Publication
Health Education Population Survey (HEPS) 1996-2003
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.