Scottish Health Survey 2019 - volume 1: main report

Introduction

Policy Context

As a study of public health, the Scottish Health Survey (SHeS) plays an important role in assessing health outcomes, health risks and the extent of health inequalities in Scotland and how these have changed over time. With one of the lowest life expectancies in Western Europe and the lowest of all UK countries, as well as continued disparity in health outcomes between those living in the most and least deprived areas^[1], improving the health and wellbeing of Scotland's population continues to be a serious and complex challenge at local and national level.

In 2018, the Scottish Government launched six, whole system based, inter-related public health priorities designed to improve the health of the population and reduce unacceptable variation in life expectancy over the next decade^[2]. A revised National Performance Framework (NPF)^[3], developed together with the public, practitioners and experts, was also launched in 2018 with the core purpose being to create a more successful country, give opportunities to all people living in Scotland, increase their wellbeing, create sustainable and inclusive growth and reduce inequalities. It includes eleven National Outcomes that help to describe the kind of Scotland the Framework aims to create and reflect the values and aspirations of the people of Scotland. In addition, the National Outcomes have been designed to link with a number of the United Nation's Sustainable Development Goals^[4]. The specific goals that the health outcomes relate to are:

• Gender equality
• Reduced inequalities
• Responsible production and consumption
• Good health and wellbeing

The eleven National Outcomes provide a means of measuring progress towards the NPF vision for Scotland, and one is focussed exclusively on health - 'we are healthy and active'. Underpinning this National Outcome are a number of National Indicators related to:

• Healthy life expectancy
• Mental wellbeing
• Healthy weight
• Health risk behaviours (smoking, harmful drinking, low physical activity and obesity)
• Undertaking recommended levels of physical activity
• Journeys by active travel (walking/cycling)
• Quality of care experience
• Work related ill-health
• Premature mortality

However, as well as these, many other National Indicators that track progress towards the national outcomes have relevance to health^[5]. SHeS is used to monitor progress towards the following National Indicators:

• Mental Wellbeing
• Healthy Weight
• Health Risk Behaviours
• Physical Activity
• Child wellbeing and happiness
• Food insecurity

The Scottish Government's Programme for Scotland: Protecting Scotland, renewing Scotland 2020-21, published on the 1^st of September 2020^[6], highlights the need to address health inequalities as well as improve population health overall.

It includes actions designed to renew the focus on tackling health inequalities, to drive efforts to improve mental health and wellbeing, as well as work to expand access to digital care for both physical and mental health.^[7]

As well as being the official source for measuring progress on a number of NPF indicators, SHeS is used to monitor numerous Scottish health strategies, programmes and initiatives.

Each of the chapters included in this volume addresses an aspect of health that relates either directly or indirectly to the Government's objective that 'we are healthy and active'.

The Scottish Health Survey (SHeS) Series

SHeS has been carried out annually since 2008 and prior to this was carried out in 1995^[8], 1998^[9], and 2003^[10]. The 2019 survey was the fifteenth in the series.

Commissioned by the Scottish Government Health Directorates, the series provides regular information on aspects of the public's health and factors related to health which cannot be obtained from other sources. The SHeS series was designed to:

• estimate the prevalence of particular health conditions in Scotland
• estimate the prevalence of certain risk factors associated with these health conditions and to document the pattern of related health behaviours
• look at differences between regions and subgroups of the population in the extent of their having these particular health conditions or risk factors, and to make comparisons with other national statistics for Scotland and England
• monitor trends in the population's health over time
• make a major contribution to monitoring progress towards health targets

Each survey in the series includes a set of core questions and measurements (height and weight and, if applicable, blood pressure, waist circumference, and saliva samples), plus modules of questions on specific health conditions and health risk factors that vary from year to year. Each year the main sample has been augmented by an additional boosted sample for children. Since 2008, NHS Health Boards have also had the opportunity to boost the number of adult interviews carried out in their area.

The 2019 survey was undertaken by ScotCen Social Research, with the Office of National Statistics (ONS) sharing fieldwork. From 2012 to 2019, survey contributors have included the MRC/CSO Social and Public Health Sciences Unit (MRC/CSO SPHSU) based in Glasgow, The Centre for Population Health Sciences at the University of Edinburgh and The Public Health Nutrition Research Group at Aberdeen University.

The 2019 Survey

It is important to note that, as the data presented in this report is for 2019, it will not capture the significant impact that the subsequent COVID-19 pandemic has had - and will continue to have - on the physical and mental health and wellbeing of the people of Scotland.

Topics

Cardiovascular disease (CVD) and related risk factors remains the principal focus of the survey. The main components of CVD are ischaemic heart disease (IHD) (or coronary heart disease) and stroke, both of which are clinical priorities for the NHS in Scotland^[11],[12]. Diseases of the circulatory system are one of the leading causes of death in Scotland in 2018, this includes 11% of deaths which are caused by IHD, with a further 7% caused by cerebrovascular disease (including stroke)^[13]. Despite a decrease in the incidence rate of cerebrovascular disease of 12% over the last ten years^[14], stroke remains one of the biggest killers in Scotland and the leading cause of disability^[15]. In addition, while the coronary heart disease mortality rate decreased by 32% between 2009 and 2018, the rate of decline has slowed in the last five years^[16] and concern remains about continuing inequalities in relation to morbidity and mortality linked to these conditions^[17]. The SHeS series now has trend data going back over two decades and providing time series data remains an important function of the survey.

Many of the key behavioural risk factors for CVD are in themselves of particular interest to health policy makers, public health professionals and the NHS. For example, smoking, poor diet, lack of physical activity, obesity and problematic alcohol use are all the subject of specific strategies targeted at improving the nation's health. SHeS includes detailed measures of all these factors which are reported on separately in Chapters 4-7. The other four chapters focus on health conditions and experiences which have the potential to influence health outcomes in later life - General Health, Cardiovascular Disease and Diabetes (Chapter 1), Mental Health and Wellbeing (Chapter 2), Dental Health and Services (Chapter 3) and Adverse Childhood Experiences (ACEs) (Chapter 8).

Sample

The Scottish Health Survey is designed to yield a representative sample of the general population living in private households in Scotland every year.

The current survey design also means that estimates at NHS Health Board level are available by combining four consecutive years of data. NHS board results for the period 2016-2019 have been published at the same time as this report.

Those living in institutions, who are likely to be older and, on average, in poorer health than those in private households, were outwith the scope of the survey. This should be borne in mind when interpreting the survey findings.

A random sample of 6,451 addresses was selected from the Postcode Address File (PAF), using a multi-stage stratified design. Where an address was found to have multiple dwelling units, one was selected at random. Where there were multiple households at a dwelling unit, a single household was selected at random. Everyone within a selected household was eligible for inclusion. Where there were more than two children in a household, two were randomly selected for inclusion, to limit the burden on households. The individuals interviewed at these addresses form the 'main sample'.

Two further samples were selected for the survey in 2019: a child boost sample (5,425 addresses) in which up to two children in a household were eligible to be interviewed but adults were not, and a Health Board boost sample (213 addresses) for those Health Boards which opted to boost the number of adults interviewed in their area.

Fieldwork

A letter stating the purpose of the visit was sent to each sampled address in advance of the interviewer visit. Interviewers sought the permission of each eligible adult in the household to be interviewed, and both parents' and children's permission to interview up to two children aged 0-15.

Interviewing was conducted using a combination of Computer Assisted Interviewing (CAI), where the questionnaire answers are input directly to a laptop, and self-completed paper questionnaires. The content of the interview and full documentation are provided in the accompanying technical report.

Adults (aged 16 and over) and children aged 13-15 completed the interview themselves. Parents of children aged 0-12 completed the interview on behalf of their child.

Those aged 13 and over were also asked to complete a short paper self-completion questionnaire on more sensitive topics during the interview. Parents of children aged 4-12 years selected for interview were also asked to fill in a self-completion booklet about the child's strengths and difficulties designed to detect behavioural, emotional and relationship difficulties.

Towards the end of the interview height and weight measurements were taken from those aged 2 and over.

In a sub-sample of households, interviewers sought permission from adults (aged 16 and over) to take part in an additional 'biological module'. The biological module was administered by specially trained interviewers. In the module, participants were asked questions about prescribed medication and anxiety, depression, self-harm and suicide attempts. In addition, the interviewer also took participants' blood pressure readings and waist measurement, as well as samples of saliva. Data from the biological module are reported every second year to allow two years of survey data to be combined. Data was last reported in 2017 on the combined 2016/17 data, therefore, data has been reported in 2019 on the combined 2018/19 data. Further details of these samples and measurements are available both in the Glossary and in the accompanying technical report.

Survey response

In 2019, across all sample types, interviews were held in 3,245 households with 4,903 adults (aged 16 and over), and 1,978 children (aged 0-15). Of these, 1,281 adults completed the biological module. The number of participating households and adults in 2019 is listed in the table below. Further details on survey response in 2019 are presented in Chapter 1 of the technical report.

Main and Health Board boost samples
Participating households	3,245
Eligible households responding	56%
Adult interviews	4,903
Eligible adults responding	49%
Adults eligible for biological module	1,828
Adults who completed biological module	1,281
Child boost sample
Participating households	675
Eligible households responding	67%
Child interviews (child boost sample only)	1,036
Child interviews (main and child boost sample combined	1,978

Ethical Approval

Ethical approval for the 2019 survey was obtained from the REC for Wales committee (reference number 17/WA/0371).

Data Analysis

Weighting

Since addresses and individuals did not all have equal chances of selection, the data had to be weighted for analysis. SHeS comprises of a general population (main sample) and a boost sample of children screened from additional addresses. Therefore, slightly different weighting strategies were required for the adult sample (aged 16 or older) and the child main and boost samples (aged 0-15). Additional weights have been created for the biological module and for use on combined datasets (described below). A detailed description of the weights is available in Chapter 1 of the technical report.

Weighted and unweighted data and bases in report tables

All data in the report are weighted. For each table in the report both weighted and unweighted bases are presented. Unweighted bases indicate the number of participants involved. Weighted bases indicate the relative sizes of sample elements after weighting has been applied.

Standard analysis variables

As in all previous SHeS reports, data for men, women, boys and girls are presented separately where possible. Many of the measures are also reported for the whole adult or child population. Survey variables are tabulated by age groups and in some cases also by Scottish Index of Multiple Deprivation (SIMD).

Statistical information

The SHeS 2019 used a clustered, stratified multi-stage sample design. In addition, weights were applied when obtaining survey estimates. One of the effects of using the complex design and weighting is the standard errors for the survey estimates are generally higher than the standard errors that would be derived from an unweighted simple random sample of the sample size. The calculations of standard errors shown in tables, and comment on statistical significance throughout the report, have taken the clustering, stratifications and weighting into account. Full details of the sample design and weighting are given in the technical report, Chapter 1.

Presentation of trend data

In this report, trends based on the thirteen surveys from 2003 onwards are presented for all adults aged 16 and over. Prior to this the survey eligibility criteria were set at a maximum age of 64 in 1995 and then a maximum age of 74 in 1998. Trends for children are based on the 2-15 years age group from 1998 onwards, and 0-15 years from 2003 onwards.

Presentation of results

Commentary in the report highlights differences that are statistically significant at the 95% confidence level. Statistical significance is not intended to imply substantive importance. A summary of findings is presented at the beginning of each chapter. Each chapter then includes a brief overview of the relevant policy area. These overviews should be considered alongside the higher-level policies noted above and related policy initiatives covered in other chapters. A description of the methods and key definitions are also outlined in detail in each chapter. A link to the tables showing the results discussed in the text is included at the end of each chapter.

Availability of further data and analysis

As with surveys from previous years, a copy of the SHeS 2019 data will be deposited at the UK Data Archive along with copies of the combined datasets for 2017/2019, 2018/2019 and 2016/2017/2018/2019. In addition, a detailed set of web tables for 2019, providing analysis by age, area deprivation, equivalised income and long-term condition for a large range of measures is available on the Scottish Government website^[18].

Key indicators for local areas are available in the Scottish Health Survey App published on the Scottish Government website alongside this report.

Further breakdowns are also available for smoking, long-term conditions, general health and caring indicators from the Scottish Survey Core Questions, which asks harmonised questions across the three major Scottish Government household surveys, available here: https://www.gov.scot/collections/scottish-health-survey.

Comparability with other UK statistics

Guidance on the comparability of statistics across the UK is included in the introductory section of individual chapters.

Content Of This Report

This volume contains chapters with substantive results from the SHeS 2019, and is one of two volumes based on the survey, published as a set as 'The Scottish Health Survey 2019':

Volume 1: Main Report

1. General Health, CVD and Diabetes
2. Mental Wellbeing
3. Dental Health
4. Alcohol
5. Smoking
6. Diet & Obesity
7. Physical Activity
8. Adverse Childhood Experiences

Volume 2: Technical Report

Volume 2 includes a detailed description of the survey methods including: survey design and response; sampling and weighting procedures; and, information on laboratory analysis of saliva samples.

Both volumes along with a summary report of the key findings from the 2019 report are available on the Scottish Government website: https://www.gov.scot/collections/scottish-health-survey.

References and notes

1. Scottish Government: Population Health Directorate. Health improvement. [Online]. Available from: https://www.gov.scot/policies/health-improvement/

2. Scottish Government: Population Health Directorate. Scotland's Public Health Priorities. [Online].Available from: https://www.gov.scot/publications/scotlands-public-health-priorities/pages/1/

3. See: http://nationalperformance.gov.scot//

4. United Nations (2015). Transforming Our World: The 2030 Agenda for Sustainable Development. [Online]. Available from: https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20Sustainable%20Development%20web.pdf

5. See: http://nationalperformance.gov.scot//

6. Protecting Scotland, Renewing Scotland - The Scottish Government's Programme for Scotland 2020-21. Edinburgh, Scottish Government. 2020. Available from: https://www.gov.scot/publications/protecting-scotland-renewing-scotland-governments-programme-scotland-2020-2021/

7. See: http://www.healthscotland.scot/health-inequalities/the-right-to-health/overview-of-the-right-to-health

8. Dong W and Erens B. The 1995 Scottish Health Survey. Edinburgh:The Stationery Office. 1997. Available from: https://www.sehd.scot.nhs.uk/publications/sh5/sh5-00.htm

9. Shaw A, McMunn A and Field J. The 1998 Scottish Health Survey. Edinburgh:The Stationery Office. 2000. Available from: https://www.sehd.scot.nhs.uk/scottishhealthsurvey/sh8-00.html

10. Bromley C, Sproston K and Shelton N [eds]. The Scottish Health Survey 2003. Edinburgh: The Scottish Executive. 2005

11. Heart Disease Improvement Plan. Edinburgh, Scottish Government. 2014. www.gov.scot/Publications/2014/08/5434

12. Stroke Improvement Plan. Edinburgh, Scottish Government. 2014. www.gov.scot/Publications/2014/08/9114

13. See: https://www.nrscotland.gov.uk/statistics-and-data/statistics/scotlands-facts/leading-causes-of-death-in-scotland

14. Public Health Scotland. (2020). Scottish Stroke Statistics. Available from: https://beta.isdscotland.org/find-publications-and-data/conditions-and-diseases/stroke-statistics/scottish-stroke-statistics/

15. NSS Information and Intelligence, NHS National Services Scotland (2018). Scottish Stroke Improvement Programme: 2018 Report. [Online] Available from:

https://www.strokeaudit.scot.nhs.uk/Publications/docs/2018-07-10-SSCA-Report.pdf

16. Information Services Division (2020). Scottish Heart Disease Statistics. Available from: https://beta.isdscotland.org/find-publications-and-data/conditions-and-diseases/heart-disease-and-blood-vessels/heart-disease-statistics/

17. Public Health Reform (2020). The reform programme: why reform is important [Online] Available from: https://publichealthreform.scot/the-reform-programme/why-reform-is-important

18. See: https://www.gov.scot/collections/scottish-health-survey

Notes to Tables

1 The following conventions have been used in tables:
n/a no data collected
- no observations (zero value)
0 non-zero values of less than 0.5% and thus rounded to zero
[ ] normally used to warn of small sample bases, if the unweighted base is less than 50. (If a group’s unweighted base is less than 30, data are normally not shown for that group.)

2 Because of rounding, row or column percentages may not add exactly to 100%.

3 A percentage may be quoted in the text for a single category that aggregates two or more of the percentages shown in a table. The percentage for the single category may, because of rounding, differ by one percentage point from the sum of the percentages in the table.

4 Values for means, medians, percentiles and standard errors are shown to an appropriate number of decimal places. Standard Errors may sometimes be abbreviated to SE for space reasons.

5 ‘Missing values’ occur for several reasons, including refusal or inability to answer a particular question; refusal to co-operate in an entire section of the survey (such as a self-completion questionnaire); and cases where the question is not applicable to the participant. In general, missing values have been omitted from all tables and analyses.

6 The population sub-group to whom each table refers is stated at the upper left corner of the table.

7 Both weighted and unweighted sample bases are shown at the foot of each table. The weighted numbers reflect the relative size of each group in the population, not numbers of interviews conducted, which are shown by the unweighted bases.

8 The term ‘significant’ refers to statistical significance (at the 95% level) and is not intended to imply substantive importance.

9 Within the report Figures have generally been produced using data rounded to the nearest whole number. There are a small number of Figures which show data to the nearest decimal place to aid interpretation.