Scottish Health Survey (2024 onwards): content review

3. Review findings

Respondents were asked to provide feedback on any or all of the topics presented below, as well as suggesting new topics for inclusion.

• Accidents
• Adverse Childhood Experiences (ACEs)
• Alcohol and drinking experiences
• Asthma
• Biological measurements
• Cardiovascular disease and use of services
• Chronic pain
• COVID-19
• CPR training
• Dental health and services
• Diet
• Discrimination and harassment
• Drugs
• Food insecurity
• Gambling
• General health and long-term conditions
• Mental wellbeing
• Parental history
• Physical activity
• Prescribed medicines and drug coding
• Respiratory
• Smoking
• Social capital and loneliness
• Strengths and Difficulties Questionnaire (SDQ)
• Stress at work
• Unpaid caring
• Vitamin supplements
• New topic

Please note that each respondent could have more than one recommendation for each topic at the same time (e.g. add new questions and remove some of the existing questions etc.) and as a result the totals presented in the tables within each section may not add up to the total number of responses.

3.1 Accidents

Overall recommendation for topic	Responses
Retain existing questions	1
Add new questions	3
Remove some of the existing questions	0
Replace existing questions	0

Frequency of data required	Responses
Annually	2
Biennially	0
4-yearly	0
One-off	0
As it currently is	2
Other	0

Scale of impact if data not collected	Responses
No impact	0
Some impact	3
Major impact	1

Add new questions/answer options

PHS and GCPH suggested adding two supplementary questions 'to ascertain the mode of transport of the casualty at the time of the crash and to ascertain the other type of vehicle(s) involved in the crash' if 'road traffic crash/collision' is the response to 'Who had an accident in past year; what caused the accident', as 'it is currently difficult to differentiate between road collisions associated with different modes of transport and the extent to which other vehicles are involved' e.g. cycle casualties which involved a car, pedestrian casualties involving buses etc.

• What mode of transport were you using at the time of the collision (walking, cycling, wheeling, car, public transport)?
• What other vehicles were involved in the collision (bicycle, car, bus scooter)?

PHS stated that 'better data on types of road collision is important in relation to active travel because active travel has received significant investment in Scotland, but levels of everyday walking and cycling remain low and real and perceived risks related to motorised traffic discourage many people from walking, cycling and wheeling.'

Scottish Community Safety Network suggested:

adding two answer options (poisoning and choking) under 'Who had an accident in past year; what caused this accident?', as 'these are some of the most frequent types of accidents' and it would be good to have the data to monitor these.

including further answer options under 'Who had an accident in past year: from which of the people on this card did you get help or advice about the injury you suffered?' e.g. minor injuries unit. They noted that 'often hospital A&E departments will direct lesser injuries in this way and it would be useful to know about the less serious as well as the more serious injuries'. They also suggested 'including an option for seeking advice from NHS 24 which is normally recommended following some accidental injuries.'

offering a few more options (both by respondent or others) under the last section '.... do you think anything could have been done to avoid it', i.e.: installation of safety equipment; information leaflet/education; environmental changes; or personal protective equipment.

Changes in terminology

PHS suggested 'replacing the term 'accidents' with 'unintentional injury', as the term unintentional injury is commonly preferred to the term accidents. This is because injuries are predictable and preventable'. They also suggested to change the term "road traffic accident" to "road collision" or "road transport crash".

GCPH also suggested changing the 'road traffic accident' response option to the 'What caused an accident?' question to 'road transport crash' (or 'road transport collision'). They also agree that 'the term 'accident' has been criticised, as it implies an unpredictable (and therefore unavoidable event) and it is avoided by the BMJ and associated journals'. For more information, see: (BMJ bans "accidents" - https://www.bmj.com/content/322/7298/1320)

Retain existing questions

The Scottish Government Children and Families analysis unit suggested retaining the existing questions in this topic with the following reasons given: there is no/limited population level data available elsewhere the data is used to inform/evaluate public policy, monitor trends and validate other data sources.

3.2 Adverse Childhood Experiences (ACEs)

Overall recommendation for topic	Responses
Retain existing questions	2
Add new questions	1
Remove some of the existing questions	0
Replace existing questions	2

Frequency of data required	Responses
Annually	2
Biennially	0
4-yearly	1
One-off	0
As it currently is	1
Other	0

Scale of impact if data not collected	Responses
No impact	0
Some impact	2
Major impact	2

Add new questions

The Scottish Government Mental Health Directorate suggested adding a few questions. They noted that:

• 'There are no questions regarding neglect e.g. physical and emotional which are more common forms of adverse childhood events and which have a significant impact on mental health and wellbeing. Neglect often leads to separation anxiety and attachment issues.'
• 'A further requirement is to include a question on resilience (regarding a trusted adult), since this is recognised evidence gap and some stakeholders have criticised inclusion of questions on adversity without also looking at resilience. There is a standardised question from the Welsh ACEs survey in 2017 which could be used; this would not impact on ACEs prevalence data or analysis.'
• To help provide some balance between risk factors and protective factors, they suggested 'adding the Benevolent Childhood Experiences (BCEs) Scale. This is a 10-item scale that can be used in a similar way to the ACEs questionnaire. It is routinely used at the Rivers Centre and found that it was more highly correlated with adult psychopathology than the ACEs questionnaire. This has major implications for policy makers, as population-based data would potentially indicate which areas to invest in with regard to early intervention and prevention.' If there is no space to add a whole new questionnaire, they suggested alternating the ACE and BCE.
• 'It would also be helpful to add the question: "As a child, did you ever spend time in care?"'

Replace existing questions

GCPH stated that 'it would be extremely useful to ensure the questions are worded in the same manner as they were – for example – in the English (e.g. in 2014 ^[1]) and Welsh (e.g. 2015 ^[2]) surveys, as one of the aims of including the ACEs questions in the 2019 SHeS was to compare their prevalence in Scotland with elsewhere in the UK. However, this has not been possible because of differences in the wording of the physical abuse and verbal abuse questions'. They also said that for the physical abuse question, 'the English and Welsh questionnaires explicitly excluded 'gentle smacking' (the question included the statement: "This does not include gentle smacking for punishment"), whereas this was not the case with the SHeS questionnaire. The answer categories for the verbal abuse question were also different, meaning that in SHeS an answer of verbal abuse having occurred 'once' counts as an ACE, whereas in the other surveys it only counts if it was reported as having occurred 'more than once'. This can obviously lead to quite different, and unhelpful, results when the different surveys' data are analysed.'

The Scottish Government Mental Health Directorate stated that ACE questions were included in the 2019 SHeS but that 'there were a number of issues with the questions (including question wording and response categories) which led to some over reporting and an inability to compare data across the UK nations. There is a need to review the questions included in the 2019 SHeS and potentially replace with a new set of ACE questions. One proposed approach could be to replace the questions with the questions used by Public Health Wales in a national ACE Survey undertaken in Wales (2017).'

Retain existing questions

PHS and the Scottish Government Children and Families analysis unit suggested retaining the questions in this topic with the following reasons given: there is no/limited population level data available elsewhere and . the data is used to inform/evaluate public policy and to monitor trends.

3.3 Alcohol and drinking experiences

Overall recommendation for topic	Responses
Retain existing questions	4
Add new questions	4
Remove some of the existing questions	1
Replace existing questions	1

Frequency of data required	Responses
Annually	5
Biennially	0
4-yearly	0
One-off	0
As it currently is	2
Other	0

Scale of impact if data not collected	Responses
No impact	0
Some impact	4
Major impact	3

Add new questions/answer options

Alcohol Focus Scotland suggested adding a few questions 'in order to help account for changes in consumer behaviours and purchasing habits':

• 'No- and low-alcohol products. Sales of products such as alcohol-free beer, no / low alcohol wines, and 0% abv spirits have increased dramatically in recent years, but there is currently insufficient evidence available to determine the impacts of this trend. For example, low- and no-alcohol products could potentially be of public health benefit if they replace rather than add to existing consumption of higher strength products, but conversely could negatively affect public health if they are consumed alongside alcoholic drinks and used for the proxy marketing of alcohol. As such, it would be beneficial to have access to a series of data that could be analysed to show how/why these types of products are being purchased and consumed.'
• 'Online alcohol sales and deliveries. Alcohol deliveries and internet sales are not a new issue but are an evolving and expanding area of retail, with significant implications for national and local efforts to control the availability of alcohol. The types of businesses that sell alcohol online now range from small independent traders, specialist drinks retailers/clubs, local convenience stores, and supermarkets through to multinational e-commerce companies (e.g. Amazon). There is also a growing variety of app-based retailers who have arrangements with restaurants, takeaways and off-licences to deliver alcohol directly to people's homes. The COVID-19 pandemic and related restrictions have accelerated the general trend to online shopping. Despite the reopening of physical stores, it is predicted that online sales will remain high as people have become more accustomed to online shopping. However, there is currently a distinct lack of information available about the business operations of online retailers in Scotland. For example, there is no data available pertaining to their distribution areas, or the volumes and types of alcohol they sell. It would therefore be beneficial to include questions about the types and volumes of alcohol that people buy remotely, to help us understand and respond to these growing markets.'
• 'Alcohol availability and purchasing habits: Linked to the above, the only licensing data at a national level is the number of on- and off-trade outlets and the number of licences granted and refused. This is insufficient to provide any robust estimate of alcohol availability; without alcohol sales data it is not possible to get a true measure of availability from different types of outlets, fully inform licensing decisions about where and when alcohol is sold, or to monitor changes over time. As such, it would be beneficial to include questions relating to where people usually buy alcohol from (e.g., supermarket, local convenience store, bars/pubs etc) and their ease of access to alcohol.'

An individual also suggested adding a few questions:

• 'Add to the recovery questions (Q11 & Q12) by asking about treatment and support.'
• 'Ask about polysubstance use (e.g. cocaine and alcohol or opioids and alcohol) given the part alcohol contributes to Scotland's drug deaths.'

PHS suggested a few potential additional questions. However, they stated that retention of the current questions should be a priority over any of the suggestions below:

• Add responses for 'sports venues/events' and 'cultural events (e.g. music concerts, cinema)' to question 'In which of these places would you say you drink the most alcohol?'
• Add a response for 'with my children and/or dependants who I have guardianship of' to question 'Who are you usually with when you drink the most alcohol?'
• Add a question around the most common time of the day to drink
• Add questions on alcohol recovery and treatment. PHS felt this is not covered in the current questions. An additional theme, or extension of current questions could include questions on:
  • Currently being in recovery
  • Ever having accessed different types of treatment for drinking (including being hospitalised, A&E attendance, attending residential rehabilitation), how frequently, and when
• Add questions on effect of drinking on work e.g. number of days taken off work/off sick due to drinking, occurrence of work-related accidents
• Add questions on crime e.g. ever having had contact with the police due to drinking, ever having been the victim of a crime (such as domestic abuse) by someone who was under the influence of alcohol
• Add questions on marketing & brand awareness. This could include questions such as:
  • Where do you feel you see the most advertising for alcohol (e.g. supermarket, other shops, sports venues, social media/online, TV, bus stops)?
  • What is most important for you when deciding to buy alcohol (e.g. price, brand, taste, it's what my friends buy)?
  • Where do you buy the most alcohol (e.g. supermarket, off-license, online)?

Scottish Health Action on Alcohol Problems proposed that the following questions should be included in the survey:

• Do you know what the low-risk drinking guidelines are? If so, can you state what the guidelines are?
• Do you know what the health risks associated with exceeding the low-risk guidelines are?
• Do you know how many units of alcohol are in your favourite drink?
• Are you aware that alcohol is a major risk factor for certain types of cancer?
• Have you ever attended hospital because of your drinking?
• Where do you usually purchase alcohol from?

They said that 'the first question is asked in the Scottish Social Attitudes Survey, and would be useful to include in Scottish Health Survey. The other questions are not currently asked in other surveys'. They also stated that 'questions on cancer risk have been assessed in various research studies with mixed results of public awareness of cancer risk from alcohol'.

Clarification in terminology

Scottish Health Action on Alcohol Problems suggested that 'there is a need to define and clarify what is meant by a small and large bottle of beer, for example. This lack of clarification may lead to wide variation in the answers given by participants and could reduce the comparability of results'. They also support the inclusion of the drinking experiences questions in the survey, as these 'provide some insight and reflect on the impact of alcohol and the harm it causes to others'. In question 1 of the drinking experiences questions, 'reference to the amount of alcohol in the drink should be made, as the strength of the product will result in different experiences and outcomes for both the person consuming the alcohol and the people around them, potentially experiencing harm'. Additionally, in question 3 of the drinking experiences questions, 'a 'drink' needs to be defined and quantified – does this mean one unit, one glass, one bottle? Again, the outcomes and experiences will differ significantly based on what is consumed'. They said that 'clarifying this will also assist with analysis of trends, patterns and comparison'.

Remove some of the existing questions

ScotPHO suggested removing questions on types of alcohol consumed, 'as this level of detail is not used.'

Replace existing questions

Scottish Health Action on Alcohol Problems suggested that questions on alcohol consumption 'could be simplified and the overall number of questions could be condensed'. They also mentioned that 'the current questions should be updated to reflect changing patterns of consumption in Scotland and the types of drinks consumed, such as the change in drinking behaviour towards increased home drinking and greater consumption of spirits'. Additionally, they stated that 'in one of the questions in the alcohol consumption section it is mentioned that non-alcoholic or low alcohol drinks should be excluded, when asking participants if they had consumed different types of alcoholic drinks in the last year'. Scottish Health Action on Alcohol Problems questioned 'why such products have been excluded and believe they should be included to provide a more accurate picture of (changes in/to) consumption patterns/trends and the types of drinks consumed. This would also enable trends to be monitored.'

Retain existing questions

Alcohol Focus Scotland, Obesity Action Scotland, PHS and the Scottish Government Children and Families analysis team suggested retaining the questions in this topic with the following reasons given: there is no or limited population level data available elsewhere the data is used to inform/evaluate public policy, to inform local interventions, to better allocate resources, to validate other data sources and to monitor targets and trends.

3.4 Asthma

Overall recommendation for topic	Responses
Retain existing questions	3
Add new questions	0
Remove some of the existing questions	0
Replace existing questions	0

Frequency of data required	Responses
Annually	1
Biennially	0
4-yearly	1
One-off	0
As it currently is	1
Other	0

Scale of impact if data not collected	Responses
No impact	1
Some impact	2
Major impact	0

Retain existing questions

Asthma and Lung UK Scotland, ScotPHO and the Scottish Government Children and Families analysis team suggested retaining the existing questions in this topic, with the following reasons given: there is no or limited population level data available elsewhere, the data is used to inform/evaluate public policy, to validate other data sources and to monitor targets and trends.

3.5 Biological measurements

Overall recommendation for topic	Responses
Retain existing measurements	5
Add new measurements	4
Remove some of the existing measurements	0
Replace existing measurements	1

Frequency of data required	Responses
Annually	1
Biennially	0
4-yearly	1
One-off	1
As it currently is	1
Other	3

Scale of impact if data not collected	Responses
No impact	0
Some impact	3
Major impact	4

Add new measurements

An individual proposed to 'add a one-off blood collection to undertake nutritional biomarker analysis to assess micronutrient status, similar to the National Diet and Nutrition Survey (NDNS). Recommended biomarkers to assess include: (1) vitamin D status using 25-hydroxyvitamin D; (2) iron status using ferritin and soluble transferrin receptor; (3) anaemia using haemoglobin; (4) vitamins/metabolites involved in one-carbon metabolism including folate, vitamin B6 (4-pyridoxic acid), vitamin B12 (holotranscobalamin), and homocysteine; and (5) selenium. These represent a select subset of nutrient biomarkers assessed in NDNS with particular relevance to the Scottish context. Blood biomarkers are useful to improve measurements of dietary intake, and for characterising participants based on their nutritional status.'
They said that 'to reduce the cost of blood sample collection and the time taken by the SHeS interviewer, different approaches can be used, e.g. providing labelled blood tubes which can be taken to the GP surgery for venepuncture by the practice nurse, as used in the Breakthrough Generations study ^[3] or finger-prick blood sampling, as used for antibody testing in the ONS COVID Infection Survey ^[4]'.

FSS also proposed 'the inclusion of blood samples as part of the biological measures module, taken at least in 2024 (and preferably 2027). Ideally, participants in the biological measures module would also complete Intake24 to build a fuller picture of participants nutrient intake and status. In terms of analytes, measures of serum vitamin D status and 3 separate measures of folate/folic acid status are of most interest.' FSS also proposed 'the inclusion of a urinary sodium survey because it is not possible to provide a robust measure of salt intake from dietary intake records. As such, urinary sodium is the best measure, to assess salt intakes. A one-off urinary sodium survey may be sufficient, to correspond with dietary data collection by Intake24 in either 2024 or 2027.'

PHS also suggested 'including blood sample measurements for folate and vitamin D and urinary sodium samples taken. This would include a measure of serum vitamin D status and 3 separate measures of folate/folic acid status. To ensure comparability, it would be best practice if blood samples could be analysed for these micronutrients with the same method used for the UK National Diet & Nutrition Survey.' PHS stated that 'samples should be taken in 2024 and preferably also in 2027 to enable linkage with Intake24. Ideally, this would be for the same sample completing both the biometric measures and the Intake24. However, this should not exclude individuals from participating in either.'

PHS also stated that 'in relation to measuring weight and blood pressure it is important to ensure that appropriate equipment is available and used. It is important that weighing scales are suitable to capture the weight of individuals of higher weight. This is to minimise any potential weight stigma associated with being above the weight capacity of the scales and to ensure that we are capturing this data. This point is relevant for blood pressure in that the correct blood pressure cuff is available to enable this measurement to be taken and recorded.'

The Scottish Government HABIT team also suggested the 'introduction of blood assessment of folic acid and vitamin D status and urinary sodium of a sample that has completed INTAKE24. This would be to set a baseline and to monitor the impact of fortification of flour with folic acid, which is due to come into effect no earlier than 2024. Also in respect of vitamin D status, the last assessment of this was in 2010.' They said that 'measuring current vitamin D plasma levels would be useful to understand current vitamin D status across the population and the impact of current advice and policy on vitamin D and whether more targeted interventions are required.'

Replace existing measurements

BEAT (eating disorder charity) expressed the concern that 'when training and guidance is given to interviewers, the survey team should consider that awareness of these measurements can be sensitive or even distressing, particularly for people with eating disorders.' They said that 'for some people with eating disorders being informed of their weight and/or waist circumference can trigger urges to engage in compensatory (e.g. purging or fasting) and self-harm behaviours.'

Retain existing measurements

An individual, Obesity Action Scotland, PHS, ScotPHO and the Scottish Government HABIT team suggested retaining the existing measurements with the following reasons given: there is no or limited population level data available elsewhere, the data is used to inform/evaluate public policy, to inform local interventions, to validate other data sources and to monitor targets and trends.

3.6 Cardiovascular disease and use of services

Overall recommendation for topic	Responses
Retain existing questions	0
Add new questions	1
Remove some of the existing questions	0
Remove the suggested questions	1
Replace existing questions	1

Frequency of data required	Responses
Annually	0
Biennially	0
4-yearly	0
One-off	0
As it currently is	1
Other	0

Scale of impact if data not collected	Responses
No impact	0
Some impact	0
Major impact	1

Add new questions

The Scottish Government Clinical Priorities policy team suggested adding the following questions:

• Following [ 'Were you told by a doctor that you had a stroke', the addition of a similar question to determine if people were reporting a doctor diagnosis of transient ischaemic attack (TIA) e. g. 'Were you told by a doctor that you had a TIA?'
• The inclusion of an impact of condition question within the cardiovascular disease module. For consistency, the same impact questions which are already asked in the long-term conditions module could be included:
  If have a heart condition or ever had a stroke
  • 'Does (name of condition) limit your activities in any way?' (Yes, a lot/Yes, a little/Not at all)
  • 'Does this condition or illness affect you in any of the following areas?'
    Psychological impact
    Reduction in mobility
    Cognitive impact
    Communication
    Reduced quality of life- independence
    Vision/Sensory
    Incontinence
    Sexual function.
    Fatigue
    Ability to work
    And
    If have doctor-diagnosed diabetes (except where pregnant)
  • 'Does (name of condition) limit your activities in any way?' (Yes, a lot/Yes, a little/Not at all)
  • 'Does this condition or illness affect you in any of the following areas?'
    Psychological impacts
    Ability to work
    Vision
    
• They said that 'it would also be important to include a wellbeing question to enable measurement against policy actions to improve person-centred care. Within the Use of Services questions the inclusion of the question below which is a validated question already used in the Care and Experience Survey (Q26) is recommended':
  • 'How much do you agree or disagree with the following about your care, support and help services over the past 12 months: The help, care or support improved or maintained my quality of life?' (Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree). This question should be asked of all respondents reporting heart disease, stroke or diabetes.
• Finally, they stated that 'it would be important to add a question to determine the mechanism people use to deliver their insulin.' The current question: 'Do you currently inject insulin for diabetes?' is recommended to be updated to
  • 'Do you currently manage your diabetes with insulin?' with the addition of a follow up question:
  • 'If so, do you use an insulin pump?' Yes/No

Remove the suggested questions

The Scottish Government Clinical Priorities policy team agree that the suggested questions ('Do you have, or have you ever had…?') can be removed, as they are duplicated by doctor asked questions ('Were you told by a doctor that you had…?').

Replace existing questions

The Scottish Government Clinical Priorities policy team suggested replacing the following questions:

• Were you told by a doctor that you had (name of 'other heart condition'). They recommended the following conditions to be used in name of other heart condition and that a question is asked for each as it is for abnormal heart rhythm:
• Heart valve disease
• Congenital heart disease (present from birth)
• Heart failure
• An inherited/genetic heart condition
• This will also require the following questions in the Use of Services questions to be updated accordingly:
  
  (Were any of these consultations/Was this consultation) about your (heart condition, high blood pressure, diabetes or stroke)
  Other heart trouble
  

They would also like 'to see all questions which refer to a 'doctor' be updated to more realistically reflect that care and information for people living with cardiovascular conditions is provided by a range of healthcare professionals and not just doctors.' They recommended 'replacing doctor with healthcare professional as outlined below':

• [During the 2 weeks ending yesterday, apart from any visit to a hospital, have you talked to a healthcare professional on your own behalf, either in person or by telephone?
• How many times have you talked to a healthcare professional in these 2 weeks?
• Apart from any visit to a hospital, when was the last time you talked to a healthcare professional on your own behalf?
  

3.7 Chronic pain

Overall recommendation for topic	Responses
Retain existing questions	1
Add new questions	0
Remove some of the existing questions	0
Replace existing questions	0

Frequency of data required	Responses
Annually	1
Biennially	0
4-yearly	0
One-off	0
As it currently is	0
Other	0

Scale of impact if data not collected	Responses
No impact	0
Some impact	0
Major impact	1

Retain existing questions

The Scottish Government Clinical Priorities policy team suggested retaining the existing questions in this topic with the following reasons given: there is no or limited population level data available elsewhere, the data is used to inform/evaluate public policy, to inform local interventions, to better allocate resources, to validate other data sources and to monitor targets and trends.

3.8 COVID-19

No feedback was received on the COVID-19 questions.

3.9 CPR training

No feedback was received on CPR training questions.

3.10 Dental health and services

No feedback was received on the dental health and services questions.

3.11 Diet

Overall recommendation for topic	Responses
Retain existing questions	3
Add new questions	4
Remove some of the existing questions	0
Replace existing questions	4

Frequency of data required	Responses
Annually	5
Biennially	1
4-yearly	1
One-off	0
As it currently is	0
Other	2

Scale of impact if data not collected	Responses
No impact	0
Some impact	4
Major impact	4

Add new questions/answer options

An individual recommended 'retaining the question on the intake of oily fish in children and the addition of the same question for adults. Oily fish is an important source of nutrients in the UK but consumed episodically and therefore best captured by a food frequency question rather than a single 24-hour dietary recall.'

FSS 'strongly support the continued use of Intake24 in SHeS, preferably in years 2024 and 2027. This will help develop a long term assessment of dietary intake in Scotland. Data extracted from SHeS helps FSS to provide expert, evidence-based advice on how to achieve a healthier diet and identify population groups that are at risk from less healthy dietary intakes.' FSS said that 'in addition to monitoring progress towards the Scottish Dietary Goals and supporting Scottish Government policy on other food and drink groups of interest, a survey in 2024 will help look at folate and folic acid intakes in the population, prior to implementation of a folic acid fortification policy. The addition of folic acid to non-wholemeal wheat flour is proposed as a public health measure to reduce incidence of neural tube defect-affected pregnancies. The measure is currently out to consultation and is likely to come into force in 2025. A further survey of Intake24 through SHeS in 2027, would allow FSS to look at folate and folic acid intakes at two years post-implementation.'

GCPH suggested adding questions on the frequency of consumption of non-meat/plant-based food.

Obesity Action Scotland stated that 'it would be valuable to have a more detailed breakdown of the diet/overweight and obesity data':

• Data broken down by SIMD 'is valuable and helpful for tracking change over time, including tracking changes in outcomes between different socioeconomic groups and it should continue to be provided annually.'
• 'In line with this, the supplementary tables and raw data continue to be invaluable and a clear timetable for when the raw data would be made available would also be welcomed.'
• 'Another useful summary would be that for ethnic minorities. Although there is insufficient samples to present this particular data as part of any trend analysis, it would be valuable to have access to the raw data for this category. There is now extensive evidence on associations between ethnicity and obesity however this area is relatively unexplored in the Scottish context.'
• 'An annual summary of prevalence by specific age groups of the entire population (not just child and adult) would also be useful as it would allow for identification of the most vulnerable groups and development of age-appropriate interventions.'

They said that 'it would also be valuable to have more consistency in the diet monitoring data. Intake24 is a valuable tool for measuring people's food options and Obesity Action Scotland would prefer to see this method of data collection used on an annual basis to ensure trends are spotted more easily alongside the impacts of external events (e.g. COVID-19, the cost of living crisis). If this was not able to be employed every year, other diet monitoring questions which are less intensive, such as questions covering fruit and vegetable consumption, would need to be maintained as a minimum to cover this area. In the 2020 SHeS, fruit and vegetable consumption questions were dropped in favour of questions around discretionary food intake and Obesity Action Scotland would like to see the reintroduction of the fruit and vegetable questions on an annual basis.'

Changes in terminology

Obesity Action Scotland suggested 'for the term 'morbid obesity' to be replaced', as 'the term is now recognised as stigmatising and is no longer seen as appropriate in public health discourse.' They recommended 'replacing 'morbid obesity' with the term 'severe obesity' when referring to individuals with a BMI of 40 or above, which is the term widely used in the literature by patient advocacy groups and other organisations including the World Obesity Federation. The World Health Organisation (WHO) use a 3-tiered obesity classification system, categorising BMI ranges into Class I, Class II, or Class III obesity, with the latter used for individuals with a BMI of 40 or above, and is commensurate with the 'severe obesity' category outlined above. This is another alternative to morbid obesity that could be used.' Additionally, they said that 'across all relevant questions, the survey should avoid using the word 'obese' where possible. The term is highly stigmatising and should be avoided. Instead, when used in a data categorisation context, obesity should be used. When used in relation to individuals, person-first language should be used, such as people living with obesity. This is line with recommendations from patient advocacy groups, stigma advocates and emerging framing evidence and methodologies.'

The Scottish Government HABIT team suggested to 'use lower BMI thresholds as a practical measure of overweight and obesity for people with a South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background, as they are prone to central adiposity and their cardiometabolic risk occurs at lower BMI:

overweight: BMI 23 kg/m² to 27.4 kg/m²

obesity: BMI 27.5 kg/m² or above.'

Replace existing questions

An individual recommended 'replacing all questions (except oily fish intake) with Intake24 for children and young people to align with the methodology for assessing dietary intake in adults as well as the methodology used by the UK-wide National Diet and Nutrition Survey (NDNS) assuming Intake24 is to be carried out annually.' They said that 'if Intake24 is not used annually, then the fruit and vegetable and sugar-sweetened beverage questions should be retained for both children and adults to allow monitoring of changes, which would provide continuity with previous SHeS surveys.'

FSS suggested that Intake24 may be used for children aged 2-15 to monitor fruit and vegetable consumption and eating habits, instead of using the existing questionnaire. 'Many of the fruit & vegetable and eating habits module questions are now out of date. Intake24 supersedes the modules as a robust method of diet, it provides a measure of total food and drink intake, from which nutrient intakes may be estimated.' FSS recommended 'collecting data at least on a three yearly basis, alongside the adult diet data collection. To note, FSS are running a stand-alone survey of diet in children and young people (2-15 years), early in 2023, as a robust measure of dietary intakes in children has not been collected since 2010.'

PHS recommended that 'the child diet module is removed and replaced by Intake 24 in 2024 and again in 2027 to retain 3-year intervals to support continuation of Intake 24 for adults at 3 yearly intervals, as the current diet questions for children are outdated.' They also stated that 'it would be worth considering other users of the data, for example, Health Boards, who would benefit from annual data collection.'

The Scottish Government HABIT team requested that 'INTAKE24 for children is instigated from 2024 onwards on an annual basis to replace the two diet modules for children currently in SHeS. Child INTAKE24 was tested as a pilot in SHeS in 2018, however, was not implemented at the same time as for adults due to low response rate. Reassurance would need to be provided that substantial efforts would to be made to ensure an appropriate response level.' They also said that 'before implementing, it is important to check the questions around energy drink consumption and that they meet requirements for evidence on this. Several questions in the children's diet modules (fruit and vegetables and diet behaviours) are now quite dated. If a change to INTAKE24 is not possible, these questions need revisited. Consideration could be given to reframed questions in the current modules for those years where INTAKE24 is not possible, although thought would need to be given to what that would mean for monitoring trends.'

Retain existing questions

An individual, ScotPHO and the Scottish Government Children and Families analysis team at the Scottish Government suggested retaining the existing questions in this topic with the following reasons given: there is no or limited population level data available elsewhere, the data is used to inform/evaluate public policy, to inform local interventions, to better allocate resources and to monitor targets and trends.

3.12 Discrimination and harassment

Overall recommendation for topic	Responses
Retain existing questions	3
Add new questions	1
Remove some of the existing questions	0
Replace existing questions	1

Frequency of data required	Responses
Annually	2
Biennially	1
4-yearly	0
One-off	0
As it currently is	1
Other	0

Scale of impact if data not collected	Responses
No impact	1
Some impact	0
Major impact	2

Add new questions/answer options

PHS suggested 'supplementing the existing questions with the use of an internationally validated tool, such as The Everyday Discrimination Scale so as to improve the available data in this area, as it is being increasingly understood that experiences of discrimination are an independent determinant of health.' PHS also suggested 'adding questions to the scale focused on accessing health and social care services, so that experiences in these settings can be considered in the data.'

An individual also suggested adding respondent's weight as an answer option to the discrimination question.

Replace existing questions

GCPH suggested replacing the existing questions on discrimination and harassment, as they 'do not take the approach of the everyday discrimination scale which is more sensitive to 'micro aggressions' and the impact of assumptions and practices that may fall short of outright discrimination yet nevertheless accumulate to cement a sense of exclusion.' They said that 'the current question asks respondents to not only identify when they were harassed or discriminated against but for what reason. Unless the offender has been explicit, a victim of discrimination is unlikely to know for which reason, particularly in cases of intersecting identities.'

Retain existing questions

An individual, the Scottish Government Scottish Household Survey team and PHS suggested retaining the existing questions in this topic with the following reasons given: there is no or limited population level data available elsewhere, the data is used to inform/evaluate public policy, to inform local interventions, to better allocate resources and to monitor targets and trends.

PHS 'would prioritise retaining the existing questions, particularly in relation to the following indicators, as these are included in the PHS Adult Mental Health Indicators set. Changing or removing the questions used to populate these indicators would have obvious implications for maintaining these indicators:
- Percentage of adults who have been unfairly treated or discriminated against in Scotland in the past year
- Percentage of adults who have experienced harassment or abuse in Scotland in the past year due to discrimination'

3.13 Drugs

Overall recommendation for topic	Responses
Retain existing questions	4
Add new questions	4
Remove some of the existing questions	0
Replace existing questions	0

Frequency of data required	Responses
Annually	3
Biennially	0
4-yearly	0
One-off	0
As it currently is	3
Other	0

Scale of impact if data not collected	Responses
No impact	1
Some impact	4
Major impact	1

Add new questions/answer options

An individual suggested the following:

• 'Adding buprenorphine to list of drugs'
• 'Adding 'other' with free text due to fast rate of change of markets/usage'
• 'Asking something about treatment and support'
• 'Asking something about overdose'

PHS would 'welcome a discussion exploring whether the drugs questions module could be further developed/enhanced to help address the data needs related to supporting, monitoring and evaluating the Scottish Government's National Drug Deaths Mission.'

The Scottish Government drugs policy team suggested the following:

• The list of drugs is regularly reviewed to ensure that it is related to current information regarding drug use
• Other methods of opioid substitution therapy (apart from methadone) are given as options such as buprenorphine (Buvidal)
• Benzodiazepines are put into their own category rather than being listed under the section on tranquilisers
• Further questions are added to the final two to include:
• Are you seeking support for drug harms you are experiencing?
• Do you know how to access services?
• How often have you accessed treatment?

The Scottish Government drugs analysis team also suggested that 'the drugs listed need to be fit for purpose. For example, the current list only includes 'methadone', but does not include buprenorphine or any other opioid substitution therapy. Separately, benzodiazepines are listed under the umbrella term 'Tranquilisers', which is somewhat problematic given the disproportionate share of benzos implicated in drug deaths.' They said that 'in sum, the question set needs to a have a list of drugs that is commensurate with the reality 'on the street' as it were. However, the need to ensure that survey information is compatible with previous data collection (i.e. this module has been migrated to SHeS from the Scottish Crime and Justice Survey) is also appreciated.'

They also suggested adding 'questions exploring knowledge of substance use treatment services and survey user access thereof':

• If you do have a problem with your use of drugs (including prescription drugs?), are you currently seeking support?
  Tick ONE box
  Yes
  No
  
• To what extent do you agree or disagree with the following statement: I know how and where to access treatment services for drug use?
  Strongly agree
  Agree
  Neither agree nor disagree
  Disagree
  Strongly disagree
  Don't have an opinion
  
• How often have you sought or accessed treatment services for your drug use?
  Never
  Less than monthly
  Monthly
  Weekly
  Daily or almost daily
  

And 'questions looking at the impact of drug use (including on mental health and day to day function(s)). The format of these questions is replicated from questions asked elsewhere in SHeS about alcohol and gambling issues and it is hoped that this will provide insights on trends in 'addiction' in general':

• How often during the last year have you failed to do what was normally expected of you because of drug use?
  Never
  Less than monthly
  Monthly
  Weekly
  Daily or almost daily
  
• How often during the last year have you had a feeling of guilt or remorse after drug use?
  Never
  Less than monthly
  Monthly
  Weekly
  Daily or almost daily
  
• How often have you felt that drug use has caused you any health problems, including stress or anxiety?
  Never
  Less than monthly
  Monthly
  Weekly
  Daily or almost daily

Retain existing questions

PHS, ScotPHO, the Scottish Government Children and Families and Drugs analysis teams suggested retaining the existing questions in this topic with the following reasons given: there is no or limited population level data available elsewhere, the data is used to inform/evaluate public policy, to inform local interventions, to validate other data sources and to monitor targets and trends.

3.14 Food insecurity

Overall recommendation for topic	Responses
Retain existing questions	7
Add new questions	3
Remove some of the existing questions	0
Replace existing questions	0

Frequency of data required	Responses
Annually	8
Biennially	0
4-yearly	0
One-off	0
As it currently is	1
Other	0

Scale of impact if data not collected	Responses
No impact	1
Some impact	4
Major impact	4

Add new questions

GCPH suggested adding a question on fuel poverty.

IFAN suggested including 'the ten United States Department of Agriculture (USDA) food insecurity measurement questions now included in the Department of Work and Pensions (DWP) Family Resources Survey (FRS), as well as the new food bank questions currently out in the field with the FRS. This would enable comparison with results from the FRS. Beyond the key 10 USDA food insecurity measurement questions and the food bank questions suggested, this wider list could include questions linked to:

• knowledge, confidence in, availability and use of advice, income-boosting and holistic support services
• knowledge, confidence in, availability and use of the Scottish Welfare Fund
• knowledge, confidence in, availability and use of the Scottish Child Payment
• improved household resilience
• improved household well-being'

An individual suggested 'the use of the Food Insecurity Experience Scale questions alongside the introduction of the USDA Adult Food Security Survey module. This could be done by having half the sample answer one set of questions and half the sample answering the USDA questions if these sub-samples have enough statistical power to enable comparative analyses between them. Currently, the Scottish Health Survey includes 3 questions based on the FAO's Food Insecurity Experience Scale (FIES) and there are three main limitations:

• A skip pattern is used, such that if the first question is not answered affirmatively, neither of the following questions are asked. Whilst a skip pattern is used in the USDA's Food Security Survey Module, the screen in this module asks three questions. A screener based on one question is not adequate, as people may not answer this specific question affirmatively, but may have other experiences that indicate food insecurity. In the development of food insecurity scales, the use of multiple items has been identified as important for identifying households experiencing food insecurity, since it can manifest in different ways. The use of the screener in the FAO Food Insecurity Experience Scale is not recommended practice. All 8 questions are asked when this scale is used. The use of this screener may be leading to an underestimation of food insecurity in the Scottish population.
• Similarly, the selection of only 3 items from the FAO's FIES rather than the full set of questions may also result in an underestimation of food insecurity. A shorter version of this module has not been tested for its validity to measure food insecurity.
• The last limitation is that both the Department for Work and Pensions and Food Standards Agency in England, Wales, and Northern Ireland are using the USDA Adult Food Security Module in their surveys, the Family Resources Survey and Food and You 2 surveys, respectively. To be consistent with these surveys, the use of the USDA Adult Food Security module may be desirable. Whilst the DWP's survey covers Scotland and provides an estimate of food insecurity in their data, their data is limited in that it only provides a measure in the past 30 days. The FSA's Food and You 2 covers a 12 month period, as do the food insecurity questions currently in use on the Scottish Health Survey, but the FSA's survey does not cover Scotland, thus, a 12-month measure based on the USDA's Adult Food Security Module is not available. This module, whilst 10 questions, has been validated to allow for the use of skip patterns, based on the aforementioned 3 question screener.'
  

Retain existing questions

Two individuals, GCPH, Obesity Action Scotland, PHS and the Scottish Government Children and Families analysis and Housing and Social Justice teams at the suggested retaining the existing questions in this topic with the following reasons noted:, there is no or limited population level data available elsewhere, data is used to inform/evaluate public policy, to inform local interventions, to better allocate resources, to validate other data sources and to monitor targets and trends.

3.15 Gambling

Overall recommendation for topic	Responses
Retain existing questions	0
Add new questions	1
Remove some of the existing questions	0
Replace existing questions	0

Frequency of data required	Responses
Annually	1
Biennially	0
4-yearly	0
One-off	0
As it currently is	0
Other	0

Scale of impact if data not collected	Responses
No impact	0
Some impact	0
Major impact	1

Add new questions/answer options

PHS suggested adding the following:

• 'Additional modes of online gambling (e.g. eSports betting) added to existing methods
• Additional questions on gaming (loot boxes, skins betting)
• Additional questions on trading in crypto currency and whether crypto currency used to gamble'

3.16 General health and long-term conditions

Overall recommendation for topic	Responses
Retain existing questions	3
Add new questions	3
Remove some of the existing questions	0
Replace existing questions	2

Frequency of data required	Responses
Annually	6
Biennially	0
4-yearly	1
One-off	0
As it currently is	0
Other	0

Scale of impact if data not collected	Responses
No impact	0
Some impact	3
Major impact	4

Add new questions/answer options

The Scottish Government Clinical Priorities policy team suggested adding the following questions on endometriosis:

• 'How were you diagnosed with your condition (surgery/imaging/doctor)?
• Have you had surgery in relation to your condition?
• What surgery have you had?
• What treatment plan are you currently on for your condition?
  • Hormone treatment (please name)
  • Pain relief
  • Physiotherapy
  • Other (please specify)
• How much do you agree or disagree with the following about your help, care and support services over the past 12 months (Strongly agree/Agree/Neither agree nor disagree/Disagree/Disagree Strongly)?
  • I was aware of the help, care and support options available to me
  • I had a say in how my help, care or support was provided
  • My health, support and care services seemed to be well coordinated
  • The help, care or support improved or maintained my quality of life'

The Scottish Government Mental Health Directorate stated that they 'would like learning disabilities, autism, attention deficit hyperactivity disorder and foetal alcohol spectrum disorder to be captured within the long-term conditions question.'

The Scottish Government mental health, learning disabilities and autism team also proposed 'adding questions to gather data about existing neurodiversity conditions (i.e. learning disabilities, autism, attention deficit hyperactivity disorder).' They said that 'while these are long term conditions, they do not fit well into existing questions. Understanding the changing health and mental wellbeing of these groups would be a large step towards improving a robust evidence base around Scotland neurodiverse population. The long-term health condition could have the variables to include autism, learning disability, attention deficit hyperactivity disorder and learning difficulty.'

Replace existing questions

SCLD suggested that 'the reference to 'Mental Handicap' is removed from the general health section of the Scottish Health Survey, for two reasons. Firstly, 'Mental Handicap' is very dated language that is unacceptable terminology to use when speaking about people with learning disabilities. Secondly, a learning disability is not a health condition, and for that reason, asking about a person's learning disability status within the general health section of the survey is not appropriate. The most appropriate way to gather information about a person's learning disability status, is for all the major population surveys, including the Scottish Health Survey, to include the 'Disability or Long Term Health Condition' core question, as well as the more detailed follow up question related to impairments.' SCLD suggested that 'the follow up question be redesigned in such a way that would allow for the disaggregation of learning disability, by following the disability and long term health condition question from the 2022 Census', as shown below:

An individual also suggested removing the reference to 'Mental Handicap', as 'this is outdated and offensive language, and at the very least should be replaced with up to date language.' They said that 'there is a question as to whether learning disabilities should be asked about in a health survey given that is an impairment rather than a health condition. However, there is a severe lack of data collected about people with learning disabilities, and therefore there is merit for including it if it is asked in a way that will provide robust data. The census question on learning disability has been tested and may be suitable.'

Retain existing questions

PHS, ScotPHO and the Scottish Government Children and Families analysis team suggested retaining the existing questions in this topic with the following reasons noted:, there is no or limited population level data available elsewhere, data is used to inform/evaluate public policy, to inform local interventions, to better allocate resources, to validate other data sources, to monitor targets and trends and to calculate healthy life expectancy.

3.17 Mental wellbeing

Overall recommendation for topic	Responses
Retain existing questions	4
Add new questions	5
Remove some of the existing questions	0
Replace existing questions	1

Frequency of data required	Responses
Annually	3
Biennially	0
4-yearly	0
One-off	0
As it currently is	4
Other

Scale of impact if data not collected	Responses
No impact	1
Some impact	2
Major impact	2

Add new questions/answer options

The charity, BEAT, suggested adding 'questions on eating disorders to the anxiety, depression, suicide and self-harm module in version B of the health survey.' They proposed including 'the five-item Sick, Control, One stone, Fat, Food (SCOFF) questionnaire and a supplementary question regarding impacts on quality of life' ('Did your feelings about food interfere with your ability to work, meet personal responsibilities and/or enjoy a social life?'). 'The SCOFF is a brief screening tool, which has been validated for use in general adult population samples in the UK, that can identify individuals who may be experiencing a pattern of disordered eating and require a clinical assessment.' BEAT suggested not presenting the name of the questionnaire to respondents due to the ill-advised wording.

Glasgow Centre for Population Health (GCPH) suggested adding questions to the mental wellbeing module on 'the use of, and potential unmet demand for, mental health services'. For the young adults self-completions they recommended adding additional questions on issues such as:

• 'Not feeling in control
• Self-harming
• Suicide ideation
• Loneliness
• Barriers to socialising
• Bullying'

The Scottish Government Children and Families Analysis team suggested adding items from the General Self-Efficacy Scale to the mental wellbeing module.

The Scottish Government Mental Health Directorate suggested 'an explicit steer towards coping strategies, prevention and wellbeing' be added to the mental wellbeing module. They suggested adding questions such as:

• 'Overall, how well do you think you are coping with stress?'
• 'Which, if any, of the following have helped you to cope with stress …. Going for a walk outside; contacting family and friends; exercising; being able to visit green space…etc.'

PHS suggested that questions on stigma around mental health could potentially be included in the survey.

Replace the existing questions

The Scottish Government Mental Health Directorate suggested making changes to some of the current suicide/self-harm questions, including:

• Replacing the current question about suicide ('Have you ever made an attempt to take your life, by taking an overdose of tablets or in some other way?) with a more explicitly worded question (Have you ever attempted suicide?') with no reference to the methods.
• Adding the option of 'within the last month' to the questions about when suicide attempt was made or when an person deliberately harmed themselves. The current response options include 'the last week,' 'the last year' or 'some other time'.

They also suggested considering 'the World Health Organisation Quality of Life (WHOQOL) – BREF questionnaire if alternative scales are to be added to SHeS.' This questionnaire includes '26 items covering 4 domains: physical health, psychological, social relationships and the environment. It takes a more holistic approach' and would allow international comparisons.

Retain existing questions

PHS, ScotPHO, the Scottish Government Scottish Household Survey and Children and Families analysis teams requested that we retain the questions in this topic without any changes. The reasons given included there being no viable alternatives to the current questions, the data being needed for annual reporting, to monitor trends and to inform policy, prevention and service delivery.

3.18 Parental history

No feedback was received on the parental history questions.

3.19 Physical activity

Overall recommendation for topic	Responses
Retain existing questions	6
Add new questions	2
Remove some of the existing questions	0
Replace existing questions	1
Replace existing questions with IPAQ	1

Frequency of data required	Responses
Annually	4
Biennially	0
4-yearly	0
One-off	0
As it currently is	3
Other

Scale of impact if data not collected	Responses
No impact	1
Some impact	1
Major impact	5

Add new questions/answer options

The charity Paths for All recommended including a number of new questions including:

• 'A question or questions about the 'setting' for physical activity e. g. did the activity take place indoors or outdoors.'
• 'Reasons for doing an activity*. This could reflect the mental health benefits of the outdoors.'
• 'Reasons for not doing any/more outdoor physical activities/sport in the last 4 weeks*. This could reflect the availability of paths and greenspace.'
• A question on 'informal outdoor activities.'
• 'A question relating to levels of sedentary behaviour*.'

*It should be noted that questions on sedentary behaviour and motivations/barriers to physical activity are currently included in SHeS. The exact wording of these questions are available in the physical activity document, here Supporting documents - Scottish Health Survey: content review - gov.scot (www.gov.scot)

Replace the existing questions

An individual suggested that if it was not possible to continue to include the existing physical activity questions in SHeS annually, they would support moving to include the International Physical Activity Questionnaire (IPAQ) on a biennial or 4-yearly basis instead, with the IPAQ and existing questions included for the first few iterations so they could be calibrated against each other.

ScotPHO were supportive of replacing the existing physical activity questions with the IPAQ questionnaire, as they 'don't require as much detail about physical activity types' and they could 'accept the same simplified data collection scheme' as was used during the short 2020 SHeS telephone survey.

PHS suggested that 'the existing physical activity questions are included for a further 2 years to determine the impact of covid/recovery and to maintain trend data from pre-pandemic and thereafter, consider transitioning to IPAQ or the Active Lives Survey conducted by Sport England.' They also support the undertaking of a validation exercise to better understand the comparability between the existing SHeS question and the IPAQ or alternative questions.

PHS also made a number of smaller suggestions to the physical activity modules:

• Using a 4 week recall for physical activity questions for the questions that currently ask about a 7 day recall.
• Removing snooker/billiards/pool from the list of sports on the showcards.
• Recording any amount of physical activity, rather than asking about '10 minute bouts,' as this is no longer in line with the UK CMO's physical activity guidelines.
• Addition of duration to showcard E10 'on average how long did you spend in this place?'
• Consider drawing on recent NatureScot categorisation of locations to refresh the current list on showcard E9.
• Add 'to do everyday activities such as shopping, commuting or taking children to school' to showcard E7 to capture incidental forms of physical activity undertaken as part of daily living.
• Possible amendment to general response 'for health reasons/to improve health' on showcard E7 to include two additional response options 'to improve mental health' and 'to improve physical health'.
• Suggest the question on showcard E8 is broadened to look at physical activity and not just sport.

Retain the existing questions

An individual, Obesity Action Scotland, the charity Paths for All, the Scottish Government Scottish Household Survey team, PHS and the Strategic Planning team at SportsScotland requested that we retain the existing physical activity questions. There were various reasons given for this including: there being no/limited population level data available elsewhere, for annual reporting, to inform/evaluate public policy, to inform local interventions, to better allocate resources, monitor targets and to monitor trends.

3.20 Prescribed medicines and drug coding

No feedback was received on prescribed medicines and drug coding.

3.21 Respiratory

Overall recommendation for topic	Responses
Retain existing questions	1
Add new questions	1
Remove some of the existing questions	0
Replace existing questions	0

Frequency of data required	Responses
Annually	0
Biennially	1
4-yearly	0
One-off	0
As it currently is	1
Other	0

Scale of impact if data not collected	Responses
No impact	0
Some impact	1
Major impact	1

Add new questions

Asthma and Lung UK Scotland 'would like to see questions that cover a diagnosis of obstructive sleep apnoea (OSA), which is one of the main disease areas covered in the Respiratory Care Action Plan.'

Retain existing questions

PHS suggested retaining the questions in this topic giving the following reasons: there is no or limited population level data available elsewhere, the is used to inform/evaluate public policy, to better allocate resources, to validate other data sources and to monitor trends.

3.22 Smoking

Overall recommendation for topic	Responses
Retain existing questions	5
Add new questions	1
Remove some of the existing questions	0
Replace existing questions	0

Frequency of data required	Responses
Annually	1
Biennially	1
4-yearly	0
One-off	0
As it currently is	3
Other	0

Scale of impact if data not collected	Responses
No impact	2
Some impact	2
Major impact	1

Add new questions/answer options

ASH Scotland proposed several additional answers to existing questions:

• An additional answer option for the question: "We are also interested in whether people use any nicotine replacement or other products. Have you used any of the following products as part of your most recent attempt to stop smoking?"

New additional proposed answer "Stop smoking app" (i.e. smart phone application/program to stop smoking).

Then: IF stop smoking app is used, which one?

In addition: Currently answer "No" of the above questions, flows into question:

Was this accompanied by smoking cessation support?

New additional proposed answer to this question: No self-directed (this would provide a direct answer to screen out people who quit without support)

They proposed that all answers for the question on what cessation products are used, flow into the above follow-up question

• Additional answers and the addition of 'second-hand vapour' to the below existing question:

"Are you regularly exposed to tobacco smoke (OR VAPOUR) in any of these places?"

[New options to tick one or both substances]

1 At own home
2 At work
3 In other people's homes
4 In cars, vans etc
5 Outside of buildings (e.g. pubs, shops, hospitals)

New For exposure to second hand vapour would need to allow for inside of pubs, shops, hospital etc)
6 In other public places

New additional answer: Smoke or vapour drifts into my home from communal areas (such as hallways or entrances)

New additional answer: Smoke or vapour drifts into my home from neighbouring properties
7 No, none of these

Where applicable they also proposed the addition of second-hand vapour exposure to be added elsewhere in the Scottish health survey, e.g. in the sections for children and young people.

ASH Scotland also proposed 'some new analysis to be published in the supplementary materials. SHeS asks smokers what they used for their most recent quit attempt, e. g. nicotine gum and nicotine patches. Survey participants can provide multiple answers. Use of multiple cessation products is associated with increase quit success.' ASH Scotland proposed 'to report on the effects of using multiple cessation products along with the existing products as is currently provided by the supplementary smoking tables W533 to W540c for the 2019 Scottish Health Survey. Analysing this can help optimise smoking cessation services and provide information to people trying to stop smoking without using stop-smoking services to choose the most effective methods.'

Retain existing questions

ASH Scotland, Asthma and Lung UK Scotland, PHS, ScotPHO and the Scottish Government Children and Families analysis team suggested retaining the existing questions in this topic with the following reasons given: there is no or limited population level data available elsewhere, the data is used to inform/evaluate public policy, to inform local interventions, to better allocate resources, to monitor targets and trends, to validate other data sources and it also gives the ability to cross analyse with other topics in the survey.

3.23 Social capital and loneliness

Overall recommendation for topic	Responses
Retain existing questions	1
Add new questions	0
Remove some of the existing questions	0
Replace existing questions	0

Frequency of data required	Responses
Annually	0
Biennially	0
4-yearly	0
One-off	0
As it currently is	1
Other

Scale of impact if data not collected	Responses
No impact	0
Some impact	1
Major impact	0

Retain existing questions

The Scottish Government Children and Families analysis team suggested retaining the questions in this topic without any changes with the following reasons given: there is no or limited population level data available elsewhere and this data is used to inform/evaluate public policy.

3.24 Strengths and Difficulties Questionnaire (SDQ)

Overall recommendation for topic	Responses
Retain existing questions	1
Add new questions	0
Remove some of the existing questions	0
Replace existing questions	0

Frequency of data required	Responses
Annually	1
Biennially	0
4-yearly	0
One-off	0
As it currently is	0
Other	0
Scale of impact if data not collected	Responses
No impact	0
Some impact	1
Major impact	0

Retain existing questions

The Scottish Government Children and Families analysis team suggested retaining the existing questions in this topic without any changes for the following reasons: there is no or limited population level data available elsewhere, the data is used to inform/evaluate public policy and to monitor targets and trends.

3.25 Stress at work

Overall recommendation for topic	Responses
Retain existing questions	1
Add new questions	1
Remove some of the existing questions	0
Replace existing questions	0

Frequency of data required	Responses
Annually	1
Biennially	0
4-yearly	0
One-off	0
As it currently is	0
Other	0

Scale of impact if data not collected	Responses
No impact	0
Some impact	0
Major impact	1

Add new questions

PHS suggested adding the following question; 'it is currently used in the Understanding Society longitudinal survey, but that does not provide a suitable indicator for monitoring & planning purposes':

• 'I would like you to think about your employment prospects over the next 12 months. Thinking about losing your job by being sacked, laid-off, made redundant or not having your contract renewed, how likely do you think it is that you will lose your job during the next 12 months?'

Retain existing questions

PHS suggested retaining the questions in this topic existing for the following reasons: there is no or limited population level data available elsewhere, this data is used to inform/evaluate public policy, to inform local interventions, to better allocate resources and to monitor targets and trends.

3.26 Unpaid caring

Overall recommendation for topic	Responses
Retain existing questions	2
Add new questions	2
Remove some of the existing questions	0
Replace existing questions	0

Frequency of data required	Responses
Annually	1
Biennially	1
4-yearly	0
One-off	0
As it currently is	0
Other	0

Scale of impact if data not collected	Responses
No impact	1
Some impact	0
Major impact	1

Add new questions/answer options

ASH Scotland suggested adding questions on 'whether a child or young person has been in care (foster care, residential care etc.) or whether they had care responsibilities (e.g. having to look after a parent).' This experience has 'substantial consequences for many aspects of their whole life ahead, including smoking, drinking (alcohol), drug use, employability, earning potential, housing, and increases the likelihood of developing many physical and mental illnesses.' They also proposed to ask these or similar questions of participants under 18 years of age. These questions could either be part of unpaid caring or parental history topics. Examples could be:

• 'Used to be looked-after – as a child or young person were you: placed, in care at any point (in residential care, adopted, foster, living with family other than your parents, living at home under guidance of social services)?'
• 'Care experienced - as a child or young person did you have care responsibilities of a parent, carer, or sibling or other family member?'
  

The Scottish Government carers policy team suggested including 'something about vouchers, discounts and subscriptions, currently available through the Young Scot Package' to the answer options of the question for carers (aged 4-15). 'However, the package is only eligible for carers aged 11-18 and this question is for 4-15 year olds.'

Retain existing questions

PHS suggested retaining the existing questions in this topic for the following reasons: there is no or limited population level data available elsewhere, the data is used to inform/evaluate public policy, to inform local interventions, to better allocate resources and to monitor targets and trends.

The Scottish Government carers policy team also highlighted the importance of the 'unpaid caring questions remaining in the survey, as the data that the survey returns is used nationally to help identify which areas of carer support needs targeting. It also helps understand the scale and intensity of caring and see the extent of carer support which informs policies and helps predict costs.'

3.27 Vitamin supplements

Overall recommendation for topic	Responses
Retain existing questions	1
Add new questions	3
Remove some of the existing questions	1
Replace existing questions	0

Frequency of data required	Responses
Annually	1
Biennially	0
4-yearly	0
One-off	0
As it currently is	0
Other	3

Scale of impact if data not collected	Responses
No impact	0
Some impact	3
Major impact	1

Add new questions

FSS requested 'an expansion of the vitamin D question to include two further specific questions':

• When do consumers take a vitamin D supplement (year round or winter only)?
• What is the dosage of their supplement?

FSS also 'support the continued inclusion of folic acid supplement questions to allow for monitoring of the fortification policy.' Furthermore, they would 'recommend that the current folic acid questions are extended to the whole population (not just pregnant women and women of child-bearing age) and include a question on supplement dosage. Folic acid supplements are important for women of child-bearing age to help prevent neural tube defect affected pregnancies. However, due to folic acid fortification proposals, there is a risk that certain individuals may consume too much folic acid through fortified foods and supplements. A measure of the number of individuals taking supplements, plus the dosage, will contribute towards the monitoring of the fortification policy.'

PHS also suggested:

• 'Current folic acid supplement question to be asked of all adults'
• 'An additional question to be added to ask the amount of folic acid that is taken'
• 'Expand Vitamin D question to ask if supplement taken all year or only in the winter'
• 'An additional question to be added to ask the amount of vitamin D that is taken'

The Scottish Government HABIT team also requested that 'the folate supplement question is asked of the entire sample, not just women of childbearing age, to enable assessment of folate status against supplement intake and importantly, to assess the risk of excess intake in older people.' Additionally, they also requested that 'the vitamin D question is expanded to include two additional questions:

• Whether a supplement is taken all year round or only in winter

• What quantity/dosage is taken daily'

Retain existing questions

An indivdual suggested retaining the existing questions in this topic for the following reasons: there is no or limited population level data available elsewhere and this data is used to inform/evaluate public policy and to monitor trends.

FSS supported the continued inclusion of the 'supplements questions within SHeS and encouraged that these are aligned with the years when Intake24 is included. This would allow the data to be analysed collectively and data from supplements and diet to be combined for a more comprehensive picture.'

Remove some of the existing questions

An individual suggested removing the following question: "Are you taking folic acid supplements because you hope to become pregnant?", as it is subjective. 'The most important information is to know whether or not they are taking a supplement and their pregnancy status, in conjunction with their dietary intake.'

3.28 New topic

Homelessness

Crisis (homelessness charity) suggested adding two questions on homelessness. They stated that 'including questions on experiences of homelessness will add valuable data on a group at particular risk of poor health outcomes which will be valuable in ensuring parity of care and informing service planning.'

• 'Do you consider yourself to have ever been homeless?'
• 'Do you consider yourself to have been homeless in the past two years? (two years is in line with other UK surveys on this topic)'

Non-medical management techniques (such as social prescribing)

An organisation suggested adding:

• 'a question which picks up on the positive wellbeing benefits from a variety of non-medical management techniques (such as social prescribing) for managing each of the listed physical and mental health conditions'
• they would also be 'keen to hear whether this is the main management route or one of many techniques used'
• Their 'interest would be looking at the positive wellbeing outcomes generated from engagement with the historic environment - such as using historic places and intangible heritage for meeting, taking exercise, volunteering or engaging in other activities to manage/improve conditions or as a means of prevention.'

Headache disorders and musculoskeletal conditions

PHS identified headache disorders and musculoskeletal conditions as two new topics for consideration. The following questionnaires were suggested:

• Headache disorders: 'The HARDSHIP questionnaire is a modular instrument and incorporates demographic questions, diagnostic questions (ICHD-3 beta criteria) and enquires into each of the following as components of headache-attributed burden: symptom burden, health care utilisation, disability and productive time-loss; impact on education, career and earnings; perception of control, interictal burden, overall individual burden; effects on family, relationships and family dynamics; effects on others; QoL; wellbeing; obesity as a comorbidity. It has demonstrated validity and acceptability in multiple languages and cultures and was developed by a UK team (Imperial). Whilst it has in low- and middle- income countries been administered by lay interviewers, in Europe and within the Eurolight study it has been mailed or handed out for self-completion and therefore is validated for use in both standardised interviews and self-administered formats.'
• Musculoskeletal conditions: 'Several tools have been developed to measure musculoskeletal conditions, particularly low back pain, and an overview of these is provided in the table below. Of these, the Oswestry disability scale and Quebec Back Pain Disability scale appear to be the most widely evaluated (Wiitavaara et al 2020).'

Questionnaire/scale	Format	Strengths	Weaknesses/limitations
Oswestry Low Back Pain disability questionnaire Oswestry.pub (aaos.org)	10-point questionnaire	Free for non-commercial use Considered as 'gold standard' for low back pain Well-validated with good validity and reliability One of the most frequently evaluated Appropriate to use when attempting to assess activity and participation.	More specific to secondary care settings Not applicable beyond low back pain 10 areas covered may not be those of most importance to some patients Exclusive to low back pain
Roland & Morris Disability Index (RMDQ) Roland Morris Disability Questionnaire - Download Questionnaires (rmdq.org)	24 statements	Free to use Good validity and reliability	Test-retest reliability poorer over longer intervals Long set of questions Exclusive to low back pain
Aberdeen Low Back Pain Scale ABPS)_SAMPLE.pdf">Unbekannt (agedcaretests.com)	19 item scale.	Widely used	May need to purchase. Few studies evaluated psychometric properties
Extended Aberdeen Spine Pain Scale Extending the Aberdeen Back Pain Scale to include the whole spine: a set of outcome measures for the neck, upper and lower back - ScienceDirect	35 items	Look at spine as a whole Originally designed to be used in primary care	Not widely evaluated. Very lengthy
Quebec Back Pain Disability Scale Microsoft Word - Quebec.doc (tac.vic.gov.au)	20 item scale.	Evaluated to have adequate psychometric properties One of the most frequently evaluated Appropriate to use when attempting to assess activity and participation.	Only answered if considered to have back pain i.e. may underdiagnose prevalence.
Global Alliance for Musculoskeletal Health Survey Module Use of the global alliance for musculoskeletal health survey module for estimating the population prevalence of musculoskeletal pain: findings from the Solomon Islands (springer.com)		Short module, integrated well into other surveys previously e.g. Demographic Health Survey. Broader than low back pain.	Not widely evaluated as relatively new instrument.

They said that 'the chronic pain section will have overlap with both questions for headache disorders and musculoskeletal conditions. Therefore, it would seem opportune to review the chronic pain questions and assess whether these could be updated or augmented 'a once for all' list of questions which could be used going forwards instead of questions in disparate sections.'

Women's health

PHS also suggested including the following questions on menopause and endometriosis.

Menopause

Q1. How well informed do you feel you are about the menopause?

Invert List, Single Code

• 1. Very well informed
• 2. Well informed
• 3. Not very well informed
• 4. Not informed at all
• 5. I have never heard of the menopause
• 6. Prefer not to say * ^fixed

If Not Heard of Menopause Close, Others Continue

Ask All Aware Of The Menopause

Q2. If you needed to, how comfortable do you, or would you, feel talking about the menopause with…

a)……your partner?

b)……close family/friends?

d)……work colleagues?

Invert List, Single Code

• 1. Very comfortable
• 2. Quite comfortable
• 3. Not very comfortable
• 4. Not comfortable at all
• 5. Prefer not to say * ^fixed
• 6. Not applicable * ^fixed

Ask All Aware Of The Menopause

Q3. Which of the following, if any, are you aware of as symptoms of menopause?

Randomise List, Multicode

• 1. Heavy or irregular menstruation/periods
• 2. Ceasing of menstruation/periods
• 3. Hot flushes
• 4. Night sweats
• 5. Difficulty sleeping
• 6. Reduced sex drive
• 7. Vaginal dryness/discomfort
• 8. Headaches
• 9. Low mood, depression
• 10. Anxiety, panic
• 11. Short temper, irritability
• 12. Palpitations
• 13. Joint stiffness, aches and pains
• 14. Reduced muscle mass
• 15. Recurrent urinary tract infections
• 16. Weight gain
• 17. Problems with memory and concentration
• 18. Other (SPECIFY) * ^fixed
• 19. Don't know * ^{fixed * exclusive}
• 20. Prefer not to say * ^{fixed * exclusive}

Ask All Aware of The Menopause

Q4. Which of the following describes :

a) you

b) your partner

If you are not currently in a relationship choose 'not applicable' for partner.

Single Code For Each

1. Already experienced menopause

2. Currently experiencing menopause

3. Will experience menopause in the future

4. None of the above

5. [PARTNER ONLY] Not applicable

6. Don't know

7. Prefer not to say

Ask Q5 – Q6 For Respondent If Q4a Code 1,2,3; Otherwise Ask For Partner If Q4b Codes 1,2,3

Q5. Which, if any, of the following symptoms of the menopause IF Q4 CODE 1,2,3: have you] [Otherwise: has your partner] experienced?

List As Q3

Q6. Thinking about the impact of the menopause or menopausal symptoms. How would you describe the effect of the menopause or menopausal symptoms [IF Q4 CODE 1,2,3: on your] [Otherwise: on your partner's]……

a)……life overall?

b) …...relationship with your partner?

c)……relationships with other family/friends?

Even if you/your partner haven't experienced the menopause, we are still interested in your views about what impact it might have

Invert List, Single Code

• 1. Very positive
• 2. Positive
• 3. Neither positive nor negative
• 4. Negative
• 5. Very negative
• 6. [b) ONLY] Not applicable * ^fixed
• 7. Prefer not to say * ^fixed

Ask All Aware Of The Menopause

Q7. What sources of information, help and advice have you personally used to find out more about the menopause?

Randomise List, Multicode

1. Friends/relatives

2. Work colleagues/workplace support

3. Doctors/Healthcare Services

4. TV/Radio Programmes

5. Articles in newspapers/magazines

6. NHS Inform

7. Other healthcare websites

8. Other websites

9. Social media

10. Other (SPECIFY) * ^fixed

11. None * ^{fixed * exclusive}

12. Don't know * ^{fixed * exclusive}

13. Prefer not to say * ^{fixed* exclusive}

Ask All Aware Of The Menopause

Q8. What, if anything, might stop you from seeking information, help or advice on menopause? OPEN

Ask All Aware Of The Menopause

Q9. What are your preferred ways of getting information, support and advice on subjects like the menopause?

Randomise List, Multi Code

1. Face to face

2. Leaflets, booklets

3. Online: websites

4. Social media

5. TV/Radio Programmes

6. Articles in newspapers/magazines

7. Other (SPECIFY) * ^fixed

8. Don't know * ^{fixed* exclusive}

9. Prefer not to say * ^{fixed * exclusive}

Ask All Aware Of The Menopause

Q10. Which, if any, of the following would you appreciate knowing more about?

Randomise List, Multi Code

1. The full list of menopause symptoms

2. What can be done to relieve menopause symptoms

3. How long the symptoms of menopause go on for

4. How to manage symptoms at home

5. How to manage symptoms at work

6. How to talk to friends/family about it

7. How to talk to work colleagues about it

8. How to deal with the impact on mood and emotions

9. Where to go for professional help and advice

10. What treatments may be available

11. The experiences of other women

12. Other (SPECIFY) * ^fixed

13. Don't know * ^{fixed * exclusive}

14. Prefer not to say * ^{fixed * exclusive}

Ask All Aware Of The Menopause

Q11. How much do you agree or disagree with each of the following statements about the menopause?

Randomise

i. Boys and girls should be taught about the menopause at school

ii. People are generally too embarrassed to talk about the menopause

iii. Menopause is an issue for women, not for men

iv. I don't think there is enough understanding of the effect that the menopause can have on women's lives

v. I think the menopause is very personal and not something to be discussed openly

vi. I don't think the menopause is that big a deal for most women

vii. I feel that women's experience of menopause is too often ignored in the workplace

viii. The menopause can be a positive change for women, offering them the chance to live without concerns about their monthly cycle

ix. The menopause is an important health issue for all women

Invert List, Single Code

1. Agree strongly

2. Agree slightly

3. Neither agree nor disagree

4. Disagree slightly

5. Disagree strongly

6. Prefer not to say * ^fixed

Endometriosis

Do you have a gynaecological condition?

If so, what condition have you been diagnosed with?

• How were you diagnosed with your condition (surgery/imaging/doctor)
• Have you have surgery in relation to your condition
  • What surgery have you had?

Does (name of condition) limit your activities in any way?

Does this condition or illness affect you in any of the following areas?

1. Mobility (e.g. walking short distances or climbing stairs)

2. Dexterity (e.g. lifting or carrying objects)

3. Mental health

4. Fertility

5. Other areas of your body (bladder, bowel, lungs)

6. Socially

7. Other (please specify)

8. None of the above

What treatment plan are you currently on for your condition?

• Hormone treatment (please name)
• Pain relief
• Physiotherapy
• Other

How satisfied are you with the treatment you have received for your condition?

0 – Extremely dissatisfied / 10 – Extremely satisfied (assume SHS have their standard scales)

Do you feel that the clinicians involved in your care listened carefully to you and treated you with empathy?

Do you feel your clinicians gave you the information you needed in order to make an informed decision about your care?

GP and A&E contact

The Scottish Government Mental Health Directorate would be interested 'to know the number of contacts people have had with their GP and A&E department in the past 3 months.'

Heating

The Scottish Government Mental Health Directorate also mentioned that 'it would be worth asking people how they heat their home', as 'this might help with climate change policy as well as the response to the cost of living crisis.'

Violence against women and girls

The Scottish Government violence against women and girls policy team suggested adding questions on violence against women and girls. 'Violence against women and girls damages health and wellbeing and is a violation of the most fundamental human rights. Equally Safe: Scotland's strategy for preventing and eradicating violence against women and girls includes the following definition of violence against women and girls, which includes, but is not limited to:

• sexual and psychological violence occurring in the family (including children and young people), within the general community or in institutions, including domestic abuse, rape, and incest;
• sexual harassment, bullying and intimidation in any public or private space, including work;
• commercial sexual exploitation, including prostitution, lap dancing, stripping, pornography and trafficking;
• child sexual abuse, including familial sexual abuse, child sexual exploitation and online abuse;
• so called 'honour based' violence, including dowry related violence, female genital mutilation, forced and child marriages, and 'honour' crimes.'

Other topics

PHS stated that 'the following topics/issues have been identified through PHS' Mental Health Indicators work as "data gaps".' At present they are not requesting specific questions to address these gaps, as further work is planned to identify exactly what is needed. In the meantime, PHS 'would support proposals from others that would enhance the available data on these topics:

• Sleep
• Social media
• Racism
• Stigma around mental health
• Eating disorders'

Survey coverage

The Scottish Government Mental Health Directorate also wondered if 'the survey could go beyond private households to include people who live in care homes or other residential settings.'