The Scottish Health Survey 2022 – 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. While positive changes have been recorded, Scotland continues to record a significantly lower life expectancy compared to other countries in the UK and Western Europe, 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 key challenge at both the local and national level.

In 2018, the Scottish Government launched six inter-related public health priorities designed to improve the health of the population and reduce health inequalities in Scotland over the next decade^[2]. In the same year, a revised National Performance Framework (NPF)^[3] was also launched containing eleven National Outcomes that link with several of the United Nation’s Sustainable Development Goals^[4], including several health outcomes. Underpinning the outcome focused exclusively on health - ‘we are healthy and active’ - are several National Indicators. SHeS is used to monitor progress towards indicators relating to mental wellbeing, healthy weight, health risk behaviours, physical activity, child wellbeing and happiness, and food insecurity.

The impact of the COVID-19 pandemic is likely to be felt for some time, with both physical health and mental and emotional wellbeing being affected. The Scottish Government’s mental wellbeing transition and recovery plan^[5] and Long Covid-19 service paper ^[6] are among the approaches and initiatives published to tackle this impact.

Chronic pain (persistent pain lasting for longer than 12 weeks) is projected to increase amongst the Scottish population and can place considerable strain on health services and the lives of those affected. Supporting the Scottish Government’s initiatives and policies in this area are a framework for the delivery of pain management services^[7], as well as guidelines for the management and prescription approach for those living with chronic pain^[8],[6].

The Scottish Health Survey (SHeS) Series

SHeS has been carried out annually since 2008 and prior to this was carried out in 1995^[9], 1998^[10], and 2003^[11]. Due to disruption to the survey at the onset of the pandemic, the survey data collected in 2020 was published as experimental statistics and was not comparable with the time series^[12]. This data has not been included in the survey trends.

Commissioned by the Scottish Government Health Directorates, the SHeS series aims to provide 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 official 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 SHeS series has 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.

The 2018 to 2022 surveys were undertaken by the Scottish Centre for Social Research, with the Office of National Statistics (ONS) sharing fieldwork. 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 2022 Survey

For the first two months of the 2022 survey (March and April 2022), the methodology remained the same as the final few months of 2021 whereby interviewers were able to visit households on the doorstep to encourage response to a telephone interview (known as a knock-to-nudge approach). However, from May 2022, interviews (with the exception of the child boost) were undertaken using a primarily in-home face-to-face approach with a telephone contingency for respondents who were not willing to have an interviewer in-home. As a result of building the bio interviewer panel back up after the pandemic, bio measures were reintroduced part way through fieldwork.

For the child boost sample, up to July 2022 potential respondents were initially contacted by letter and asked to opt-in to an interview conducted over the phone. August 2022 was a transition month in order to introduce linkage of the sample with the Community Health Index (CHI) to identify households with children. From September 2022, this linked sample was worked face-to-face in-home, significantly improving the sample efficiency and response.

Further details on the fieldwork approach can be found in Chapter 1 of the Scottish Health Survey 2022 - volume 2: technical report.

The SHeS series now has trend data going back over two decades and providing time series data remains an important function of the survey. The impact of Covid-19 restrictions means that caution should be applied when comparing the 2022 results with the 2021 survey data, which were collected via a telephone approach. Further details on the fieldwork approach in 2021 can be found in Chapter 1 of the Scottish Health Survey 2021- volume 2: technical report, while information on the differences between the 2021 survey data and previous years can be found in Chapter 2 of the Scottish Health Survey 2021- volume 2: technical report.

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 remain clinical priorities for the NHS in Scotland^[13],[14], particularly in light of the impact of the pandemic. CVD is one of the leading causes of death in Scotland. In 2022, this included 11% of deaths which are caused by IHD, with a further 6% caused by cerebrovascular disease (including stroke)^[15]. The incidence rate of cerebrovascular disease has fallen by 8% over the last decade^[16], however, stroke remains one of the biggest causes of death in Scotland^[17]. In addition, while the coronary heart disease mortality rate has decreased by 18% in the last ten years, the rate of decline has slowed in the last five years^[18] and despite improvements, there remains concern about continuing inequalities in relation to morbidity and mortality linked to these conditions^[19].

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; poor diet, obesity, lack of physical activity, smoking, and levels of alcohol consumption are all the subject of specific strategies targeted at improving Scotland’s health. SHeS includes detailed measures of all these factors which are reported on separately in Chapters 6-9. The other five chapters focus on health conditions and experiences which have the potential to influence health outcomes in later life - Mental Wellbeing (Chapter 1), General Health, Cardiovascular Disease and Caring (Chapter 2), Respiratory Conditions including long-Covid (Chapter 3), Dental Health (Chapter 4) and for the first time, Chronic pain (Chapter 5).

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, usually by combining four consecutive years of data. Due to disruption of the survey in 2020 and comparability issues with the results collected from the short telephone survey conducted that year, NHS board results have been produced using data from the 2018, 2019, 2021 and 2022 surveys combined. These have been published within the survey dashboard 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 total of 29,106 addresses was drawn from the Postcode Address File (PAF) in 2022. Of these, 17,417 were child boost addresses, 16,266 of which were issued as opt-in until July 2022. The rest of the child boost addresses were issued following linkage with the Community Health Index (CHI) database to increase the likelihood of identifying households with children present. A total of 8,689 addresses in the core sample (main (core) sample version A, main (core) sample version B) were issued for the whole of the 2022 fieldwork period. The first two months of the core sample were worked on a knock-to-nudge basis, with interviews undertaken by telephone. Face-to-face in-home interviewing for the core sample resumed from May 2022.

Fieldwork

There were two phases of fieldwork for SHeS 2022 for the core sample and also two phases for the child boost Sample. During phase 1 for the core sample, potential participants were contacted by letter and recruited to participate by interviewers knocking on their door, in what is termed a ‘knock-to-nudge’ methodology. Interviews were conducted by telephone. This phase covered the months of March and April 2022 and included similar content to earlier survey years, as well as interviews with or on behalf of children.

Between March and July 2022, participants from the child boost sample continued to be invited to opt in via letter. Fieldwork for the child boost sample was suspended in August 2022 to allow the transition to use of sample linked to the Community Health Index (CHI) database. This was undertaken following approval from the NHS Scotland Public Benefit and Privacy Panel for Health and Social Care. The transition to the use of the CHI database was undertaken to increase the efficiency of the sample.

Each sampled address was sent an advance letter that introduced the survey and to let the resident know that an interviewer would be calling to seek permission to interview. A number of versions of the advance letter were used in 2022: one for the core version A addresses, one for core version B addresses (with the biological module), and two for child boost addresses (one for opt in and one for in-home interviews). There was a version of each of these letters for each organisation conducting interviews (ScotCen Social Research and ONS), with the exception of child boost cases which were worked by ScotCen only. A copy of the survey leaflet was included with every advance letter. The survey leaflet introduced the survey, described its purpose in more detail and included some summary findings from previous surveys.

For copies of the advance letters and survey leaflets, see the documents listed in Appendix A.

For the main sample, all adults aged 16 and over in responding households were eligible for interview. To ease respondent burden, for child interviews for both the main and the child boost samples a maximum of two children were interviewed at each household. If a household contained more than two children, then two were randomly selected for interview.

Data collection involved a main computer assisted personal (CAPI) or telephone (CATI) interview, and online or paper self-completion questionnaire.

No height and weight measurements or biological measures could be taken for interviews conducted by telephone. For these interviews, participants were therefore asked to estimate their own height and weight during the interview. The bio interviewer panel was also not at full strength at the outset of fieldwork but increased in size over the course of 2022. These issues meant that only a proportion of the core version B sample completed a biological module. These addresses were only assigned to trained bio interviewers. No biological measurements could be taken by a non-bio trained interviewer. Otherwise, the key differences between the core version A and version B interviews were a slightly longer telephone interview for version A to cover the rotating modules (those not asked every year) and a slightly longer self-completion for version B to cover the depression, anxiety, self-harm and attempted suicide questions which are only included for the bio sample.

Survey response

In 2022, across all sample types, interviews were held in 3,602 households with 4,394 adults (aged 16 and over), and 1,764 children (aged 0-15). The number of participating households and adults in 2022 is presented separately for the opt-in and knock-to-nudge samples in the tables below. Further details on survey response in 2022 are presented in Chapter 2 of the Scottish Health Survey 2022 - volume 2: technical report.

When considering the household response rate, households classed as “responding” were those where at least one eligible person opted-in/consented to interview and was interviewed.

It should be noted that whilst 2022 response rates are improved upon those seen in 2021, they remained lower than typical pre-pandemic rates.

Ethical Approval

Ethical approval for the 2022 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). The address selection weights were calculated to compensate for unequal probabilities of selection of addresses in different survey strata, within the opt-in and knock-to-nudge/in-home samples. Additional weights have been created for use on combined datasets. A detailed description of the weights is available in Chapter 2 of the Scottish Health Survey 2022- volume 2: 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 by Scottish Index of Multiple Deprivation (SIMD) or other variables such as smoking status.

Statistical information

SHeS 2022 used a partially 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 that standard errors for survey estimates are generally higher than the standard errors that would be derived from an unweighted simple random sample of the same size. The calculations of standard errors shown in tables, and comments on statistical significance throughout the report, have taken the clustering, stratification and weighting into account. Full details of the sample design and weighting are given in Chapter 2 of the Scottish Health Survey 2022 - volume 2: technical report.

Presentation of trend data

In this report, trends based on the fourteen 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. Unless specified otherwise, 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 detailed in Chapter 2 of the Scottish Health Survey 2022- volume 2: technical report. 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 2022 data will be deposited at the UK Data Archive along with copies of the combined datasets for 2021/2022, 2018/2022 and 2018/2019/2021/2022. In addition, a detailed set of web tables for 2022, 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^[20].

Key indicators for local areas are available in the Scottish Health Survey Dashboard 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 from the Scottish Government website.

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 SHeS 2022, and is one of two volumes based on the survey, published as a set as ‘The Scottish Health Survey 2022’:

Volume 1: Main Report

1. Mental Wellbeing

2. General Health, CVD and Caring

3. Respiratory Conditions

4. Dental Health

5. Chronic Pain

6. Alcohol

7. Smoking

8. Diet and Obesity

9. Physical Activity

Volume 2: Technical Report

Volume 2 includes a detailed description of the survey methods including: survey design and response; sampling and weighting procedures.

Both volumes along with a summary report of the key findings from the 2022 report are available on the Scottish Health Survey pages of the Scottish Government website.

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

[ ] small sample bases (unweighted base is between 30 and less than 50)

* very small sample bases (unweighted base is less than 30)

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.