Scottish Health Survey - topic report: UK comparisons

1 GENERAL HEALTH, LONG-TERM CONDITIONS, PSYCHOSOCIAL HEALTH AND CARDIOVASCULAR DISEASE

1.1 INTRODUCTION

This chapter reports self-assessed general health, long-term conditions, psychosocial health and cardiovascular disease. Adults were asked to rate their own health in general and whether they had any long-standing illness or condition. They also completed a module of 12 questions about psychosocial health in the last month and were asked to report any cardiovascular diseases. Responses are based on subjective assessments and will therefore be prone to some recall bias.

The Scottish Government has set several targets for general and mental health in recent years. The National Performance Framework launched in 2007 ¹ includes a target to match average European ( EU15) population growth over the period from 2007 to 2017, supported by increased healthy life expectancy in Scotland over this period. This target is underpinned by a strategic objective to: help people to sustain and improve their health, especially in disadvantaged communities, ensuring better, local and faster access to health care.

The 2008 report of the Ministerial Taskforce on Health Inequalities, Equally Well, highlighted the significant inequalities associated with general and mental health and stated that "enhancing mental health, wellbeing and resilience" was one of its key priorities. ² A new policy and action plan for mental health improvement in Scotland was launched in 2009: Towards a Mentally Flourishing Scotland ( TAMFS). ³ This plan outlined six strategic priorities aimed at: promoting good mental wellbeing; reducing the prevalence of common mental heath problems, suicide and self harm; and improving the quality of life of those experiencing mental health problems and mental illness.

In England, specific Public Service Agreement ( PSA) Targets were set for the Department of Health in 2007. These included increasing overall life expectancy at birth to 78.6 years for men and 82.5 years for women by 2010. ⁴ The actions to deliver this involve continuing to increase life expectancy in England by tackling the biggest killer diseases, with an emphasis on ill health prevention and promotion of good health, and sustaining the drive to promote equality and to reduce inequalities in health. For mental health the PSA target covers improving the wellbeing and inclusion of people with depression and / or anxiety disorders through improved access to psychological therapies.

In Wales, the Welsh Assembly Government's Mental Health Promotion Action Plan for Wales, devised in 2002 and revised in 2005, aims to improve the mental health and wellbeing of the population of Wales. ⁵ The 2010 Our healthy future strategic framework for public health in Wales includes an action area on health and wellbeing through the life course with key priority tasks to reduce inequities in health and to improve people's mental wellbeing. ⁶ For example, there is a target to increase the mean Mental Component Summary Score for Wales to 50 by 2012 (this is measured via the SF-36 questionnaire ⁷ included in the Welsh Health Survey). There is also a target to reduce the EASR⁸ from suicide at all ages (including undetermined deaths) by at least 10 per cent by 2012.

In Northern Ireland, a target was set in 2002 to improve levels of life expectancy towards the levels of the best EU countries, by increasing life expectancy by at least 3 years for men and 2 years for women between 2000 and 2010. Life expectancy at birth for men and women born in Northern Ireland in 1998-2000 was 74.5 and 79.6 years respectively. A psychosocial health target was set to promote mental health and emotional well-being at individual and community level by reducing the proportion of people with a potential psychiatric disorder (as measured by the GHQ12 scale) by a tenth by 2010. ⁹

Scotland, England and Wales also have targets relating to cardiovascular ( CVD) mortality (there are no equivalent targets in Northern Ireland). In Scotland, the latest targets (revised in 2004) included a 60% reduction in CHD mortality and a 50% reduction in stroke mortality in the under 75s between 1995 and 2010. ¹⁰ England set a target in 1999 to reduce the death rate from CHD, stroke and related diseases in the under 75s by 40% by 2010. ¹¹ The target in Wales is to reduce CHD mortality in those aged 65-74 from 600 to 400 per 100,000 by 2012, with a health inequalities target to improve CHD mortality in all groups and at the same time aim for a more rapid improvement in the most deprived groups. ¹²

1.2 Self assessed general health

1.2.1 General health

The surveys in Scotland, England and Northern Ireland included a question that asked participants to assess their health in general as either very good, good, fair, bad, or very bad. Wales also measured this aspect of health via the SF-36 questionnaire but it uses a different question format that is not comparable. Self-assessed health is a useful measure of how an individual regards their own condition generally and is known to be related to the incidence of chronic and acute disease, as well as being a good predictor of hospital admission and mortality. ¹³, ¹⁴

The proportion of men reporting their health as either good or very good was very similar in all three countries (76% in Scotland and England, 75% in Northern Ireland). The same was true for women (75% in Scotland and England, 73% in Northern Ireland). Good or very good self-assessed general health was highest in younger men and women in all three countries and decreased steadily with age. Table 1.1

These findings are similar to those in most previous years. The reports of the 2003 ¹⁵ and 1998 ¹⁶ Scottish Health Surveys showed that the prevalence of good or very good self-assessed general health did not differ between Scotland and England for either sex. In contrast, the 1995 ¹⁷ report showed that adults in Scotland aged 16-64 ¹⁸ had slightly lower levels of good or very good self-assessed health than their counterparts in England (77% and 81%, respectively).

Given that many health outcomes are worse in Scotland than in England the similar levels of reporting good self-assessed health could be due to the cultural norms and expectations of what is considered good health being different in the two countries. It is also worth noting that some of the difference in life expectancy and health outcomes might be explained by higher rates in Scotland of premature deaths from substance misuse, violence and suicide (among men particularly). ¹⁹ Many people at risk of these kinds of outcomes are from the most disadvantaged groups in society, who are also the least likely to participate in population health surveys.

1.3 Long-term conditions

1.3.1 Long-term conditions

All four countries asked questions about long-term conditions but the question wording varied somewhat. Full details are provided in Appendix 1, but the key differences are set out here. The question in Scotland asked about long-standing physical or mental conditions, or disabilities, that had lasted, or were likely to last, for at least 12 months. In England and Northern Ireland the question referred to long-standing illness, disability or infirmity lasting for a period of time. In these three countries participants were also asked to say whether their condition or conditions limited their daily activities in any way (conditions could therefore be further classified as limiting or non-limiting). In contrast, Wales asked a single question about long-term illnesses, health problems or disabilities which limit daily activities or work. As the nature of the question differed between countries any differences between them shown here should be treated with caution as they may be due to differences in wording rather than genuine population differences.

The prevalence of limiting long-term conditions among men in Scotland (23%) was not significantly different to the rate found in England (21%) or Northern Ireland (25%). The rate in Wales (26%) was significantly higher, but only marginally so. The corresponding pattern for women was different. The rates in Scotland (28%), Wales (29%) and Northern Ireland (28%) were almost identical. However, the difference between the prevalence of limiting long-term conditions in women in Scotland (28%) and England (25%) was marginally statistically significant. Table 1.2, Table A1

There have been changes over time in the way these measures have differed between Scotland and England. In 2003, men in Scotland reported lower levels of long-standing illness than in England while there were no significant differences between the countries for women. In 1998, as in 2003, the prevalence of long-standing illness was lower in men aged 16-74 in Scotland than in England, but also lower in women in Scotland. As the question wording changed in 2008 in Scotland the differences in these patterns over time must be treated with caution.

1.4 psychosocial health

1.4.1 GHQ12 Scores

The General Health Questionnaire was included in the surveys in Scotland, England and Northern Ireland (a similar, but not comparable instrument was used in the Welsh Health Survey). GHQ12 is a widely used standard measure of mental distress and psychological ill-health, consisting of 12 questions on concentration abilities, sleeping patterns, self-esteem, stress, despair, depression, and confidence in the previous few weeks. As the GHQ12 measures deviations from people's usual functioning in the previous few weeks it cannot, therefore, be used to detect chronic conditions. Furthermore, estimates cannot be made of the duration of any incidence of recent psychological ill-health and as such it is simply a measure of ill-health at a particular point in time. However, the strength of the GHQ12 is that it enables comparisons between groups and trends over time to be investigated.

Responses to the GHQ12 items were scored, with one point given each time a particular feeling or type of behaviour was reported to have been experienced 'more than usual' or 'much more than usual' over the past few weeks. These scores are combined to create an overall score of between zero and twelve. A score of four or more (referred to as a 'high' GHQ12 score) has been used here to indicate the presence of a possible psychiatric disorder. A score of zero on the GHQ12 questionnaire can, in contrast, be considered to be an indicator of psychological wellbeing.

The proportion of men in Scotland (12%) and England (11%) with a high GHQ12 was very similar. In contrast, the rate in Northern Ireland (16%) was significantly higher than in Scotland. The proportion of men with a GHQ12 score of zero was significantly higher in Scotland (64%) than in Northern Ireland (60%). The figure in England (66%) was not significantly different to that in Scotland. Table 1.3, Table A1

The pattern for women was the same. The proportion of women with a high GHQ12 score was significantly lower in Scotland (17%) than in Northern Ireland (21%), but similar to the rate in England (15%). The proportion of women with a GHQ12 score of zero was significantly higher in Scotland (58%) than in Northern Ireland (51%), and was marginally lower than in England (60%). Table 1.3, Table A1

There have been changes over time in the proportion of high GHQ12 scores comparing Scotland and England. The 2003 survey (based on all aged 16 and over) and 1995 survey (aged 16-64 only) reported no significant differences between Scotland and England for men or women. However, in 1998 the prevalence of high GHQ scores were the same in men aged 16-74 in Scotland and England, but lower in women in Scotland than in England.

1.5 cardiovascular disease

1.5.1 CVD and diabetes

As noted in the Introduction, the surveys in Scotland, England and Northern Ireland have many common features one of which is their focus on cardiovascular ( CVD) conditions. While the questions in Scotland and England for this topic are identical, the format in Northern Ireland is slightly different and is worth mentioning briefly (full details are in Appendix 1). Participants in Scotland and England were asked if they had ever had any of a number of cardiovascular and circulatory conditions, or diabetes (excluding women with diabetes or heart murmur which only occurred during pregnancy). They were then asked if their condition was confirmed by a doctor. In Northern Ireland the conditions were not asked about separately and participants were instead presented with a card and asked if a doctor had ever told them they had had any of them. Diabetes which only occurred in pregnancy was excluded, but, unlike Scotland and England, heart murmur confined to pregnancy was not. Finally, Scotland and England asked directly about abnormal heart rhythm whereas this was not on the card used in Northern Ireland. It is assumed for this report that it would have been reported as "other kind of heart trouble." Comparisons with Northern Ireland should therefore be treated with caution due to the different question formats. The Welsh Health Survey asks about cardiovascular conditions (current treatment for angina, heart failure, hypertension, other heart condition and diabetes, and whether ever treated for heart attack or stroke) but uses different methodology so the information is not comparable and is therefore not included in this report.

Based on participants' answers, conditions were grouped as follows:

• Any CVD (angina, heart attack, stroke, heart murmur, abnormal heart rhythm, 'other' heart trouble);
• Any CVD or diabetes (the preceding category plus diabetes);
• IHD²⁰ (angina, heart attack); and
• IHD or stroke (the preceding category plus stroke).

Among men, the prevalence of any CVD in Scotland (15.1%) was not significantly different to that in England (13.6%) or in Northern Ireland (13.7%). The prevalence of any CVD or diabetes was not significantly different in Scotland (18.2%), England (17.1%) or Northern Ireland (16.1%). The prevalence of IHD was higher in Northern Ireland (8.3%) than Scotland (6.9%), though rates of IHD and stroke, did not differ significantly between the three countries. For example, the rates for IHD and stroke were 8.7% in Scotland, 8.1% in England and 9.3% in Northern Ireland. Table 1.4, Table A1

Women in Scotland had a higher prevalence of all four condition types than those in England, and higher rates of CVD and CVD or diabetes than women in Northern Ireland. The prevalence of any CVD among women in Scotland (15.5%) was slightly higher than the comparable rates for women in England (13.0%) or Northern Ireland (12.8%). The pattern was the same for any CVD or diabetes (18.2% in Scotland, 16.0% in England, and 14.9% in Northern Ireland). The difference between Scotland and England was marginally significant.

The prevalence of IHD in women was similar in all three countries (Scotland 5.6%, England 4.0%, and Northern Ireland 6.2%) though the small difference between Scotland and England was statistically significant. The prevalence of IHD or stroke was significantly higher in women in Scotland (7.5%) than in England (5.6%), while the rate in Northern Ireland (7.0%) was very similar to that in Scotland.

Although all these differences were significant at the 1% level their size was generally small. As noted in the introduction, small differences with large samples can often be statistically significant even though they represent little substantive importance (and it is worth noting that the sample size for women in Scotland is larger than it is for men). However, it is also possible that true population differences between these conditions also exist for men but that the differences are very small so the samples are not big enough to detect them. Table 1.4, Table A1

The prevalence of CVD in Scotland compared with England has changed over time. In 2003 CVD prevalence in adults aged 16 and over was not significantly different in Scotland and England. In 1998 (comparing adults aged 16-74) and 1995 (comparing adults aged 16-64) CVD prevalence was significantly higher in men but not in women in Scotland compared with England. The caveats about the large sample sizes and relatively small differences between Scotland and England in 2008 suggest that these changes over time in the difference between the countries' rates are unlikely to signify a change of any clinical importance.