Publication
Health Education Population Survey (HEPS) 1996-2003 A Summary
| Contents: | Summary |
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.
Background
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 the Health Education Board for Scotland (HEBS) in 1995 to monitor 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 in two waves each year (March and September) to form a nationally representative annual sample of 1800 adults aged between 16 and 74 years. This report presents an overview of the main patterns and trends from HEPS data during the first eight years (1996-2003).The survey is conducted by BMRB Social Research‚ part of BMRB International Ltd. This report was written by Sally Malam and Helen Angle from BMRB with Erica Wimbush and Elizabeth Fraser from Health Scotland.
Finding out more
A full report‚ including references‚ entitled Health Education Population Survey 1996-2003 is available at www.hebs.com/research/sd/index.cfm. If you would like more information or have any comments‚ please contact Health Scotland's Research Officer (research.officer@health.scot.nhs.uk) quoting reference numbers 1996/97 RE029 and 2001/02 RE012.