowledge of recommended levels of consumption‚ and in motivation to eat more healthily.

Fig 6.5: Time trends in knowledge of recommended fruit and vegetable consumption and motivation to eat more healthily (tried to or would like to)‚ 1996-2003

Base: all respondents

 

6.5 Breastfeeding in public

Breastfeeding is another aspect of protective dietary behaviour and an aspect of the Scottish diet where there have been significant improvements. 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 rose from 34.6% in 1999 to 36.5% in 2003 (ISD‚ 2004). Improvements in breastfeeding are evident in both deprived and affluent areas. The Scottish Health Survey records 85% of mothers from deprived areas not breastfeeding at 6-8 weeks compared to 51% from affluent areas but by 2002 the proportion of mothers not breastfeeding had fallen to 76% and 44% respectively (Scottish Executive‚ 2003).

For some years‚ 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 directed at encouraging positive attitudes amongst the general public towards breastfeeding in public places so that mothers feel more comfortable breastfeeding their babies in a variety of settings. From 1997‚ HEPS respondents were asked to what extent they agreed with a series of statements about breastfeeding. The results are shown in Tables 6.6-6.8.

Table 6.6: Agree that women should be made to feel more comfortable breastfeeding in public, by age

%	1996	1997	1998	1999	2000	2001	2002	2003
All	–	84	82	82	–	88	88	88
Age
16-24	–	78	82	64	–	91	85	90
25-34	–	91	91	93	–	92	90	91
35-44	–	88	91	90	–	94	92	92
45-54	–	83	80	81	–	90	91	88
55-64	–	92	68	81	–	86	84	84
65-74	–	71	74	74	–	65	79	81
Base: all respondents	–	1795	1794	880	–	1757	1742	1720

Significant changes (p<0.05)

Attitudes towards breastfeeding were generally very positive with almost nine in ten agreeing that women should be made to feel more comfortable breastfeeding in public (Table 6.6). There is some evidence that attitudes towards breastfeeding have become more positive over time as there was a significant increase in the percentage agreeing with this statement from 1998 to 2001. This may be due to the shift in attitudes among those aged 16-24: agreement with the statement rose from eight in ten in 1997 to nine in ten in 2003. Those aged 65-74 were generally less likely to agree with this statement than younger respondents. There were no consistent differences between men and women.

Table 6.7: Disagree that women should only breastfeed at home or in private‚ by age/social grade

%	1996	1997	1998	1999	2000	2001	2002	2003
All	–	73	73	74	–	78	82	81
Age
16-24	–	70	74	59	–	79	81	81
25-34	–	82	84	89	–	89	85	87
35-44	–	80	81	82	–	87	87	88
45-54	–	76	68	74	–	79	85	85
55-64	–	65	59	67	–	72	75	71
65-74	–	54	65	60	–	46	68	64
Social grade
AB	–	79	75	76	–	85	87	90
C1	–	76	75	85	–	76	82	85
C2	–	71	73	71	–	81	81	79
DE	–	67	70	65	–	73	77	72
Base: all respondents	–	1795	1794	880	–	1757	1742	1720

Significant changes (p<0.05)

There was a significant shift in attitudes regarding the statement that women should only breastfeed at home or in private. In 1997‚ three in four disagreed but this had risen to over eight in ten by 2002 and 2003 (Table 6.7). The pattern of attitudes by age was similar to that seen for the previous statement. The oldest respondents were most negative‚ and while the youngest respondents started out slightly more negative‚ by 2002 they were no more negative than those aged 25-54. There was also a gradient by social grade with those in the lower social grades more negative to breastfeeding in public. There was some evidence‚ however‚ that attitudes were changing and becoming more positive over time.

Reactions to the third statement were equally positive. Over eight in ten disagreed that they would feel embarrassed to see a woman breastfeeding (Table 6.8). The number who disagreed increased significantly from 1997 to 2003‚ with attitudes becoming more positive. There was no consistent pattern by age but men were less positive‚ being more likely than women to say they would be embarrassed. There is some evidence that men are becoming less embarrassed and more positive over time.

Table 6.8: Disagree that would be embarrassed to see a woman breastfeeding‚ by sex

%	1996	1997	1998	1999	2000	2001	2002	2003
All	–	81	80	80	–	87	85	86
Sex
Men	–	75	77	76	–	85	81	83
Women	–	86	82	84	–	89	89	89
Base: all respondents	–	1795	1794	880	–	1757	1742	1720

Significant changes (p<0.05)

Figure 6.6 shows this positive change over time in relation to all three of these attitude measures.

Fig 6.6: Time trends in attitudes to breastfeeding‚ 1997-2003

Base all respondents

Main points

• Consumption of fruit and vegetables was higher among women‚ olderrespondents and those from higher socio-economic groups.
• There was a significant increase over time among all respondentsin terms of consuming the recommended amount of fruit andvegetables‚ with the exception of the youngest age group (aged16-24) and those living in the more deprived areas.
• There have been significant overall increases in knowledge levelsregarding the current recommendation for fruit and vegetable intake.
• Attitudes towards breastfeeding in public are changing and becomingvery positive‚ although the oldest respondents tend to be slightly lesspositive. Attitudes amongst the youngest respondents (16-24) haveshown the greatest shift over time and are now more in line with thoseof other respondents.

 

7. Smoking

Smoking is the single largest preventable cause of illness and premature death in Scotland and is a major risk factor for CHD and cancer‚ contributing to approximately 30% of all cancer deaths. Passive smoking also has health implications for non-smokers in terms of increased risk of CHD‚ lung cancer and asthma. For health education‚ the aims are to educate people about the harmful effects of smoking‚ to motivate and enable smokers to quit‚ and to improve access to smoke free environments (HEBS‚ 1995). In Scotland‚ preventative health education activities have focused on school age children and young people. For adults‚ the main efforts are around encouraging smokers to quit‚ using a combination of media communications that publicise the services of the telephone helpline‚ Smokeline (since 1992)‚ and extending the network of local smoking cessation services and the use of nicotine replacement therapy (since 1999). More recently (since 2003)‚ educational efforts have turned to increasing awareness of the harmful effects of passive smoking and changing attitudes to‚ and the availability of‚ smoke-free environments.

 

7.1 Risk behaviour

Respondents were asked whether they smoked nowadays‚ even if only occasionally (Table 7.1).

Table 7.1: Percentage of regular smokers‚ by age/social grade/DEPCAT

%	1996	1997	1998	1999	2000	2001	2002	2003
All	36	33	32	35	–	32	29	29
Sex
Men	36	32	32	40	–	32	30	29
Women	37	34	31	30	–	32	30	29
Age
16-24	32	25	34	47	–	25	32	27
25-34	48	43	34	44	–	36	33	36
35-44	35	35	31	38	–	35	35	34
45-54	37	36	36	28	–	29	29	26
55-64	29	25	33	27	–	38	25	29
65-74	32	25	15	17	–	26	16	17
Social grade
AB	16	16	13	17	–	11	14	13
C1	28	26	22	35	–	23	27	26
C2	37	40	36	30	–	34	31	34
D	47	42	47	52	–	52	42	33
E	54	48	52	37	–	53	42	44
DEPCAT
1-2	24	20	21	34	–	19	21	19
3-5	37	33	31	34	–	26	31	30
6-7	43	45	47	41	–	52	35	39
Base: all respondents	1810	1795	1794	880	–	1757	1742	1720

Significant changes (p<0.05)

Around one in three respondents said they smoked regularly (slightly higher in 1996) and around 4% said they smoked occasionally. Men and women were equally likely to be regular smokers. There was no clear pattern for age differences. There was no significant change in the overall prevalence of smoking over time‚ although it had decreased significantly for the 25-34 and 45-54 age groups. The figures for 2002 and 2003 suggest there may be a downward trend in smoking prevalence‚ but longer-term data are needed to confirm this.

Data on smoking trends for adults aged 16-64 years from the Scottish Household Survey (SHoS) do‚ however‚ also indicate a downward trend between 1999 and 2002 (Figure 7.1). For men‚ the smoking rate has decreased from 36% in 1998 to 31% in 2002‚ with an apparent decline among men in deprived areas‚ but little change among women. The overall adult smoking rate is about 2% lower in HEPS than the Scottish Household Survey‚ probably because of the inclusion of adults up to the age of 74 years.

Fig 7.1: Adult cigarette smoking trends in Scotland‚ 1996-2003

Base: all respondents

In all years‚ there was a clear social grade gradient‚ with the highest prevalence observed for social grade E. There was a similar gradient by DEPCAT area. This is clearly illustrated in Figure 7.2 overleaf using 2003 data.

Fig 7.2: Percentage of regular smokers‚ by social grade/DEPCAT‚ 2003

 

Differences were also found between light‚ medium and heavy smokers (Table 7.2). Light smokers were defined as those who smoked fewer than ten cigarettes per day‚ medium smokers as those smoking between ten and 19 per day and heavy smokers as those smoking 20 or more cigarettes per day.

Table 7.2: Number of cigarettes smoked per day‚ by sex

%	1996	1997	1998	1999	2000	2001	2002	2003
All	10	10	11	23	–	13	15	12
Light (<10 per day)
Medium (10-19 per day)	41	47	43	43	–	46	49	42
Heavy (20+ per day)	49	43	46	33	–	41	36	43
Men
Light (<10 per day)	9	6	10	30	–	13	13	11
Medium (10-19 per day)	43	46	39	47	–	46	49	42
Heavy (20+ per day)	48	48	51	24	–	40	37	47
Women
Light (<10 per day)	10	13	12	15	–	12	15	12
Medium (10-19 per day)	39	47	48	39	–	45	49	43
Heavy (20+ per day)	50	39	41	46		43	34	45
Base: regular smokers	658	588	566	308	–	563	512	530
Base: male smokers	317	266	283	172	–	281	246	227
Base: female smokers	341	321	283	136	–	282	266	303

Overall‚ there were relatively few light smokers. Whilst between 1997 and 1999 men appeared to be more likely than women to be heavy smokers‚ this was no longer the case in the period 2001-3. There was a generally consistent pattern for age in this respect (Table 7.3). Heavy smoking increased with age until the 45-54 age group‚ then declined for older respondents. There were no clear patterns of difference for social grade or DEPCAT.

Table 7.3: Percentage of heavy smokers‚ by age

%	1996	1997	1998	1999	2000	2001	2002	2003
All	48	43	46	33	–	41	36	46
16-24	27	27	21	12	–	16	13	25
25-34	50	33	40	24	–	26	36	46
35-44	59	59	52	51	–	49	35	55
45-54	60	53	60	54	–	67	51	52
55-64	57	45	58	45	–	33	46	50
65-74	31	38	48	34	–	63	39	35
Base: regular smokers	658	588	566	308	–	563	512	530

It is difficult to assess change over time as the number of respondents who are regular smokers is relatively small and so the figures are subject to considerable fluctuation year on year.

 

7.2 Motivation

Most regular smokers either wanted to cut down or quit smoking. Around half of all regular smokers tried to cut down or quit at some time (Table 7.4). Only around a fifth were not contemplating changing their smoking behaviour‚ and heavy smokers showed very similar results in this respect.

Table 7.4: Motivation to cut down or quit smoking

%	1996	1997	1998	1999	2000	2001	2002	2003
Regular smokers
Not contemplating	22	20	23	16	–	16	17	24
Would like to	31	32	27	32	–	26	35	27
Have tried	48	48	50	52	–	58	48	49
Heavy smokers
Not contemplating	20	22	22	16	–	18	19	21
Would like to	36	40	32	41	–	34	43	34
Have tried	44	38	46	44	–	49	38	44
Base: regular smokers	658	588	566	308	–	563	512	530
Base: heavy smokers	323	253	259	103	–	233	183	235

Main points

• A clear social gradient in smoking patterns is apparent by social grade and deprivation‚ with respondents from social grade AB showing the lowest prevalence.
• There was no significant change in the overall prevalence of smoking over time‚ except in the 25-34 and 45-54 age groups where smoking has decreased significantly.
• Most regular smokers are motivated to cut down or quit smoking; there has been no significant change in levels of motivation over time.

 

8. Alcohol

Alcohol is a major cause of liver cirrhosis and a risk factor for high blood pressure‚ several types of cancer and a number of other health problems. Excessive or inappropriate use of alcohol also increases the risk of accidents and crime‚ and is associated with a variety of social problems. The recent Plan for Action on Alcohol Problems (Scottish Executive‚ 2002) recognises this explicitly in its key priorities: reducing binge drinking and reducing harmful drinking by children and young people. Health education activities have been mainly focused on young people‚ with the HEBS Think About It campaign targeting 12-17 year olds and the Scottish Executive campaign targeting 16-25 year olds. Other health education work in Scotland has focused on raising awareness of alcohol problems in the workplace.

As discussed in Section 2‚ the current sensible drinking guidelines consist of daily benchmarks. However‚ because awareness of this is low‚ knowledge of recommended drinking limits is perhaps more realistically assessed in relation to the better-established weekly limits. The maximum recommended limits for alcohol consumption as set out in Towards a Healthier Scotland (The Scottish Office‚ 1999) are 14 units for women and 21 units for men per week. For the purposes of the survey‚ respondents were classified as ‘drinkers’ if they had consumed any alcohol in the past year.

 

8.1 Risk behaviour

Respondents classified as ‘drinkers’ were asked if they had drunk any alcohol in the past week and how much they had consumed of each type of alcohol. In relation to sensible drinking behaviour‚ around 15% of respondents could be classified as exceeding the recommended weekly limits described above‚ and this has remained fairly stable over time (Table 8.1). Men were two to three times as likely as women to exceed the limits. There is no evidence of any change over time.

Table 8.1 Percentage exceeding recommended weekly limits for alcohol‚ by sex

%	1996	1997	1998	1999	2000	2001	2002	2003
All	16	15	15	17	–	18	17	16
Men	25	24	21	26	–	27	26	25
Women	7	6	10	8	–	9	9	8
Base all respondents:	1810	1795	1794	880	–	1757	1742	1720

For both sexes‚ older people are less likely to exceed the weekly limits (Table 8.2). This differential is more marked for women than men‚ and may be explained by lifecourse effects such as family responsibilities. It is difficult to discern any pattern across time. Despite some fluctuation in the figures for men and women aged 16-24‚ in the longer term there does not appear to be any change over time. The apparent rise in consumption for young women in 1998 may be related to the addition of a question on alcoholic soft drinks in that year; as these drinks are most commonly drunk by the youngest age group‚ this change in methodology would be likely to affect this group more than others (Shaw et al‚ 2000). This apparent increase was‚ however‚ not sustained and may be the result of random variation in the population.

Table 8.2: Percentage exceeding recommended weekly limits for alcohol‚ by sex and age

%	1996	1997	1998	1999	2000	2001	2002	2003
Women	7	6	10	8	–	9	9	8
Women by age
16-24	17	13	30	18	–	16	14	16
25-34	15	8	7	8	–	11	12	7
35-44	4	4	8	7	–	6	8	7
45-54	5	7	11	4	–	9	9	6
55-64	1	4	1	6	–	8	2	9
65-74	1	1	2	2	–	2	4	*
Men	25	24	21	26		27	26	25
Men by age
16-24	33	26	17	57	–	43	32	32
25-34	33	22	29	18	–	31	27	36
35-44	30	35	22	33	–	28	30	19
45-54	22	19	24	15	–	24	26	25
55-64	14	21	16	17	–	13	24	16
65-74	6	15	11	7	–	20	9	15
Base: all men	886	841	879	431	–	863	856	728
Base respondents answering self-completion section:	925	954	916	449	–	894	886	992

The gradient by age for men and women in 2003 is illustrated in Figure 8.1. This shows clearly the difference between the sexes.

Fig 8.1: Percentage exceeding recommended weekly limits for alcohol‚ by sex and age‚ 2003

Base: all respondents 2003 (1720)

Data from the General Household Survey do‚ however‚ show that the proportion of women aged 16-24 exceeding the maximum weekly limits rose steadily from 15% in 1988 to 25% in 1998 (ONS‚ 2000) but show little change for men of the same age. The General Household Survey suggests that the drinking habits of young men and women are becoming more similar‚ as are patterns of smoking (ONS‚ 2000). Findings from the 1998 Scottish Health Survey showed an increase in the proportions of young women and men exceeding the recommended limits‚ as well as increases in mean consumption. These findings are not‚ however‚ supported by the HEPS data.

Longer-term data are needed to determine to what extent the scale of any changes is consistent over time‚ in particular whether the behaviour observed in the younger women is maintained over the lifecourse to a greater degree than has been observed in the past. Data from the General Household Survey indicate that drinking patterns in women have previously tended to become more moderate in later life‚ and this to a greater extent than for men‚ possibly due to differentiated responsibilities for childcare. Current changes in working patterns and family formation may have some influence on how such drinking cultures will evolve over the lifecourse.

Table 8.3: Percentage with 4+ binge drinking sessions in past month‚ by sex/age/social grade/self-assessed drinking status

%	1996	1997	1998	1999	2000	2001	2002	2003
All	11	9	9	16	–	12	9	10
Sex
Men	18	12	12	27	–	17	13	15
Women	4	6	6	6	–	8	5	5
Age
16-24	21	20	23	36	–	33	19	15
25-34	16	11	10	28	–	10	14	14
35-44	11	8	6	16	–	14	7	12
45-54	7	6	7	3	–	8	6	8
55-64	3	4	4	3	–	3	5	6
65-74	1	3	2	3	–	2	1	2
Social grade
AB	4	7	5	5	–	6	7	4
C1	13	6	8	25	–	14	9	10
C2	12	11	13	12	–	12	10	12
D	12	11	10	16	–	12	10	12
Self-assessed status
Light	3	3	3	4	–	4	5	4
Moderate	24	22	22	21	–	32	19	20
Heavy	68	45	51	83	–	74	56	64
Base: all respondents	1810	1795	1794	880	–	1757	1742	1720

A second measure of excessive drinking is the number of ‘binge drinking’ sessions in the past month. A binge drinking session is defined as exceeding 16 units for men or 10 units for women on one occasion. As explained on page 28‚ there is no agreed definition of binge drinking. The measure used in this survey has been used in previous surveys‚ and was chosen since it was an amount that respondents should consider to represent a binge (rather than just drinking a bit more than normal) and should therefore find easier to recall.

Around one in ten adults reported four or more binge drinking sessions in the past month (Table 8.3). There is little fluctuation in this figure‚ with the exception of 1999‚ where the apparently higher levels are likely to be the result of random fluctuation‚ given the smaller number of respondents.

Men were more likely to report four or more binge drinking sessions‚ as were younger people‚ especially those aged 16-24‚ in most years of the survey. Binge drinking among this youngest group appeared to increase in 1999 and 2001. However‚ in 2002 there was a return to levels seen in 1996. It is possible that the 2003 figures mark the beginning of a further decrease but further years' data are needed to confirm this possible trend. Those in social grades AB were less likely to binge drink. Interestingly‚ two in ten of those who considered themselves moderate drinkers‚ and one in twenty of those who considered themselves light drinkers‚ reported four or more binge drinking sessions in the past month. It is possible that these drinkers only drink once or twice a week‚ but when they do drink‚ do so to excess. This may be why they do not consider themselves heavy drinkers‚ though their binge drinking behaviour would suggest otherwise.

 

8.2 Knowledge

Respondents were asked how many units of alcohol they thought was the recommended weekly limit for their own sex. This question was only asked in March 1996 and March 1997‚ and was then put to all respondents in the period 2001-2003. From 2001 onwards‚ respondents were able to give daily or weekly limits. For those giving daily limits‚ weekly limits were derived by multiplying their response by seven.

Each year‚ around 15% said they did not know what a unit was‚ and this response is included in the don't know category shown in Table 8.4.

In 1996‚ over four in ten drinkers said they did not know what the recommended weekly limits were‚ and under one in ten correctly identified the weekly limits of 21/14 units. Men were more likely than women to say they did not know. Knowledge levels rose significantly between 1996 and 1997 with 23% identifying the weekly limits of 21/14 units correctly by 1997; this knowledge level was sustained in the period 2001-2003. By 2001/2002 men were more likely than women to know the exact limit for their sex‚ and this was largely because women were more likely to underestimate the limit for women. Men were more likely to have no idea what the recommended limits were for their sex. By 2003 both sexes were equally likely to know the recommended limits.

Table 8.4: Knowledge of recommended weekly limits for own sex

%	1996	1997	1998	1999	2000	2001	2002	2003
All
Under limit	23	33	–	–	–	34	35	32
Exact limit (21/14 units per week)	9	23	–	–	–	20	20	21
Over limit	24	11	–	–	–	16	15	17
Don’t know	44	33	–	–	–	32	30	30
Men
Under limit	19	28	–	–	–	26	29	36
Exact limit (21 units per week)	8	22	–	–	–	23	26	20
Over limit	19	10	–	–	–	14	11	20
Don’t know	53	40	–	–	–	37	34	25
Women
Under limit	26	38	–	–	–	41	41	27
Exact limit (14 units per week)	9	23	–	–	–	16	15	23
Over limit	29	12	–	–	–	17	18	15
Don’t know	36	26	–	–	–	26	26	34
Men exceeding weekly limits
Under limit	16	34	–	–	–	44	39	28
Exact limit (21 units per week)	12	29	–	–	–	13	16	22
Over limit	36	14	–	–	–	28	19	30
Don’t know	36	23	–	–	–	16	26	20
Base: all who have had an alcoholic drink in past year (March waves only 1996-1997)	903	893	–	–	–	1570	1545	1486

Significant changes (p<0.05)

Men who exceeded the recommended maximum weekly limits were more likely to think they knew the limit compared with men overall. However‚ in 2001 and 2002 they were less likely to identify the correct limit of 21 than male drinkers overall and more likely to give a limit that was too low or too high. In 2003 men who exceeded the limit were no less likely than all men to give the correct limit‚ although they were still more likely to give a limit that was too high. Too few women exceeded the maximum weekly limits to allow separate analysis for this group.

 

8.3 Motivation

In the period 1996-1999 approximately one-fifth of drinkers reported having tried to reduce their alcohol consumption in the past year‚ or having wanted to do so; this increased to around one-quarter in the 2001-2003 period (Table 8.5). Among those who exceeded the recommended weekly limits‚ the proportion motivated to cut down their drinking was around four in ten in the 1996-1999 period‚ rising to almost half of those who exceed the weekly limits in the period 2001-2003. The change amongst those exceeding the limits is not statistically significant given the small base size‚ so future data are needed to confirm this apparent trend for this group.

Table 8.5: Motivation to reduce alcohol consumption

%	1996	1997	1998	1999	2000	2001	2002	2003
All drinkers
Not contemplating	80	81	84	82	–	78	76	74
Would like to	4	5	4	5	–	5	6	5
Have tried	16	14	13	14	–	18	18	22
Those exceeding weekly limits
Not contemplating	61	63	67	61	–	59	52	53
Would like to	14	15	10	15	–	14	15	14
Have tried	24	23	23	24	–	27	33	33
Base: all who have had an alcoholic drink in past year (March waves only 1996-1997)	1630	1615	1591	775	–	1570	1545	1486

Significant changes (p<0.05)

The apparent trends over time in those who have tried to cut down or would like to cut down their alcohol consumption are illustrated below in Figure 8.2.

Fig 8.2: Time trends in motivation to reduce alcohol consumption (have tried or would like to)‚ 1996-2003

Base: all having drink in past year and all exceeding weekly limits

Men were more likely than women to say they had tried to cut down drinking or wanted to do so (around one in four men and one in six women)‚ and this is probably related to the higher levels of drinking among men. While base sizes were relatively low‚ a comparison of men and women who exceeded the weekly limits showed no difference in motivation between the sexes.

Main points

• Men were more likely to exceed the recommended weekly limits and to binge drink than women. Men were also more likely than women to say they did not know what the recommended weekly limits are.
• The proportions of respondents exceeding the weekly limits decreased with age‚ and this was more marked for women.
• There was a significant increase in knowledge levels regarding the recommended weekly limits between 1996 and 1997‚ but these levels are still relatively low and have shown no further increases.
• There has been some increase in motivation to reduce alcohol consumption over time.

 

9. Mental health

Mental health is an integral part of health as defined by the World Health Organization. The most common problems presented to GPs are linked to mental health and it is one of the top priorities for the NHS in Scotland (SODoH‚ 1999). As life expectancy increases and treatment or prevention of the main causes of mortality improves‚ issues such as mental health and well-being become increasingly salient on the health agenda. In addition‚ material and social disadvantage can affect health through indirect psychosocial pathways‚ thus contributing to the added burden of morbidity and mortality attributable to behavioural factors (Marmot and Wilkinson‚ 1999).

For health education‚ mental health has been a broad underlying theme of much public communications activity‚ especially that which concerns young people's decision making. Stress in the workplace has been a more specific focus of preventative actions. In 2001‚ a new national programme was launched in Scotland to promote mental health and well-being which will attempt to reduce the rising levels of suicide among young people‚ particularly young men‚ and which features a public education campaign (See Me) to reduce the stigma associated with mental illness. A separate national survey of public attitudes to mental health‚ well-being and mental health problems was carried out in 2002 (and will be repeated in 2004) to provide population-level information on a broad spectrum of mental health issues (Scottish Executive‚ 2002d).

 

9.1 Stress

In terms of the relationship between mental and physical health‚ it is interesting to note that respondents in the Health Education Population Survey have consistently mentioned stress management as one of the main factors in reducing hypertension (HEBS‚ 2000). Such perceptions echo findings from the longitudinal Health and Lifestyle Survey which suggest that exposure to stressful and disruptive life events is associated with physical and mental ill health (Cox et al‚ 1993). Evidence from a wide range of studies suggests that social isolation is associated with negative health outcomes‚ both mental and physical (Stansfeld‚ 1999)‚ thus highlighting the importance of taking into account wider issues of social health when considering variations in health status.

From 1999 onwards‚ specific questions on stress were included in the HEPS questionnaire. Around one in four respondents said they had experienced large amounts of stress (Table 9.1 overleaf).

Table 9.1: Percentage with large amount of stress‚ by sex/age

%	1996	1997	1998	1999	2000	2001	2002	2003
All	–	–	–	20	–	23	25	25
Sex
Men	–	–	–	16	–	20	21	20
Women	–	–	–	25	–	26	30	28
Age
16-24	–	–	–	9	–	25	22	12
25-34	–	–	–	17	–	22	29	29
35-44	–	–	–	32	–	23	28	32
45-54	–	–	–	31	–	31	29	31
55-64	–	–	–	22	–	24	25	22
65-74	–	–	–	8	–	9	14	13
Base: all respondents:	–	–	–	880	–	1757	1742	1720

Women were more likely than men to report a large amount of stress. In terms of age‚ stress levels were lowest for those aged 65-74. It seems probable that the reported stress is related to the combined responsibilities of study‚ work and raising a family which are likely to be greater from 25-64 than for older people. Those aged 16-24 were also generally less likely to report stress than older respondents‚ but this did fluctuate year on year. There were no consistent differences by social grade.

Table 9.2: Percentage with harmful stress‚ by sex/age/social grade

%	1996	1997	1998	1999	2000	2001	2002	2003
All	–	–	–	40	–	36	36	38
Sex
Men	–	–	–	34	–	33	28	33
Women	–	–	–	45	–	39	44	43
Age
16-24	–	–	–	28	–	39	30	24
25-34	–	–	–	47	–	32	38	46
35-44	–	–	–	45	–	38	33	46
45-54	–	–	–	45	–	46	42	39
55-64	–	–	–	38	–	34	39	36
65-74	–	–	–	25	–	21	34	32
Social grade
AB	–	–	–	28	–	32	35	31
C1	–	–	–	37	–	32	35	31
C2	–	–	–	37	–	35	33	38
D	–	–	–	35	–	49	35	42
E	–	–	–	74	–	53	48	55
Base all respondents:	–	–	–	880	–	1757	1742	1720

If respondents reported experiencing stress‚ they were also asked if they considered this harmful. Over a third reported harmful stress (Table 9.2). Women were more likely to report harmful stress than men‚ and those aged 65-74 were less likely to do so than those aged 25-64. Those in social grade E were more likely to report harmful stress than those in the other social grades.

 

9.2 Mental health status (GHQ12)

As in the Scottish Health Survey‚ the mental health indicator used in HEPS is the twelve-item version of the General Health Questionnaire (GHQ12) which consists of a list of symptoms of mental distress and is scored on a scale from zero to twelve‚ with higher scores reflecting the reporting of more symptoms. This questionnaire has been widely used in general population surveys in order to assess levels of potential psychological morbidity (Bowling‚ 1991). The generally recommended threshold score for detecting potential psychiatric morbidity is two (Goldberg and Williams‚ 1988). For the purposes of this survey‚ a score greater than two is taken as an indicator of potential mental health distress. Consideration is also given to those with a score of four or more as an indicator of potential psychological disorder. The GHQ12 was part of the self-completion section of the questionnaire which approximately 5% of respondents refused to complete. The data in this section are based on responses from those who completed the section.

Table 9.3 Percentage with GHQ12 score greater than two‚ by sex/age/social grade/DEPCAT

%	1996	1997	1998	1999	2000	2001	2002	2003
All	24	27	27	–	–	23	23	28
Sex
Men	20	21	22	–	–	19	19	22
Women	27	32	32	–	–	27	27	33
Age
16-24	21	32	32	–	–	26	32	25
25-34	33	31	25	–	–	25	23	33
35-44	23	28	30	–	–	24	23	30
45-54	26	26	30	–	–	23	24	31
55-64	14	18	22	–	–	24	13	25
65-74	20	20	21	–	–	10	19	16
Social grade
AB	16	25	20	–	–	23	18	24
C1	25	25	25	–	–	19	23	25
C2	19	25	27	–	–	25	18	26
D	15	25	31	–	–	18	25	27
E	42	37	40	–	–	34	38	44
DEPCAT
1-2	17	20	23	–	–	28	18	21
3-5	23	28	28	–	–	21	22	27
6-7	31	28	31	–	–	23	31	39
Base: respondents answering self-completion section	1727	1735	1687	–	–	1648	1621	1529

Around a quarter of respondents had a score greater than two‚ and this showed no significant change over time (Figure 9.1). Women were more likely than men to report more than two symptoms.

This supports findings of other studies‚ such as the 1993 Survey of Psychiatric Morbidity carried out by the Office of Population Censuses and Surveys‚ that women show higher levels of psychiatric morbidity than men (Meltzer et al‚ 1995). However‚ there is also evidence that while men tend to report fewer symptoms of mental distress‚ they are more likely to exhibit behaviours linked to poor mental health such as heavy drinking and drug misuse (Johnson and Buscewicz‚ 1996). It is therefore possible that sex differences in self-reported mental health are due more to men under-reporting (or not recognising) symptoms of mental distress‚ than to being less prone to them.

There was also an age gradient‚ with fewer older respondents scoring over two‚ particularly those aged 55 or over. It is difficult to establish any patterns of change over the eight years. The proportion of those aged 16-24 with a score over two increased significantly between 1996 and 1998. However‚ data from the 1995 and 1998 Scottish Health Surveys show very little change for this group (Shaw et al‚ 2000) and‚ indeed‚ the increase was not consistently maintained in the 2001-2003 HEPS data.

There was a clearer pattern by social grade. Those in social grade E were consistently more likely to have a GHQ12 score over two. Again‚ it is difficult to establish any patterns of change across time. With the exception of 2001 there was a gradient by DEPCAT‚ with those in the more deprived areas most likely to have a GHQ12 score over two. The patterns described above are illustrated in Figure 9.1 using the 2003 data.

Fig 9.1: Percentage with GHQ12 score greater than two‚ by age/social grade/DEPCAT 2003

One in five had a GHQ12 score of four or more which is a possible indicator of psychological disorder (Table 9.4). As for scores over two‚ women were more likely than men and those in social grade E were more likely than those in other social grades to display four or more symptoms. Older respondents tended to be less likely to score four or more than those aged 25-54. These patterns and trends in GHQ12 scores of four or more are consistent with results from the Scottish Health Survey‚ which showed no significant changes between 1995 and 1998 and females suffering poorer mental health than males. In 1998‚ those living in deprived areas were around 1.4 times more likely to suffer from poor mental health than those in affluent areas (Shaw et al‚ 2000).

Table 9.4: Percentage with GHQ12 score of four or more‚ by sex/age/social grade

%	1996	1997	1998	1999	2000	2001	2002	2003
All	18	20	20	–	–	17	18	22
Sex
Men	15	17	15	–	–	13	14	18
Women	22	24	24	–	–	20	21	26
Age
16-24	15	22	19	–	–	19	23	19
25-34	27	25	19	–	–	18	18	25
35-44	17	22	23	–	–	19	18	26
45-54	20	21	23	–	–	18	19	23
55-64	10	13	16	–	–	16	11	21
65-74	16	16	15	–	–	7	14	13
Social grade
AB	12	20	14	–	–	17	14	18
C1	19	20	19	–	–	13	16	20
C2	14	19	17	–	–	19	13	21
D	11	18	24	–	–	14	21	23
E	35	29	31	–	–	24	34	37
Base respondents answering self-completion section:	1727	1735	1687	–	–	1648	1621	1529

 

Similar patterns were observed for mean GHQ12 scores (Table 9.5). Women‚ those in social grade E and the under-55s had the highest mean scores.

Table 9.5: Mean GHQ12 scores‚ by sex/age/social grade

%	1996	1997	1998	1999	2000	2001	2002	2003
All	1.8	1.9	1.9	–	–	1.7	1.8	2.0
Sex
Women	2.0	2.2	2.1	–	–	2.0	2.2	1.6
Men	1.4	1.6	1.6	–	–	1.4	1.5	2.3
Age
16-24	1.4	2.2	2.1	–	–	1.9	2.4	1.8
25-34	2.5	2.2	1.8	–	–	1.7	1.8	2.3
35-44	1.6	1.9	2.2	–	–	1.9	1.9	2.3
45-54	1.9	1.9	1.9	–	–	1.9	2.0	2.0
55-64	1.2	1.3	1.5	–	–	1.6	1.1	1.7
65-74	1.4	1.6	1.4	–	–	0.8	1.4	1.2
Social grade
AB	1.3	1.8	1.4	–	–	1.6	1.5	1.5
C1	1.6	1.8	1.7	–	–	1.4	1.8	1.9
C2	1.5	1.7	1.7	–	–	1.7	1.4	1.8
D	1.3	1.8	2.2	–	–	1.6	1.8	2.0
E	3.2	2.7	2.6	–	–	2.6	3.3	3.0
Base respondents answering self-completion section:	1727	1735	1687	–	–	1648	1621	1529

Main points

• Women were more likely than men to report symptoms of potential mental distress.
• There was a marked social gradient in symptoms of mental distress and disorder‚ with those living in more deprived areas and in social grade E reporting more symptoms.
• Older respondents (aged 55+) were less likely to report symptoms.
• There were no discernible changes over time.

 

10. Oral health

Although poor oral health is not generally fatal‚ it is a common cause of pain‚ potentially leading to disability. It is an aspect of child health showing sustained health inequalities: in 1999‚ 72% of girls and 73% of boys living in deprived areas had dental cavities by age 5‚ compared to 39% of girls and 41% of boys living in affluent areas. Poor oral health limits personal choices and social opportunities‚ and diminishes quality of life in the same way as diseases of other body systems (HEBS‚ 1998b). These broader effects of poor oral health are illustrated by findings from the 1992/93 survey carried out as part of the Scottish Health Boards’ Dental Epidemiological Programme. This survey identified relatively high levels of problems associated with oral ill-health‚ such as oral pain and discomfort‚ difficulty in eating and poor appearance (Scottish Health Boards’ Dental Epidemiological Programme‚ 1993). The Scottish Needs Assessment Programme report on adult oral health also noted that most of the Scottish population experienced some form of oral disease during their lifetime (Scottish Forum for Public Health Medicine‚ 1997).

The main aims for health education in the area of oral health were identified in The Oral Health Strategy for Scotland (The Scottish Office‚ 1995) as to encourage people to eat a healthy diet‚ to use preventative measures and to make regular visits to the dentist. A revised Scottish policy on Towards Better Oral Health in Children was undergoing consultation in 2004 and recommends further action that could be taken.

 

10.1 Behaviour

Dentist attendance in past year

There was a significant increase over time in dentist attendance. In 1999 approximately two-thirds of respondents had visited the dentist in the past year‚ rising to almost three-quarters in 2003 (Table 10.1). Women were consistently more likely to have attended the dentist in the past year‚ although these differences were marginal on the whole (77% of women compared with 69% of men in 2003). Variation by age and social grade showed more marked patterns of difference.

The proportion of respondents visiting the dentist in the past year showed a notable decline with age. Those in the 16-44 age groups were most likely to have visited a dentist‚ but only around half of those aged 65-74 had visited a dentist in the last year. There appears to have been a general increase over time in attendance for those aged over 45 years‚ although this has been subject to some fluctuation‚ and the figure for the latter group in 1996 would appear to be unusually low so the observed trend should be treated with some caution.

There was a clear social class gradient with respect to this indicator. Respondents in social grade AB were most likely to have visited a dentist in the past year‚ although the proportion of those in social grade C2 appears to have increased over time.

Table 10.1: Percentage attending dentist in past year‚ by age/social grade/ DEPCAT

%	1996	1997	1998	1999	2000	2001	2002	2003
All	65	69	69	68	–	69	72	73
16-24	76	84	83	68	–	80	73	81
25-34	77	74	76	68	–	79	75	77
35-44	76	80	82	76	–	80	81	78
45-54	63	69	60	73	–	71	77	75
55-64	51	53	52	69	–	56	67	63
65-74	34	44	50	49	–	32	50	54
Social grade
AB	78	86	88	87	–	88	81	82
C1	72	71	72	72	–	72	74	79
C2	65	66	68	72	–	71	74	72
D	55	59	62	51	–	57	63	61
E	54	59	49	58	–	52	60	60
DEPCAT
1-2	69	78	80	72	–	81	81	82
3-5	64	69	69	67	–	67	72	71
6-7	65	64	59	67	–	67	64	67
Base: all respondents	1810	1795	1794	880	–	1757	1742	1720

Significant changes (p<0.05)

The gradient by age and social grade is illustrated below in Figure 10.1 using the 2003 data.

Fig 10.1: Percentage attending dentist in the last year‚ by age and social grade‚ 2003

Base: all respondents 2003 (1720)

The social gradient by DEPCAT has increased markedly with dentist attendance increasing in the more affluent areas and little change in levels of attendance in the more deprived areas. This gradient is illustrated in Figure 10.2 using the
2003 data.

Fig 10.2: Time trends in dentist attendance in the last year‚ by DEPCAT‚ 1996-2003

Base: all respondents

 

Attending for a routine check-up in past six months

A similar time trend and patterns of difference by age‚ social grade and deprivation were observed for this indicator (Table 10.2).

Table 10.2: Percentage attending dentist for routine check-up in past six months‚ by age/social grade/DEPCAT

%	1996	1997	1998	1999	2000	2001	2002	2003
All	34	40	41	40	–	41	45	43
Age
16-24	38	51	49	28	–	41	40	48
25-34	40	40	43	39	–	46	47	41
35-44	40	48	51	50	–	48	47	46
45-54	33	42	35	49	–	44	49	50
55-64	26	28	33	43	–	31	48	38
65-74	19	20	24	27	–	23	32	30
Social grade
AB	52	55	55	63	–	62	57	55
C1	41	43	48	44	–	46	48	48
C2	34	34	39	39	–	36	41	40
D	27	31	30	24	–	32	35	33
E	16	29	21	28	–	23	35	32
DEPCAT
1-2	40	50	53	44	–	55	57	56
3-5	34	40	42	40	–	42	44	42
6-7	28	29	20	33	–	27	32	32
Base: all respondents	1810	1795	1794	880	–	1757	1742	1720

Significant changes (p<0.05)

From 1997‚ approximately two-fifths of respondents had visited their dentist for a routine check-up in the past six months‚ representing a significant increase since 1996. Older respondents were less likely to have had a routine dental examination in the past six months and there was again a clear class gradient‚ with AB respondents being most likely to have done so. There was a similar pattern by DEPCAT‚ with those in the most affluent areas most likely to have had a routine check-up in the last six months and showing a greater level of increase over time.

Fig 10.3: Time trends in dentist attendance in the last year and routine appointments in last 6 months‚ 1996-2003

Base: all respondents

 

10.2 Motivation

The majority of respondents were intending to visit their dentist in the next six months. The proportion increased significantly from two-thirds in 1996 to three-quarters in the period 2002-2003 (Table 10.3). Those who had not visited their dentist in the past year were substantially less likely to intend to visit the dentist‚ indicating lower levels of motivation. Motivation does not appear to have increased over time for this group.

Table 10.3: Percentage intending to visit dentist in next six months

%	1996	1997	1998	1999	2000	2001	2002	2003
All	65	69	68	71	–	72	75	74
No visit in past year	29	25	21	31	–	32	30	36
Base size: all respondents	1810	1795	1794	880	–	1757	1742	1720
Base: no visit in past year	618	537	549	280	–	534	481	526

The observed patterns of difference suggest that people tend either to visit the dentist on a regular basis or very infrequently‚ possibly only when experiencing problems. This is supported by other analyses of HEPS data showing a clear association between the frequency of visiting the dentist and the reason for attending: the longer it had been since the last visit‚ the more likely it was that this visit had been due to respondents having problems with their teeth or gums (HEBS‚ 2000).

Main points

• Significant increases were observed in the proportion attending the dentist in the past year‚ in the past six months for a routine check-up‚ and intended visits in the next six months.
• Older people‚ those from lower socio-economic groups and the more deprived areas were less likely to have visited the dentist.

The inequalities gap has increased‚ with the rate of improvement in dental attendance much greater in the more affluent areas and little change observed in the more deprived areas.

 

11. Drugs

The evidence from a range of sources suggests an increase in the use of illicit drugs during the late 1980s and early 1990s‚ partly because of the rave or dance phenomenon (Institute for the Study of Drug Dependence‚ 1997; Collin‚ 1997). However‚ since then‚ different indicators have given different signals and the pattern is becoming more complex (Ramsay and Partridge‚ 1999). On the whole‚ prevalence and frequency of use increases after age 16 and peaks in the early- to mid-twenties‚ but there is also evidence of increasing levels of experimentation at an earlier age. In response‚ growing emphasis has been given to the development of various programmes‚ including health education‚ to address the potential harm due to drug misuse among young people and to prevent such misuse. The report of the Ministerial Drugs Task Force‚ Drugs in Scotland: Meeting the Challenge (The Scottish Office‚ 1994)‚ identified a number of key elements in tackling the problem of drug misuse. These involved community action to dissuade young people from taking drugs‚ active policing and legislative measures to reduce the availability of illicit drugs‚ and effective services to deal with more problematic drug users. These elements also form the backbone of the government policy document Tackling Drugs to Build a Better Britain (HM Government‚ 1999b) and require multisectorial collaboration using a range of approaches for maximum impact.

The current national objectives and priorities for action in Scotland are set out in the strategy document Tackling Drugs in Scotland (The Scottish Office‚ 1999). Know The Score is the brand name of the drugs misuse education campaign in Scotland that brings together those national organisations which provide advice and information about drugs for young people‚ parents‚ friends and relatives (Scotland Against Drugs‚ Scottish Drugs Forum‚ HEBS‚ Scottish Executive) and local Drug Action Teams which are the focal point for local initiatives and services.

The aim of health education work in this area is to reduce the harm associated with the use of illicit drugs by:

• raising awareness and understanding about drugs and drug-related issues‚ focusing on young people and parents in particular
• promoting attitudes and behaviours which encourage abstinence from illicit drugs
• encouraging alternatives to illicit drug use

While questions assessing use of and attitudes toward illicit drug use were part of the core questionnaire‚ these were omitted from the March 1998 wave due to shortage of space. Therefore the 1998 data in this section are based on a smaller number of respondents than data from other years.

It must be noted that observed patterns of illicit drug use vary considerably in terms of level and context of use between different population groups‚ as well as for individuals over time. Therefore the broad indicators used in this particular survey can provide only a general measure of activity in this area‚ as they do not include frequency of use‚ nor do they distinguish between very different patterns of use such as experimental‚ recreational and chronic (MacDonald and Patterson‚ 1991; Tasker et al‚ 1999; Houston‚ 2000). In the context of this report‚ the terms drug misuse and drug use are defined as illicit drug use.

Around a third of respondents reported having used illicit drugs at some point‚ and this proportion showed a significant increase between 1997 and 1998 (Table 11.1). However‚ data from subsequent waves did not support continuation of this trend‚ indicating that the 1998 figure was perhaps anomalous and should be treated with caution. In addition‚ indicators of lifetime use are likely to be fairly insensitive to changing patterns of use over the relatively short time period during which HEPS data have been collected. Therefore‚ an indicator of recent use in the past year was considered more appropriate to assess possible changes over time among sub-groups of respondents (Ramsay and Partridge‚ 1999).

Table 11.1: Percentage ever having taken illicit drugs

%	1996	1997	1998	1999	2000	2001	2002	2003
Ever taken drugs	33	32	39	35	–	34	34	37
Base size:	1727	1735	844	823	–	1648	1621	1529
Base: respondents answering the self-completion section (1998 September wave only)

Approximately 15% of respondents had used drugs in the past year‚ and this indicator remained fairly stable over time (Table 11.2).

%	1996	1997	1998	1999	2000	2001	2002	2003
All	16	14	16	17	–	13	14	14
Sex
Men	17	17	20	25	–	17	15	20
Women	14	10	13	10	–	9	13	9
Age
16-24	41	35	39	43	–	38	39	28
25-34	23	15	27	21	–	21	21	25
35-44	6	12	7	17	–	8	9	14
45-54	8	6	7	10	–	4	7	4
55-74	3	6	5	*	–	1	2	3
Social grade
AB	10	11	5	9	–	6	7	11
C1	13	16	22	19	–	17	17	17
C2	15	11	15	11	–	10	10	12
D	17	14	20	31	–	12	12	12
E	23	16	18	15	–	19	13	14
DEPCAT
1-2	13	13	6	6	–	6	5	9
3-5	16	12	10	21	–	12	15	16
6-7	17	19	6	18	–	21	21	13
Base size:	1727	1735	844	823	–	1648	1621	1529
Base: respondents answering the self-completion section (1998 September wave only)

*Less than 0.5%

This pattern is supported by that observed in the 1994-1998 British Crime Surveys in England and Wales (Ramsay and Partridge‚ 1999) which points to a substantial measure of continuity in the mid-1990s. While data from the Scottish Crime Surveys showed a statistically significant increase in drug use between 1993 and 1996 (Anderson & Frischer‚ 1997)‚ more recent data from the 2000 survey show a return to 1993 levels (Fraser‚ 2002). This highlights the importance of considering trends over longer time periods in order not to be misled by what may be short-term fluctuations in the data.

As illustrated in Table 11.2‚ men and younger people were more likely to have used drugs in the past year‚ with use declining sharply for respondents over 35. Again‚ this supports findings from other data sources such as the Health Education Monitoring Survey and the Scottish and British Crime Survey (Hansbro et al‚ 1997; Anderson & Frischer‚ 1997; Ramsay & Partridge‚ 1999). There were no clear patterns of change over time by sex or age.

On the whole‚ respondents in the AB group were less likely to have used drugs recently. Use tended to be higher for those in social grade C1‚ with more fluctuating findings for DE respondents. The use among C1 respondents supports to some extent the findings from Tasker et al and the British Crime Survey which shows higher rates of drug use among relatively affluent or upwardly mobile younger social groups. However‚ evidence suggests that the use of illicit drugs in other‚ less privileged‚ groups may be characterised by more frequent and problematic use. Thus‚ health and social impacts associated with drug use would tend to be more detrimental for these latter groups (Institute for the Study of Drug Dependence‚ 1997). This is further supported by a pattern by DEPCAT‚ with those in the more deprived areas generally most likely to have taken drugs in the past year. There is‚ however‚ some fluctuation year on year.

The most commonly used drugs were cannabis‚ amphetamines and tranquillisers. There was no change in levels of use over time (Table 11.3).

Table 11.3: Use of cannabis‚ amphetamines and tranquillisers in past year

%	1996	1997	1998	1999	2000	2001	2002	2003
Cannabis	10	9	11	14	–	11	10	11
Amphetamines	4	3	5	3	–	3	2	2
Tranquillisers	3	2	2	1	–	2	2	1
Base size:	1727	1735	844	823	–	1648	1621	1529
Base: respondents answering the self-completion section (1998 September wave only)

Main points

• Overall‚ reported drug use remained relatively stable over the eight-year period‚ with around 15% reporting having used drugs in the past year.
• Drug use was reported predominantly among 16-24 year olds and men. Reported use declines sharply for respondents aged over 35.
• Those living in the more deprived areas were more likely to have taken drugs in the past year.

 

12. Sexual health

While the incidence of teenage pregnancy has been relatively stable over the past ten years‚ live birth rates among this group are relatively high in Scotland and the UK compared with other countries in Western Europe. It is also increasingly clear that socio-economic disadvantage can be both a cause and a consequence of teenage parenthood (Acheson‚ 1998). At present‚ the major policy focus in sexual health includes reducing the incidence of teenage pregnancy and sexually transmitted infections (STIs)‚ while recognising the need to address broader issues of sexuality and personal relationships in order to achieve this (The Scottish Office‚ 1999). The rising number of reported STIs among young people‚ particularly young women‚ is a growing cause for concern‚ although increased reporting may in part be explained by greater awareness of the symptoms of STIs and the risks of untreated infections‚ as well as willingness to seek treatment. While the extent of HIV infection has not proved as great as predicted‚ Towards a Healthier Scotland highlights the importance of continued vigilance with respect to sustained levels of new HIV infections. Existing research on teenage sexuality in Scotland has been synthesised and published as part of the HEBS Evidence into Action series‚ which draws out the implications for practice‚ policy and research (Burtney‚ 2000). A national strategy for Scotland on sexual health and relationships is currently at the consultation stage.

Health education activities in this area have been 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 Health Education Population Survey assesses self-reported changes in sexual behaviour‚ attitudes toward condom use and information needs on sexual health topics. These questions were asked in the self-completion section of the questionnaire.

 

12.1 Behaviour change

Questions on behaviour change were asked only in March in 2001 and 2002 but in both March and September in other years. Overall‚ a relatively small proportion (around 15%) of respondents reported changing their lifestyle because of HIV/AIDS and this was strongly associated with age (Table 12.1). Those aged under 35 were most likely to report changing their behaviour‚ and this is consistent with findings from other studies. There does not appear to be any consistent change over time for any age group.

The picture is less clear for differences by social grade‚ although on the whole respondents from social grade C1 tended to be most likely to change their behaviour.

Table 12.1: Percentage changing sexual behaviour because of HIV/AIDS‚ by age/social grade

%	1996	1997	1998	1999	2000	2001	2002	2003
All	13	13	15	–	–	15	14	15
Age
16-24	31	27	26	–	–	16	32	11
25-34	21	21	29	–	–	28	19	26
35-44	10	8	12	–	–	19	14	18
45-54	7	5	5	–	–	9	9	8
55-64	3	6	6	–	–	4	6	11
65-74	2	2	1	–	–	6	2	6
Social grade
AB	10	11	12	–	–	17	10	14
C1	16	14	18	–	–	18	19	15
C2	13	12	16	–	–	10	10	15
D	16	13	13	–	–	16	12	15
E	10	12	10	–	–	14	21	12
Base size:	1727	1735	1687	–	–	774	823	1529
Base: respondents answering the self-completion section (March wave only 2001-2002)

 

12.2 Motivation

Motivation levels were assessed through attitudes toward condom use. These questions were included in HEPS in March and September 1996 and 1998‚ but only in September in 1997 and only in March in 2001 and 2002 due to shortage of space in the questionnaire. In the period 1996 to 1999 around two-thirds of respondents said that they would not have sex with a new partner without a condom‚ with almost one-half expressing strong support for this statement. This increased significantly to over eight in ten in 2001-2003‚ with over half expressing strong support. The total agreement figure was higher for the key target group of those aged 16-24 and has not changed over time. By 2002 there was no difference in agreement between those aged 16-24 and all respondents (Table 12.2). However‚ there has been some movement for this group in terms of strength of agreement‚ with those aged 16-24 now more likely to agree strongly with this statement.

Table 12.1: Attitudes toward condom use – would not have sex with new partner without a condom

%	1996	1997	1998	1999	2000	2001	2002	2003
All
Tend to agree	19	18	19	20	–	28	28	28
Strongly agree	47	49	44	44	–	56	55	58
16-24
Tend to agree	32	26	23	37	–	27	15	34
Strongly agree	48	65	57	45	–	60	65	57
Base size: all adults	1698	871	4663	811	–	744	823	1529
Base size: 16-24	209	109	190	86	–	114	108	172
Base: respondents answering the self-completion section (September wave only 1997‚ March wave only 2002-2003)

Significant changes (p<0.05)

 

12.3 Knowledge

Respondents were asked if they had enough information on a series of sexual health topics. These questions were only asked in either March or September from 1996-2002 and at both waves in 2003. The information needs for the most frequently mentioned topics are shown below (Table 12.3). Expressed need for information on each of these topics has fallen significantly since 1996.

Table 12.3: Information needs regarding sexual health topics

%	1996	1997	1998	1999	2000	2001	2002	2003
All
STIs	40	28	35	–	–	28	20	30
Having an HIV test	25	21	20	–	–	17	15	20
HIV/AIDS transmission	22	16	18	–	–	15	14	17
Emergency contraception	19	15	17	–	–	11	10	11
16-24s
STIs	63	60	61	–	–	56	58	45
Having an HIV test	41	27	20	–	–	20	28	23
HIV/AIDS transmission	24	27	20	–	–	20	28	23
Emergency contraception	41	27	20	–	–	20	28	23
Base size: all adults	850	862	827	–	–	774	823	1529
Base size: 16-24	105	83	91	–	–	114	108	172
Base: respondents answering the self-completion section – only one wave per year 1996-2002

Younger respondents were consistently more likely to want information on recognising the symptoms of STIs‚ having an HIV test and emergency contraception. Their need to know about HIV transmission stayed at the same level between 1996 and 1998 but by 2002 their need for information on all four topics increased.

The age differences in terms of behaviour change and information needs are perhaps not surprising considering decreasing levels of sexual activity and fewer sexual partners for older age groups (Wellings et al‚ 1994; Hansbro et al‚ 1997; Rainford et al‚ 2000)‚ and are consistent with the findings of previous research. Other analyses of HEPS data show that the youngest age group in this survey was also the most likely to see itself as being at risk from HIV/AIDS relative to older age groups (8% compared to 4% overall) (HEBS‚ 2000). This suggests that those who see themselves as being at greater risk also appear to be more likely to adopt preventative strategies.

Main points

• There were no consistent trends in sexual behaviour change related to HIV/AIDS.
• Attitudes to condom use showed significant positive changes between 1996 and 1999 and 2001 and 2003.
• Younger respondents expressed the greatest need for information regarding STIs‚ HIV testing and emergency contraception‚ and the most concern about sexual health generally.
• There was a declining demand for more information on recognising the symptoms of STIs‚ having an HIV test‚ HIV transmission and emergency contraception. There was no equivalent decrease amongst those aged 16-24 for HIV-related information.

 

13. Conclusions

Health education has been a strong and consistent element in the efforts to improve Scotland’s health since the early 1990s. Health education, including information and communications activities, seeks to influence people’s health-related knowledge and attitudes and to motivate and support the process of behaviour change. This report presents data collected over an eight-year period for a number of indicators relevant to health education in Scotland, providing measures of health-related knowledge, attitudes, motivation to change and behaviours.

The HEPS dataset is intended to contribute to the planning and evaluation of health education activities in Scotland by monitoring population level patterns and trends. It indicates where future health education efforts might usefully be redirected by showing population level patterns and trends achieved, as well as areas where there have been no changes, or even changes in the wrong direction. Where awareness and knowledge of key health issues and recommendations are relatively low, substantial additional effort is required to influence public attitudes and motivation for change at individual and collective levels. Where knowledge and motivation levels are already high and public attitudes positive (e.g. in relation to smoking), health education efforts have the potential to reinforce these, while the broader health promotion measures are directed at strengthening infrastructures and creating environments that are supportive of pro-health choices.

The key patterns and trends over the past eight years were summarised at the beginning of this report. It is important to emphasise two points of caution when considering these. First, it is impossible to attribute directly any of the population trends and patterns observed to specific health education activities; these data allow us to make indicative correlations only, not causal links. For any linkage to be plausible we also need to consider the intensity of any health education activities and to triangulate the findings from HEPS with findings from evaluation of specific health education campaigns and findings from other national data sources, where possible. Second, when considering time-trend data over the eight-year period covered, trends that are not apparent across the whole period but are of only short duration may not be sustained in the long run. This is particularly the case if they are relatively extreme. Predictions based on short-term patterns and trends may ultimately prove misleading. However, while changes observed over a short time period may not turn out to be long-term trends, they do help to highlight directions of change or areas of stability which may be maintained over the longer term as the monitoring process continues.

 

13.1 Discussion

As indicated earlier, the data on trends and patterns that are presented in this report help to answer two important questions about health education in Scotland:

• To what extent has the recent emphasis on health education in Scotland 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 in Scotland may have inadvertently exacerbated health inequalities by accelerating the rate of improvement within the more affluent and educated groups?

The summary of key findings at the start of this report indicates that in the areas of diet/healthy eating and individual influences on health and disease prevention there have been consistent and significant improvements over the past eight years where success can be built upon. Other areas show more mixed results. For example, there has been a significant improvement in awareness of the recommended weekly alcohol limit, but no change in the proportion exceeding these limits and little sign of changes in motivation levels to reduce drinking. Conversely, in the area of physical activity, while there are small signs of improvements in behaviour and motivation, knowledge levels have remained the same. Encouragingly, no areas have shown significant deteriorations in knowledge, motivation or behaviour over time.

The data presented in this report also show some consistent variations by age, gender, social grade and the area-based Carstairs deprivation score. In certain respects, the socio-demographic patterning of changes in knowledge, attitudes and motivations to change over the eight-year period helps to elaborate on the picture of inequalities in health and health-related behaviours. The differentials by social grade and area-based deprivation appear to have increased in several respects, most notably in dental attendance, daily consumption of fruit and vegetables, and achieving the recommended levels of physical activity. This is due to the faster rate of improvement in the higher socio-economic groups and more affluent areas, and the relative lack of change in the more deprived areas and in social grades D and E. This is consistent with trends in inequalities found in the Scottish Health Survey for certain health behaviour outcomes (Scottish Executive, 2003). For example, there was a significant widening of inequalities for fresh fruit consumption for males between 1995 and 1998 due to the lack of change in deprived areas combined with significant improvements in affluent areas. In relation to other health behaviour outcomes, increasing inequalties were found to exist where there have been significant improvements in both deprived and affluent areas but the rate of improvement in affluent areas has been much greater than in deprived areas.

While the picture presented in this overview report is necessarily rather broad-brush due to the descriptive level of analysis, an in-depth analysis of the 1996-1999 HEPS dataset (Phillips et al, 2001) highlighted some interesting fine-grained patterns in terms of the linkages between clusters of health-related behaviours and socio-economic position. For instance, looking at health behaviour profiles across the four main topic areas, socio-economic advantage was associated with a profile involving relatively high alcohol consumption (particularly among young single women) combined with fairly healthy behaviours – not smoking, eating a good diet and being physically active. A clustering of unhealthy behaviours in relation to smoking, poor diet and sedentary living occurred mainly among more socio-economically disadvantaged groups, with unemployment and economic insecurity among men being particularly strongly associated with smoking and high alcohol consumption. However, the analysis also confirmed that such linkages are not necessarily straightforward and may look different for different sub-groups, and indeed change over the lifecourse.

The social patterning of knowledge, motivation and behaviour should also be understood in terms of the complexity of the health education messages. Messages relating to smoking are the clearest and most straightforward and have achieved the highest levels of public knowledge and motivation to change. The success of recent healthy eating messages has perhaps been due to the consistent focus on ‘eat five portions of fruit and vegetables a day’. Both the smoking and dietary messages are relevant to the whole population as opposed to specific population sub-groups. In addition, many messages around healthy eating have now been integrated across a range of settings and sectors, with food producers and retailers using ‘healthy lifestyle’ as a food marketing strategy. On the other hand, the health education messages on alcohol consumption and physical activity are more complicated and have been subject to recent change. For physical activity, the shift in emphasis from three 20-minute sessions of vigorous exercise each week to the ‘active living’ message of 30-minutes of moderate intensity activity every day, may cause confusion. Similarly, recommendations on alcohol consumption have also been subject to change. The communication of health messages on alcohol are further complicated by the traditinal significance of drinking within Scottish culture, the health benefits of moderate drinking, and the need to tailor messages for certain sections of the population.

Finally, the patterns and trends revealed by this descriptive statistical dataset are a necessary but not sufficient source of information to inform the planning and evaluation of health education activities in Scotland. Evidence-based health promotion also requires investment in the development and evaluation of effective interventions, as well as the generation of a shared values base and the shared goal of tackling the long-standing inequalities in health.

 

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