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Health Education Population Survey (HEPS) 1996-2003

Contents:

Summary 1. Introduction 2. Scotland's health 3. Attitudes towards own health 4. Perceptions of mortality, morbidity and risk 5. Physical activity 6. Diet 7. Smoking 8. Alcohol 9. Mental health 10. Oral health 11. Drugs 12. Sexual health 13. Conclusions References Appendix 1: Questions analysed in overview Appendix B: Topics covered 1996-2003 Appendix C: Base sizes Appendix D: Physical activity levels

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.