Scottish Health Survey 2018: questionnaire changes report

5. Existing Topics

5.1. Demographic Questions

In order to better take account of individuals with a non-binary gender identity, an additional question on gender identity has been added to the self-completion questionnaire. This is included in the core sample, and is in line with similar changes being made to other major surveys in Scotland. The new question is as below:

How would you describe your gender identity?	Tick ONE box
Man / Boy	1
Woman / Girl	2
In another way If you would like to, please write in the other words you would use below: ………………………………………………………………………	3

In a related change, alterations have been made to the household relationship matrix. The matrix captures the relationships between different members of the household. The additional text, marked in red, is designed to accommodate relations with individuals with a non-binary gender identity.

Relationship matrix:

How is (name) related to (name)? Just tell me the number on this card.

• Husband or wife or spouse [1]
• Co-habiting partner [2]
• Legally recognised civil partner [3]
• Son or daughter or child (including adopted) [4]
• Stepson or daughter or child of spouse or civil partner [5]
• Foster child [6]
• Son-in-law or daughter-in-law or child's spouse or civil partner [7]
• Parent (including adopted) [8]
• Stepparent [9]
• Foster parent [10]
• Parent-in-law [11]
• Brother or sister or sibling (including adopted) [12]
• Half brother or half sister or half sibling [13]
• Foster brother or foster sister or foster sibling [14]
• Step brother or step sister or step sibling [15]
• Brother-in law or sister-in-law or sibling through marriage or civil partnership [16]
• Grandparent [17]
• Grandchild [18]
• Other relative [19]

In line with the other major population surveys, the question on educational attainments question has also been updated to reflect new qualifications commonly achieved (additions in red).

Please look at this card and tell me which, if any, of the following educational qualifications you have.

CODE ALL THAT APPLY.

None of these qualifications = Code 12

1 School Leaving Certificate, National Qualification Access Unit

2 O Grade, Standard Grade, GCSE, GCE O Level, CSE, National Qualification Access 3 Cluster, Intermediate 1 or 2, National 4 or 5, Senior Certificate or equivalent

3 GNVQ/ GSVQ Foundation or Intermediate, SVQ Level 1 or 2, SCOTVEC/National Certificate Module, City and Guilds Craft, RSA Diploma or equivalent

4 Higher grade, Advanced Higher, CSYS, A level, AS Level, Advanced Senior Certificate or equivalent

5 GNVQ/ GSVQ Advanced, SVQ Level 3, ONC, OND, SCOTVEC National Diploma, City and Guilds Advanced Craft, RSA Advanced Diploma or equivalent

6 HNC, HND, SVQ Level 4, RSA Higher Diploma or equivalent

7 First Degree, Higher degree, SVQ Level 5 or equivalent

8 Professional qualifications e.g. teaching, accountancy

9 Other school examinations not already mentioned

10 Other post-school but pre Higher education examinations not already mentioned

11 Other Higher education qualifications not already mentioned

12 No qualifications

NHS Health Scotland Public Health Directorate highlighted through the consultation that the question used to collect information on income did not specifically identify any disability-related benefits that individuals might be receiving. We have updated this question for 2018 to capture this information. The revised question is presented below, with new sources of income in red.

Please look at this card. There has been a lot of talk about health and income. We would like to get some idea of your household's income. This card shows various possible sources of income. Can you please tell me which of these you (and your husband/wife/partner) receive?

(ALL THAT APPLY)

1 Earnings from employment or self-employment (incl. overtime, tips, bonuses)

2 State retirement pension

3 Pension from former employer

4 Personal pensions

5 Pension Credit

6 Child Benefit

7 Universal Credit

8 Job-Seekers Allowance

9 Income Support

10 Working Tax Credit, Child Tax Credit or any other Tax Credit

11 Housing Benefit

12 Employment and Support Allowance

13 Personal Independence Payments

14 Disability Living Allowance

15 Attendance Allowance

16 Carer's Allowance

17 Other state benefits

18 Student grants and bursaries (but not loans)

19 Interest from savings and investments (eg stocks & shares)

20 Rent from property (after expenses)

21 Other kinds of regular income ( e.g. maintenance or grants)

22 No source of income

5.2. General health

Consultation feedback regarding the general health questions largely concentrated on long-term conditions and impairments.

Edinburgh Health and Social Care Partnership proposed adding a question on the number of aids to daily living as a measure of dependency. However, discussions with the survey contractors suggested that capturing this information consistently would require a series of questions. Given the space pressure on the survey, this suggestion was not taken forward for 2018. It will however, be considered for future surveys.

The Equality and Human Right's Commission requested we include the questions on impairments used in the Health Survey for England to provide greater detail in this area. Whilst it was felt that this suggestion was worth considering in the future, given the pressure on survey space, it will not be incorporated in 2018.

More than one consultation response suggested that we review our overall approach to capturing long-term conditions. Currently participants describe any long-term conditions in their own words. This is recorded verbatim by the interviewer and later coded into groups of long-term conditions. Alternative approaches could include asking respondents to select from a pre-specified list of conditions or using a direct method of questioning (as is used in the survey to measure diabetes, asthma and other select conditions). Whilst no changes to the approach have been made to this version of the survey, we will investigate how changes to the recording of long-term conditions might be made for future surveys.

The Scottish Council on Deafness requested different terminology in place of 'poor hearing/deafness' in order to bring the survey in line with the 'four pillars of deafness' that the Deaf sector in Scotland use:

'Deaf ( BSL users), Deafblind (People who lose their hearing very early in their life or are born deaf, then start to lose their sight), Deafened (people who acquire a spoken language, then lose their hearing; this can be when the person is quite young), and Hard of Hearing (anyone who has a hearing loss, whether or not they use hearing aids).'

The information on deafness is collected in the same way as for other long-term conditions. So, as suggested above, any deafness or hearing problems are first described in the respondent's own words and later coded into the broader category of 'poor hearing/deafness'. It may be that respondents do use the terms from the four pillars of deafness when describing their condition. However, if they do not, the survey would require additional probing questions to establish, for example, when they lost their hearing. Given existing concerns over the survey length, we have not introduced these additional questions. We will consider our collection and reporting of deafness data as part of any wider changes to the long-term conditions questions.

Additionally the Scottish Council on Deafness requested the introduction of questions on language impairment, and communication support needs. Questions on these topics will be considered for future surveys, but will not be included in the 2018 survey.

5.3. Anxiety and Depression

The consultation feedback demonstrated strong support for retaining the questions on anxiety and depression. For example, the British Association for Counselling and Psychotherapy noted that their 'key recommendation' with regards the consultation was that 'all the questions relating to areas of mental health are retained.'

Consultation responses also included an appeal for this data to be available at a local level. Currently these questions are part of the biological module, and for the data to be available locally, the questions would need to move to the core sample. Due to space constraints these questions will not be included in the core sample for 2018.

In addition, new questions were requested which would establish whether the respondent's anxiety or depression had been diagnosed by a GP and whether the respondent was currently receiving treatment. Due to space constraints, these changes and additional questions could not be taken forward for 2018. They will be considered for inclusion if other questions can be removed in future.

The Anxiety and Depression questions will be retained unchanged in the biological module on an annual basis.

5.4. Self-harm

The consultation response from the University of Glasgow MRC/ CSO Social and Public Health Sciences Unit emphasised the importance of this topic, argued that the the questions be retained annually, and suggested the addition of 'a few simple or open answer questions' to try and understand the underlying reasons for both onset and reduction or cessation in self-harm.

Additional questions (based on those used in previous research ^[1]) could be as follows:

QA: What method(s) have you used to self-harm from the following list:

• cutting (on the arm or wrists)
• cutting (elsewhere on the body)
• scratching or scoring
• taking dangerous tablets or pills
• hitting or punching self; slamming hands in door
• burning (with cigarettes, lighter, etc)
• other way (please specify)

QB: At what age did you first self-harm? Age____

QC: What are/were the reasons for self-harming? Pick from the following list:

• to upset others
• relieve anxiety
• relieve anger
• forget about something
• make someone else take notice
• others in my social circle were doing it
• I was curious
• punish myself
• kill myself
• not sure why
• other reason (please specify) ____________________

QD: At what age did stop Self-harming? Age______ [0 = self-harmed in last year]

If no longer self-harming…

QE: Why did you stop or what helped you stop? Pick from the following list:

• It was one off or temporary phase ( e.g. `only happened once)
• I found a better way to cope What? _________________
• I found a purpose in life (child, marriage, university, job, etc. ) What? _________
• Got professional help ( e.g. `went to see psychiatrist, nurse, etc. '); Who? ______
• Got help from family; Who? ______
• Got help from friends; Who? ______
• Realised how much it hurt my family and friends.
• Realised self-harming did not help me cope.
• Other reason; What? _________________

Whilst these questions were felt to be potentially valuable additions to the survey, they could not be accommodated in 2018 due to lack of space. The additional questions will be considered for future years. In the meantime, the questions on Self Harm are unchanged and will be retained annually in the biological module.

5.5. Social Capital (including loneliness)

The consultation response from the Glasgow Centre for Population Health ( GCPH) highlighted that there are overlaps between the Social Capital questions collected via SHeS and via the Scottish Household Survey ( SHS) and suggested an opportunity for this to be streamlined.

NHS Health Scotland Public Health Science Directorate proposed expanding this section of the survey to cover loneliness. A possible new question for the survey would be:

How often have you felt lonely in the past two weeks? (All of the time / often / some of the time / rarely / never).

In response, the Scottish Health Survey and Scottish Household Survey are both introducing the same question on loneliness as per below:

How much of the time during the past week have you felt lonely?

(None or almost none of the time; some of the time; most of the time; all or almost all of the time; don't know).

Beyond this, there are no changes to the social capital module and the questions will continue to be included biennially in the rotating version A questionnaire. The loneliness question will first be included in SHeS in 2019 and the SHS in 2018.

5.6. Discrimination and harassment

The discrimination and harassment questions will be harmonised with questions on this topic asked within the Scottish Household Survey. This will provide the opportunity to combine the responses from the two surveys to provide a larger sample, enabling analysis of smaller groups. Demand for this came from stakeholders responding to the review of the Scottish Survey Core questions.

Harmonising the questions requires only minor changes to be made to these questions in SHeS. The amended questions will be retained biennially within the version A rotating module and will next be asked in 2019. The amendments are shown in red below.

The next questions are about whether you have been unfairly treated in any aspect of your life, because you belong to a particular group.

Have you personally been unfairly treated or discriminated against in Scotland in the last 12 months, that is since (date 12 months ago), for any of the reasons on this card?

PROBE: What else?

• Your accent
• Your ethnicity
• Your age
• Your language
• Your colour
• Your nationality
• Your mental ill-health
• Any other health problems or disability
• Your sex
• Sectarian reasons
• Your Other religious belief s or faith reason
• Your sexual orientation
• Where you live
• Other reason
• I have not experienced this

Have you personally experienced harassment or abuse in Scotland in the last 12 months, that is since (date 12 months ago), for any of the reasons on this card?

Please just tell me the letter next to the reasons that apply.

PROBE: What else?

• Your accent
• Your ethnicity
• Your age
• Your language
• Your colour
• Your nationality
• Your mental ill-health
• Any other health problems or disability
• Your sex
• Sectarian reasons
• Your Other religious belief s or faith reason
• Your sexual orientation
• Where you live
• Other reason
• I have not experienced this

5.7. Stress at work

NHS Health Scotland Public Health Science Directorate proposed that this existing topic be expanded to cover income and employment security:

'At present, there are some data gaps that limit the survey's potential to link welfare reform and wider changes in the labour market to health outcomes.'

Areas suggested for coverage included: respondents' employment contract status (including 'zero-hours' contracts); whether respondents had multiple jobs; and whether respondents had experienced benefit sanctions.

These topics could be explored through using questions in other surveys as the basis of new questions and through adapting existing questions:

'The issue of sanctions could be addressed by adding a follow-up for anyone reporting a state benefit.'

'The Labour Force Survey, Annual Population Survey and Family Resources surveys between them include detailed questions about employment conditions and income sources that could be adapted for SHeS.

For example, flexible working (including zero hours contracts) is measured in this LFS question:

Some people have special working hours arrangements that vary daily or weekly. In your (main) job is your agreed working arrangement any of the following...

1 Flexible working hours (Flexitime)

2 Annualised hours contract

3 Term-time working

4 Job sharing

5 Nine day fortnight

6 Four-and-a-half day week

7 Zero-hours contract

8 On-call Working

9 None of these

The following question, adapted from the LFS, could measure whether people have more than one paid job:

In the past four weeks, did you do any other paid work or have any other paid job or business in addition to the one you have just told me about? Yes / No

A follow-up question could then ask whether this is by choice or circumstance.

The LFS also has questions about contract status, e.g. :

Leaving aside your own personal intentions and circumstances, was your job...

1 a permanent job

2 or was there some way that it was not permanent?

Did you take that type of job rather than a permanent job because...

CODE 1ST THAT APPLIES

1 You had a contract which included a period of training?

2 You had a contract for a probationary period?

3 You could not find a permanent job?

4 You did not want a permanent job?

5 or was there some other reason?'

Whilst we are interested in covering more of the factors that influence wellbeing and stress, there is not space in the survey to accommodate these topics currently.

The Stress at Work module will be retained biennially without changes in the rotating version A questionnaire.

5.8. Mental Wellbeing ( WEMWBS) and symptoms of psychiatric disorder ( GHQ12)

There was strong support received through the consultation for retaining these questions. Responses included the University of Glasgow MRC/ CSO Social and Public Health Sciences Unit emphasising the importance of both GHQ12 and WEMWBS:

'Reduced ability to estimate these mental health measures would make tracking of trends and evaluating and informing policy very challenging. This is paramount since these are national statistics and mental health is an evermore important public health priority'

Another respondent noted that at NHS Board level they had 'used this information to provide evidence to support the development of initiatives and incorporated it into key strategies.'

Questions relating to mental wellbeing and psychiatric disorders will be retained annually without changes in the core questionnaire.

5.9. Strengths and Difficulties (children aged 4-12)

The Strengths and Difficulties questionnaire is designed to detect behavioural, emotional and relationship difficulties in children.

There were no detailed comments relating specifically to this topic. The Strengths and Difficulties questionnaire ( SDQ) will continue to be asked of parents of 4-12 year old children.

5.10. Respiratory conditions (including asthma)

The consultation feedback received on this topic concentrated on asthma. Two consultation respondents requested the same two changes to the asthma questions in the survey:

1) To re-include the question below, which had been dropped from the survey in 2012.

'Were you treated in the past 12 months for wheeze by GP/nurse at surgery/community/school/district nurse/hospital, consultant/specialist at hospital, consultant/specialist elsewhere, homeopath/acupuncturist/other alternative medicine professional?'

It was argued that this would help 'develop our understanding of the cost of asthma to health services. Recent research ^[2] has shown that asthma costs the Scottish public sector at least £92 million a year'.

2) To include the question below on school absenteeism due to asthma, which has been previously used in the English Health Survey.

'Over the last 12 months, how many days has your (name) asthma/wheezing/whistling in (your/his/her) chest caused (you/him/her) to be absent from school?'

This second questions would 'again allow further analysis of the impact of asthma and respiratory conditions on public services, and also allow the building of a UK-wide figure on school absenteeism due to asthma.' In turn this would enable 'an understanding of the cost and impact of asthma on people with asthma and public services.'

Both questions have been included annually in the core questionnaire from 2018, with the treatment question tweaked as per the version below.

Have you received any treatment or advice for asthma/wheezing from any of the people on this card?

1 Yes

2 No

Which ones? PROBE: Any others?

1 A general practitioner ( GP)

2 Nurse at GP surgery/Health centre

3 Community, School or District Nurse

4 Hospital casualty/Accident and Emergency department

5 Consultant/Specialist or other doctor at hospital outpatients

6 Consultant/Specialist or other doctor elsewhere

7 Homeopath

8 Acupuncturist

9 Other alternative medicine professional

No other changes are being made to the respiratory questions.

5.11. CVD and Use of Services

Questions relating to CPR were included in the survey for the first time in the 2017 questionnaire, with the first set of results due to be published in September 2018.

In response to the consultation, Save a Life for Scotland highlighted Scotland's Out of Hospital Cardiac Arrest ( OHCA) strategy, which 'aims for Scotland to become an international leader in managing OHCA by 2020.' They requested additional questions to help monitor this.

The existing questions are shown below, with the additional proposed questions in red.

INTERVIEWER READ OUT:

Cardiopulmonary resuscitation, or CPR, is an emergency procedure in which a person presses up and down on the casualty's chest (chest compressions) to help save their life when they are in cardiac arrest. CPR training is delivered either through instructor led sessions or self-instruction using DVD/online instruction with or without a manikin.

Have you ever had any type of training in CPR or learned CPR in any other way?

• Yes
• No
• Don't know

When did you first have any type of training in CPR, or learn CPR in any other way?

• Within the last 12 months
• One year ago but less than two years ago
• Two years ago but less than five years ago
• Five years ago or more

Since then, have you had any other CPR training, refresher training, or learnt CPR in any other way? If so, when was the most recent?

• Within the last 12 months
• One year ago but less than two years ago
• Two years ago but less than five years ago
• Five years ago or more
• No refresher training

Which [ONE] of these best describes how you most recently had any type of training in CPR or learned CPR in any other way?

• I taught myself from a book, through the internet ( e.g. YouTube, other website) or another self-learning tool
• Training I took primarily because I am a parent or carer
• Training which was compulsory for me to take as part of my work
• Training which I opted to take as part of my work
• Training which was compulsory for me to take as part of my voluntary work or hobby
• Training which I opted to take as part of my voluntary work or hobby
• Training I took whilst I was a student as part of my school/college/university work
• Other form of CPR training (PLEASE SPECIFY)

At your CPR training, were you taught to give rescue breaths and chest compressions or just chest compressions?

• Rescue breaths and chest compressions
• Only chest compressions

If you have been trained in CPR 'how confident, if at all, would you be about giving someone CPR?'

• Very Confident
• Fairly Confident
• Not Very Confident
• Not At All Confident

Given space constraints on the survey, the new questions will not be added to the questionnaire. In addition, the pre-existing questions on CPR will drop from annual inclusion in the core questionnaire to become rotating. They will next be included in survey in 2019.

The range of questions on use of health services presented below will also move to the rotating core questionnaire, and will next be included in survey in 2019.

During the 2 weeks ending yesterday, apart from any visit to a hospital, have you talked to a doctor on your own behalf, either in person or by telephone? EXCLUDE CONSULTATIONS MADE ON BEHALF OF OTHERS

1 Yes

2 No

How many times have you talked to a doctor in these 2 weeks? Range: 0..14

(Were any of these consultations/Was this consultation) about your (heart condition, high blood pressure, diabetes or stroke)...READ OUT…CODE ALL THAT APPLY

1 No

2 Yes, about: high blood pressure

3 Angina

4 Heart attack

5 Heart murmur

6 Abnormal heart rhythm

7 Other heart trouble

8 Stroke

9 Diabetes

Apart from any visit to a hospital, when was the last time you talked to a doctor on your own behalf?

PROMPT

1 Less than two weeks ago

2 2 weeks ago but less than a month ago

3 1 month ago but less than 3 months ago

4 3 months ago but less than 6 months ago

5 6 months ago but less than a year ago

6 A year or more ago

7 Never consulted a doctor

(Were any of these consultations/Was that consultation) about your (heart condition, high blood pressure, diabetes or stroke)?

CODE ALL THAT APPLY

1 No

2 Yes, about: high blood pressure

3 Angina

4 Heart attack

5 Heart murmur

6 Abnormal heart rhythm

7 Other heart trouble

8 Stroke

9 Diabetes

During the last 12 months, that is since (date a year ago), did you attend hospital as an out-patient, day-patient or casualty?

1 Yes

2 No

Was this because of your (heart condition, high blood pressure, diabetes or stoke)?

1 Yes

2 No

During the last 12 months, that is since (date a year ago), have you been in hospital as an in-patient, overnight or longer?

1 Yes

2 No

Was this because of your (heart condition, high blood pressure, diabetes or stroke)?

1 Yes

2 No

During the 2 weeks ending yesterday, apart from any visit to a hospital, have you talked to a doctor on your own behalf, either in person or by telephone?

1 Yes

2 No

How many times have you talked to a doctor in these 2 weeks? Range: 0..14

Apart from any visit to a hospital, when was the last time you talked to a doctor on your own behalf?

PROMPT

1 Less than two weeks ago

2 2 weeks ago but less than a month ago

3 1 month ago but less than 3 months ago

4 3 months ago but less than 6 months ago

5 6 months ago but less than a year ago

6 A year or more ago

7 Never consulted a doctor

During the last 12 months, that is since (date a year ago), did you attend hospital as an out-patient, day-patient or casualty?

1 Yes

2 No

During the last 12 months, that is since (date a year ago) have you been in hospital as an in-patient, overnight or longer?

1 Yes

2 No

The questions establishing the presence of cardiovascular conditions will remain in the core questionnaire and will be supplemented by a question clarifying whether a respondent reporting diabetes has Type 1 or Type 2 diabetes. This question was introduced in response to a consultation request from NHS Health Scotland and is shown below.

ASK ALL 16+ WITH DIABETES

Have you been told whether you have Type 1 or Type 2 diabetes?

1 Yes, Type 1 diabetes

2 Yes, Type 2 diabetes

3 Not been told

4 Not sure which type

5.12. Blood Pressure

There were no detailed comments relating specifically to this topic. Blood pressure measurements will continue to be included annually in the biological module.

5.13. Prescribed medicines

In their consultation response, the Controlling Antimicrobial Resistance In Scotland Team in Health Protections Scotland suggested including attitudinal questions relating to antibiotics.

Possible questions were suggested:

1) How acceptable or unacceptable would it be for your doctor not to prescribe antibiotics if you had a viral cough or cold? Option to choose on a scale from very acceptable to very unacceptable)

2) Antibiotics are becoming less effective at treating infections. How important, if at all do you think each of the following are in tackling this issue?(Option to chose on a scale from very important to not important)

• Individuals using antibiotics appropriately
• Doctors prescribing antibiotics appropriately
• Pharmaceutical companies developing new effective antibiotics

This type of attitudinal question is not typically included in SHeS and as a result these questions have not been included in the questionnaire for 2018. The Scottish Social Attitudes Survey may represent a better option for these questions.

Discussion at the survey's Project Board raised the prospect of gathering survey respondents' prescription information through data-linkage with the Scottish Prescriptions Database (rather than collecting the information through SHeS). This would require an application to the Public Benefits and Privacy Panel and has not been pursued for the 2018 survey.

5.14. Parental history

These questions can be divided into two parts: questions relating to the respondent's parental employment (when the respondent was aged 14); and questions relating to their family history of health conditions.

Feedback from the consultation as well as the latest Project Board meeting highlighted that the parental employment component can offer useful information on the social circumstances of the respondent at an earlier point in their life.

In response to space constraints in the survey, all Parental History questions are being moved from the core questionnaire to the rotating version A questionnaire. The questions will be asked biennially and will next be included in 2019.

5.15. Physical activity and sedentary time

The consultation gathered significant feedback on the questions regarding physical activity, with strong support for the topic and a number of suggestions for changes.

Overall, the changes made for the 2018 questionnaire are minimal. One reason for this is that physical activity already takes up a significant amount of interview time, so the addition of extra questions is difficult to accommodate.

An additional reason is that changes are likely to be made to the topic within the next two years: a revised set of indicators for the Active Scotland Outcomes Framework has been developed, which may lead to changing data demands, and there is an ongoing review of the UK's Chief Medical Officers' physical activity guidelines that may need to be reflected in SHeS data collection. The feedback gathered through this consultation exercise will continue to be used to inform these changes as they are made.

Sedentary behaviour (child and adult)

One consultation response pointed out that, whilst the questionnaire does measure recreational screen time, the question should be updated to reflect current habits. Tablets and smart phones should be included in the question wording, as should 'using' a screen (as opposed to simply 'watching') with examples such as chatting online and internet use given.

In light of this, the questions on screen time have been updated as per below:

Now thinking of the weekend, that is Saturday and Sunday, how much time on an average day do you spend sitting watching TV or another type of screen (such as a computer, tablet, phone, games console or handheld gaming device)? Again, please do not include any time spent in front of a screen while at school, college or work.

Thinking first of weekdays, that is Monday to Friday, how much time on an average day do you spend sitting watching TV or another type of screen such as a computer, tablet, phone, games console or handheld gaming device? Please do not include any time spent in front of a screen while at school, work or college.

An additional change has been made to the questions relating to sitting time. Napping is now included as an example for all adults, rather than only for those aged 65 and over.

And how much time on an average weekday do you spend sitting down doing any other activity, such as eating a meal, reading, or listening to music or napping in a chair

Please do not include time spent doing these activities while at work .

And how much time on an average weekend day (that is Saturday and Sunday) do you spend sitting down doing any other activity, such as eating a meal, reading, or listening to music or napping in a chair. Please do not include time spent doing these

Two consultation respondents suggested adding a prompt to the question on leisure-time non-screen sitting to ensure that time spent sitting in cars or other forms of motorised transport is captured. This request was considered in the context of a wider proposal to include six questions covering sedentary behaviour. These would cover sedentary time across five different domains: a) work, b) education, c) transport, d) home, and e) leisure activity outside the home (as well as including an additional question relating to time spent sitting in front of screens). The sum of the five domains would provide an estimate of total sedentary time.

These new questions were included in the cognitive testing of the survey, which suggested that there may be issues with participants' understanding of the questions as well as potential overlap between the domains. These questions were not included in the 2018 questionnaire and we are continuing to consider how sedentary time can be captured in the survey effectively.

Adult Aerobic Physical activity. Through the consultation, the Physical Activity for Health Research Centre ( PAHRC) at Edinburgh University questioned the validity of the adult aerobic domain of occupational activity given that 'under the current method, 10-15% of adults are allocated volumes of activity comparable to running a marathon on every working day, whilst the rest of the population are allocated 0 minutes.'

They felt that this 'distorts our understanding of overall physical activity at a population level, particularly how it varies around retirement' and proposed 'convening an expert group to look into the issues in greater detail' before making any changes.

As part of the questionnaire review process the survey contractors and Scottish Government met with representatives from PAHRC and the conclusion reached was to await the outcome of the developments highlighted at the beginning of this topic before committing to changes.

Outdoor Physical Activity

Three consultation respondents (Greenspace Scotland, Paths for All, and Scottish Natural Heritage ( SNH)) requested that we include question probing the 'setting' for physical activity/sport – the key element of the question being whether the activity took place outdoors in the natural environment. This was argued by Greenspace Scotland to 'allow us to measure the proportion of physical activity taking place outdoors and understand the contribution of greenspace and other outdoor spaces.'

However, to ask this question of every instance of physical activity would add to the length of the questionnaire. There are existing questions which cover the question of location more broadly (below). These can't be tied to specific instances of physical activity, but do show how often people use green space for physical activity.

In the past 4 weeks have you made use of any of the places listed on this card for any of the physical activities you have just told me about, for example for walking, cycling, sports or doing any heavy housework or gardening?

1 A woodland, forest or tree covered park

2 An open space or park

3 Country paths (not on tarmac)

4 A beach/sea shore/loch/river or canal

5 Sports fields or outdoor courts ( e.g. tennis, 5-a-side)

6 A swimming pool

7 A gym or sports centre

8 Pavements or streets in your local area

10 Your home or garden

11 Somewhere else (record at next question)

12 No-not used any of these

INTERVIEWER: WRITE IN OTHER ANSWER GIVEN.

How often in the past 4 weeks have you made use of (name of place) for physical activity?

1 Every day

2 4-6 days a week

3 2-3 days a week

4 Once a week

5 2-3 times in the last 4 weeks

6 Once in the last 4 weeks

7 (Varies too much to say)

There were further suggestions that information be gathered regarding the survey respondent's reasons for doing the outdoor activity. Reasons might include those that reflect the mental health benefits which some people experience from using green space. In addition, the survey could collect why people had not undertaken any/more outdoor recreation/sport in the last 4 weeks. Response options could reflect the availability of paths and green space.

Whilst to cover this for each instance of (outdoor) activity would add considerably to the length of the questionnaire, we have amended the broader questions relating to reasons and barriers to taking part in physical activity to reflect some of these requests. Changes are shown below in red.

I would like to ask you some more detail about the last time you did (activity/activities). What were your reasons for doing it/them?

(ALL THAT APPLY)

1 To keep fit (not just to lose weight)

2 To lose weight

3 To take children

4 To meet with friends socialise

5 To train/ take part in a competition

6 To improve my performance

7 Just enjoy it

8 To help with my injury or disability

9 Part of my voluntary work

10 To walk the dog

11 For health reasons / to improve health

12 For peace and quiet

13 To de-stress, relax and unwind

14 To feel closer to nature

15 Other

INTERVIEWER: WRITE IN OTHER ANSWER GIVEN

And which of these was your main reason?

1 To keep fit (not just to lose weight

2 To lose weight

3 To take children

4 To meet with friends socialise

5 To train/ take part in a competition

6 To improve my performance

7 Just enjoy it

8 To help with my injury or disability

9 Part of my voluntary work

10 To walk the dog

11 For health reasons / to improve health

12 For peace and quiet

13 To de-stress, relax and unwind

14 To feel closer to nature

15 Other

INTERVIEWER: WRITE IN OTHER ANSWER GIVEN

Looking at this card, are there any particular reasons why you haven't done any/more sport in the last 4 weeks?

(ALL THAT APPLY)

1 It costs too much

2 No one to do it with

3 Never occurred to me

4 Not really interested

5 Fear of injury /making current injury worse

6 I wouldn't enjoy it

7 Health isn't good enough

8 I might feel uncomfortable or out of place

9 Changing facilities are not good enough Facilities are too far away

10 Not enough information on what is available

11 It's difficult to find the time

12 I already do enough

13 Other

14 No reason INTERVIEWER: WRITE IN OTHER ANSWER GIVEN.

And which of these was your main reason?

1 It costs too much

2 No one to do it with

3 Never occurred to me

4 Not really interested

5 Fear of injury /making current injury worse

6 I wouldn't enjoy it

7 Health isn't good enough

8 I might feel uncomfortable or out of place

9 Changing facilities are not good enough Facilities are too far away

10 Not enough information on what is available

11 It's difficult to find the time

12 I already do enough

13 Other

INTERVIEWER: WRITE IN OTHER ANSWER GIVEN.

Related to this, consultation responses also highlighted that the questions in the survey to probe what physical activity the respondent had undertaken 'focus on sport'. For example, SNH suggested that it would be useful to have a question to cover 'informal outdoor activities.( e.g. family outings, bird watching, environmental volunteering) which are also recognized as delivering physical and mental health benefits.' This was considered a useful suggestion and will be considered as part of the wider review of physical activity.

Active Travel

NHS Health Scotland Public Health Science Directorate, Glasgow Centre Population Health, and Scottish Natural Heritage were all interested in greater information on active travel (ie walking or cycling for utilitarian, rather than leisure, reasons).

GCPH noted that 'currently the information collected on the Scottish Health Survey does not enable periods of active travel to be identified.' They argued that 'it is important that this domain of PA can be distinguished to enable policy interventions in this field to be monitored'.

However, it was felt that given the Scottish Household Survey contains a number of questions on active travel, including details of the active travel journeys collected as part of the travel diary, to include questions in the Health Survey would lead to a level of duplication that was difficult to justify given space constraints in the survey. This does, however mean that the detailed active travel information cannot be linked with respondents' answers to other questions on physical activity.

Additional physical activity questions

NHS Health Scotland proposed questions to establish whether the survey respondent had received medical advice to become more physically active (similar in format to existing survey questions regarding smoking):

Has a medical person such as a doctor, nurse, or physiotherapist ever advised you to take more exercise or be more physically active because of your health? (yes / no)

IF Yes

How long ago was that?

1 Within the last twelve months

2 Over twelve months ago

This would 'help evidence change in the behaviour/practice of health professionals in raising the issue of physical activity and delivery of the national Physical Activity Pathway.'

These questions have not been included in the survey for 2018 due to space constraints.

NHS Health Scotland were also interested in 'the association between people's activity levels and their perceptions of the quality, accessibility and safety of their local environment.' They highlighted that similar questions on the environment are included in the Scottish Household Survey ( SHS) and these could be adapted for SHeS.

These questions have not been included in the 2018 SHeS questionnaire, as it may already be possible to explore the relationship between environment and activity using the SHS. The SHS does not provide the level of detail on physical activity that SHeS does, but there are questions addressing how frequently respondents go walking, cycling, and running/jogging (amongst other activities). Given the pressures on the survey content, we cannot justify increasing the duplication between the two surveys.

Child Physical Activity

One consultation respondent argued that the questionnaire should specifically measure children's participation in sport. Currently, the questionnaire refers more broadly to participation in 'sport or exercise activities.' The respondent also felt that the questionnaire should measure participation in active play outdoors rather than active play which could take place indoors or outdoors. These suggestions were argued to enable measurement of the implementation and impact of key policies ( i.e. the Play Strategy and the Sporting Legacy).

The same respondent also suggested that the percentage of children who are meeting physical activity guidelines ( i.e. 60 minutes of Moderate to vigorous physical activity daily) is 'grossly overestimated.' They felt that the questionnaire should measure the intensity of physical activity to provide 'more realistic estimates'.

These suggestions have not been adopted for the 2018 questionnaire. Discussions with the survey contractor have revealed concerns from interviewers that the existing section on child physical activity is already taking a considerable amount of time to complete. Given the involvement of children this has raised concerns for the quality of data that the questions are gathering. As a result, it is not possible to adopt these changes, which would serve to increase the length of the section further . We will be considering how we can shorten this section of the questionnaire for future years, and this may entail significant change.

5.16. Knowledge of physical activity guidelines (ages 4-12, 13-15, and 16+)

Little specific feedback was received for these questions. They have been retained unchanged in the annual core questionnaire.

5.17. Fruit and Vegetable Consumption

Consultation responses emphasised that SHeS provided the only information on diet available at sub-national level and that 'more information' would be welcome.

No changes will be made to this section and the questions will continue to be included annually in the core questionnaire.

5.18. Eating Habits

Consultation feedback highlighted that it was 'important that the sugar-related soft drink dietary questions remain both for children and adults.' This was in order to enable evaluation of UK sugar taxation policy. The respondent also argued that it would be good 'to have a volume as well as frequency of consumption.'

In response to this, an additional question was considered which would measure the volume of sugary drinks consumed. A draft of the question was included in cognitive testing. However, the testing highlighted that, given the varied containers and serving sizes in which sugary drinks are available (more so than alcoholic drinks for example), it was very difficult to get a reliable measure of volume. As a result, a 'volume' question has not been included.

The testing did however lead to some clarification of the types of drinks that should be included in the wording of the 'frequency' question. These improvements have been made as per the below.

Old version:

How often do you drink soft drinks, not including diet or low-calorie drinks?

INTERVIEWER: Include cans, bottles, mixers. Include flavoured water and diluting drinks as long as they are not diet or low-calorie. Do not include fresh fruit juice.

How often do you drink diet or low-calorie soft drinks?

INTERVIEWER: Include cans, bottles, mixers. Include diet or low-cal flavoured water or diluting drinks here. Do not include fresh fruit juice or plain water

New version:

How often do you drink diet, low-calorie or no-added sugar soft drinks?

Include diet fizzy drinks, low-calorie flavoured water and no-added sugar diluting juice. Include diet or low-calorie soft drinks added to alcohol.

Do not include fresh fruit juice or plain water.

How often do you drink sugary soft drinks?

Include fizzy drinks, energy drinks and diluting juice with added sugar.

Include sugary soft drinks added to alcohol.

INTERVIEWER: Do not include diet, low-calorie or no-added sugar drinks or fresh fruit juice.

Beyond this, the questions received strong support through the consultation with responses highlighting that regular inclusion was necessary for subgroup analysis.

The questions have been retained annually in the core questionnaire.

The Health Survey's contractors (ScotCen) are currently in the process of piloting a new tool for collecting dietary information. The tool (Intake24) was developed for Food Standards Scotland by Newcastle University and prompts respondents to recount all the food and drink that they have consumed in the past 24 hours. This is done for two separate days (a weekday and a weekend day) and is completed online or over the phone. If the pilot is successful, the use of this tool may allow us to reduce the number of questions on diet within the survey.

5.19. Vitamins including Vitamin D

There were no detailed comments receive through the consultation process which related specifically to this topic. These questions will be retained annually in the core sample.

5.20. Dietary Salt Intake (urine sample)

One consultation respondent argued that due to the changes in lab methods the results from the urine sample are 'uninterpretable, especially when expressed as a Na/Cr or K/Cr ratio'.

In response, the urine sample will not be collected as part of the 2018 survey. We will liaise with subject experts to consider whether the sample should be reinstated and whether any methodological changes would be required.

5.21. Smoking and e-cigarettes

Consultation responses emphasised the importance of this set of questions and focused on arguing for their retention as frequently as possible to as large a sample as possible.

In light of this, no questions have been removed from this topic, and it will be retained annually in the core.

There was a request from the tobacco control team within the Scottish Government to include a question in order to gauge the success of different nicotine replacement therapies or similar products.

This was discussed at the most recent survey Project Board meeting, and the question in red has been included annually in the core.

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?

CODE ALL THAT APPLY

1 Yes, nicotine gum

2 Yes, nicotine patches that you stick on your skin

3 Yes, nasal spray/nicotine inhaler

4 Yes, lozenge/microtab

5 Yes, Champix/Varenicline

6 Yes, Zyban/Bupropion

7 Yes, electronic cigarette/Vaping devices

8 Yes, other

9 No

For each product:

Did using (product) help you to successfully stop smoking for a month or more?

1 Yes

2 No

5.22. Cotinine Levels

There were no detailed comments relating specifically to this topic. However, we are aware that this measurement is of significant interest to the Scottish Government tobacco policy team.

Cotinine measurements are being retained annually in the biological module.

5.23. Alcohol consumption and drinking experiences

Although there were a number of suggestions for changes to this section collected through the consultation. The large majority of the questions will remain as they are.

The rationale for this (as was articulated by one of the consultation respondents) is that at the time we were finalising the changes to the questionnaire, it was not clear whether minimum unit pricing would be introduced. We did know that the time series offered by SHeS across a range of indicators would real utility for evaluating the legislation's impact (if introduced). We opted to leave the questions largely unchanged until the final outcome of the minimum unit pricing legal review was known.

The following questions will move to the rotating core - next to be included in survey in 2019/2021.

In which of these places on this card would you say you drink the most alcohol? CODE ONE ONLY.

1 In a pub or bar 2 In a restaurant 3 In a club or disco 4 At a party with friends 5 At my home 6 At someone else's home 7 Out on the street, in a park or other outdoor area 8 Somewhere else (WRITE IN)

Who are you usually with when you drink the most alcohol? CODE ONE ONLY.

1 My husband or wife/boyfriend or girlfriend/partner 2 Male friends 3 Female friends 4 Male and female friends together 5 Work colleagues 6 Members of my family / relatives 7 Someone else (WRITE IN) 8 On my own

Also, the Alcohol Use Disorders Identification Test (AUDIT) questionnaire (a screening tool to pick up the early signs of hazardous and harmful drinking and identify mild dependence) is being moved to rotating core. This will now be included biennially within the self-completion questionnaire as below.

Q1 How often do you have a drink containing alcohol? Tick ONE box

Never

Monthly or less

2-4 times a month

2-3 times a week

4 or more times a week

Q2 How many drinks containing alcohol do you have on a typical day when you are drinking? Tick ONE box

1 or 2

3 or 4

5 or 6

7 to 9

10 or more

Q3 How often do you have six or more drinks on one occasion? Tick ONE box

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Q4 How often during the last year have you found that you were

not able to stop drinking once you had started? Tick ONE box

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Q5 How often during the last year have you failed to do what was

normally expected of you because of drinking? Tick ONE box

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Q6 How often during the last year have you needed a first drink in

the morning to get yourself going after a heavy drinking

session? Tick ONE box

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Q7 How often during the last year have you had a feeling of guilt

or remorse after drinking? Tick ONE box

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Q8 How often during the last year have you been unable to

remember what happened the night before because of your

drinking? Tick ONE box

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Q9 Have you or someone else been injured because of your

drinking? Tick ONE box

No

Yes, but not in the last year

Yes, during the last year

Q10 Has a relative, friend, doctor, or other health care worker been

concerned about your drinking or suggested you cut down? Tick ONE box

No

Yes, but not in the last year

Yes, during the last year

Q11 I have been drunk at least once a week, on average, in the last

three weeks Tick ONE box

Yes

No

AUDIT questionnaire: Copyright 1992 Thomas Babor and the World Health Organisation.

5.24. Body Mass Index / Obesity (height and weight measurements)

A number of consultation respondents emphasised their support for the continued inclusion of height and weight measurements .

NHS Health Scotland suggested that given 'there are no other routine sources of population-level BMI, the loss of this data would have a major impact on public health policy and practice.'

Another respondent reported that 'we have used this information in many pieces of work and in monitoring progress towards outcomes in our key strategies many of which run to 2020. If this was not collected we would have no alternative source.'

BMI measurements will be retained annually in the core questionnaire.

5.25. Waist Circumference measurements

One consultation respondent argued for the retention of this topic by explaining that without it we would be 'no longer able to assess prevalence and risk factors for the metabolic syndrome.' The respondent highlighted the need to be able to link this to BMI.

Waist Circumference measurements are being retained annually in the biological module.

5.26. Dental

The Dental questions in SHeS cover two main areas: Dental Health (included in the core) and Use of Dental Services (included in version A).

Two respondents highlighted that SHeS was the only source for adult dental health data for Scotland. One noted that 'Scotland has good data on the oral health of children. This is the only opportunity at national level to collect data on the dental health of adults.'

With this in mind, the Dental Health questions are being retained in the core for this version of the survey (with some changes outlined below).

The questions on appearance of teeth and problems biting or chewing food are being replaced with one question focusing on wider problems with the mouth and teeth.

The new question is a slightly modified version of a question suggested through the consultation, which had been used in the English Longitudinal Survey of Ageing. In discussions with the survey contractor, changes were made to the wording in order to clarify that the problems experienced should relate to oral and dental issues.

Questions previously in the survey:

How happy or unhappy are you with the appearance of your teeth at present?

1 Very happy

2 Fairly happy

3 Fairly unhappy

4 Very unhappy

Do you have any problems or difficulties biting or chewing food?

IF ASKED: include problems with biting or chewing food because of sensitive teeth.

1 Yes, often

2 Yes, occasionally

3 No, never

Original consultation suggestion:

Do you experience any of the following?:

1. difficulty eating food;

2. difficulty speaking clearly;

3. problems with smiling, laughing, and showing teeth without embarrassment;

4. problems with emotional stability, for example, becoming more easily upset than usual; and

5. problems enjoying the company of other people such as family, friends and neighbours.

Final version included in the survey:

Do you currently have any problems with your mouth, teeth or dentures that cause you difficulty with any of the following listed on show card K2? If you prefer please just tell me the number or numbers on the card that apply to you.

INTERVIEWER: PLEASE CODE ALL THAT APPLY.

1 Yes, eating food

2 Yes, speaking clearly

3 Yes, smiling, laughing and showing teeth without embarrassment

4 Yes, emotional stability, for example, becoming more easily upset than usual

5 Yes, enjoying the company of other people such as family, friends, or neighbours

6 No, none of these

As suggested through the consultation, the question below regarding how the respondent feels about visiting the dentist is being removed from the Dental Services question. The relevant Scottish Government policy team noted that many people will still visit the dentist despite being nervous.

Which of the options on this card best describe how you feel about visiting the dentist?

1 I don't feel nervous at all

2 I feel a bit nervous

3 I feel very nervous

The other Dental Services questions received particular support from one respondent to the consultation:

'We would be very keen that the utilisation data, frequency of attendance and provider of service are kept. Provides consistent source of information on use and non-use by type.'

They explained that these questions are used in NES dental workforce planning and that it is not possible to identify 'non-use versus non- NHS use' using existing NHS data.

The remaining dental services questions are being retained annually in version A questionnaire.

5.27. Accidents

The main piece of consultation feedback received on this topic was highlighting the usefulness of this survey topic as it provided a measure of accidents, including those not seen at hospital and having data available at a sub-national level every four years would be 'very useful'.

This would involve moving these questions from version A into core. However, due to space constraints this topic is being retained in the version A questionnaire.

5.28. Contraception

Questions on this topic have been removed from the survey. No evidence of significant use was received through the consultation process.

These questions were previously contained in the self-completion booklet and featured annually in the core sample.

5.29. Gambling

Questions on this topic were previously included annually in the self-completion questionnaire. They will now be included every four years, with their next inclusion in the 2021 survey. This change reflects limited demand for these questions on an annual basis and, given the length of the section (3 pages), serves to noticeably shorten the self-completion questionnaire in three out of every four years.

In response to the consultation, Edinburgh Health and Social Care partnership proposed that two additional questions be included on this topic:

• Would you know where to get help to stop gambling?
• Have you ever asked for help to stop gambling?

However, the number of problem gamblers captured through the survey (of particular relevance to the last question) is small. Given on-going space constraints and the existing length of the gambling section, these questions have not been included.

5.30. Cosmetic procedures

Questions on this topic have been removed from the survey. No evidence of continued significant use was received through the consultation process.

These questions were previously contained in the self-completion booklet and featured annually in the core sample.

5.31. Scottish Survey Core Questions

The Scottish Health Survey includes a number of questions which form the Scottish Surveys Core Questions ( SSCQ). These are a limited set of questions included in the core sample of all three major population surveys (Scottish Health Survey, Scottish Crime and Justice Survey, and Scottish Household Survey) in order to provide a large sample for subjects of importance.

The Scottish Government has recently undertaken a review of the SSCQ, with the changes below resulting from the review.

More details on the review can be found on the Scottish Government website.

Police confidence

The six questions on confidence in the police currently included in SSCQ, will be removed from the questionnaire:

• How confident are you in the ability of police in your local area to prevent crime?
• How confident are you in the ability of police in your local area to respond quickly to appropriate calls and information from the public?
• How confident are you in the ability of police in your local area) to deal with incidents as they occur?
• How confident are you in the ability of police in your local area to investigate incidents after they occur?
• How confident are you in the ability of police in your local area to solve crimes?
• How confident are you in the ability of police in your local area to catch criminals?

Questions on the perception of crime will remain.

Satisfaction with local services

Questions on satisfaction with key public services will be included in SSCQ for the first time as per below: (due to stakeholder demand to have this data at a more local level).

OVERALL, HOW SATISFIED OR DISSATISFIED ARE YOU WITH EACH OF THESE publicly run SERVICES?

1. Local schools

2. Social care or social work services

3. Sports and leisure centres

4. Libraries and parks

5. Museums and galleries

6. Refuse collection

7. Street cleaning

I AM GOING TO READ OUT A LIST OF PHRASES WHICH MIGHT BE USED TO DESCRIBE THINGS A LOCAL COUNCIL DOES. FOR EACH OF THESE, PLEASE TELL ME TO WHAT EXTENT YOU AGREE OR DISAGREE THAT IT APPLIES TO YOUR LOCAL COUNCIL.

1. My local council provides high quality services

2. My local council does the best it can with the money available

3. My local council is addressing the key issues affecting the quality of life in my local neighbourhood

4. My council is good at listening to local people's views before it takes decisions

5. My local council designs its services around the needs of the people who use them

6. My council is good at letting local people know how well it is performing

7. My local council is good at letting people know about the kinds of services it provides

8. I can influence decisions affecting my local area

Health questions

There are questions relating to the health contained within the SSCQ (covering smoking, caring, long term conditions, and general health).

A shortened version of the Warwick Edinburgh Mental Wellbeing Scale ( WEMWBS) was previously part of the SSCQ. However, in 2018 it will be rested from the core questions. The full version of WEMWBS will continue to be asked in the Health Survey.