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CHAPTER FIVE DETAILED INVESTIGATION OF NATURE OF HEALTHCARE NEEDS ( SHeS data)

Introduction

5.1 This chapter presents a more detailed analysis of the health and lifestyle characteristics of adults with long-term conditions using data from the SHeS. Firstly, it examines links between self-rated measures and biological indicators of health. Secondly, it profiles the ways in which long-term conditions affect people's quality of life. In addition it will also outline the patterns of use of health services by adults with long-term conditions.

Prevalence and types of long-term conditions

5.2 Estimates from the SHeS show that in 2003, 26.5% of adults in Scotland reported a long-standing illness, disability or infirmity which limited their activities in some way. This is broadly comparable to the figures reported in Chapter 3 from the SHS. A further 14.7% reported long-term conditions that were not limiting. The following analyses of SHeS data will focus on those with 'limiting long-standing conditions', but will also take into account those who report 'non-limiting long-standing conditions' where relevant.

5.3 The SHeS Report (2005: 214, Table 6.2) showed that incidence of limiting long-standing conditions varied little by gender, but increased markedly with age. This is consistent with the patterns shown by SHS data.

Nature of long-standing condition

5.4 The SHeS uses the International Classification of Diseases ( ICD-10) coding schema to classify the nature of the long-term illness or disability. The conditions most reported by adults with limiting long-standing conditions were associated with the musculoskeletal system and the heart and circulatory system. These also featured highly in the nature of conditions affecting those reporting non-limiting illness/disability (Table 5.1). ²⁶

Table 5.1: Nature of disability, illness or health problem

Column percentages

Source: Scottish Health Survey 2003
Notes: Columns do not add to 100 because of multiple responses
- numbers less than 30
[ ] numbers less than 50

Health measures

Acute sickness

5.5 SHeS asked about episodes of acute sickness over the 2 weeks prior to the survey. The responses were then coded in terms of number of days' sickness, ranging from none to the entire fortnight. Nearly 40% of adults with limiting long-term conditions reported at least one day of sickness, compared to only 9% of those with a non-limiting condition, and 7% of those reporting no illness or disability (Figure 5.1).

Figure 5.1: Number of days of acute sickness within fortnight prior to survey

5.6 Previous analysis ( SHeS Report, 2005: Chapter 6) has shown that incidence of acute illness differed by sex, age and key socio-demographic variables (socio-economic status ²⁷, household income ²⁸, and Scottish Index of Multiple Deprivation (simd) ²⁹). Further analysis showed that whether or not the individual had a limiting long-standing health condition was by far the most significant predictor of acute illness in the previous fortnight (see Table 8.1 in appendix for results of logistic regression analysis). The odds of being acutely ill in the previous fortnight were more than 7 times higher amongst those with a long-standing condition as compared to those without.

Obesity & waist to hip ratio

5.7 Adults with limiting long-standing conditions were more likely to be classed as 'obese' (having a Body Mass Index, BMI, of 30 or more): 36.0% of this group were obese, compared to 30.3% of those with a non-limiting condition, and 18.5% of adults with no long-term illness or disability. Further analysis, controlling for age, sex and deprivation, confirmed the relative likelihood of being obese was highest for those with limiting long-standing conditions (Table 8.2 in Appendix). Adults with non-limiting conditions were also relatively more likely than those without long-term conditions to have a BMI of 30 or more.

5.8 Similarly, men and women with long-standing conditions (especially limiting conditions) were more likely to have waist-hip ratios considered to indicate high levels of abdominal fat (men 0.90 or more; women 0.80 or more) (Figure 5.2). Analysis controlling for potential confounding factors of age and deprivation found that men and women with limiting long-standing conditions (and men with non-limiting conditions) had relatively higher waist-hip ratios compared to their counterparts without long standing conditions; the difference between women with non-limiting conditions and women with no long-standing conditions was not statistically significant. See Tables 8.3 and 8.4 in Appendix for details.

Figure 5.2: Proportion of each group with high waist-hip ratios (men 0.9+; women 0.8+)

Self-assessed general health

5.9 Adults with limiting long-standing health conditions were markedly less likely to report that their general health over the year prior to the survey had been good and much more likely to report poor health (Table 5.2). Reported health was grouped into 2 broad categories of 'very good or good' versus 'poor to very bad' and analysis was conducted to control for some of the key factors previously shown to affect perceptions of general health ( SHeS Report, 2005: 198). The results (Table 8.5 in Appendix) show that the association between adults with limiting long-standing health conditions and the likelihood of reporting poor health were robust even after controlling for other significant factors (age, sex, socio-economic status, equivalised household income and deprivation).

Table 5.2: Self-assessed general health

Row percentages

Source: Scottish Health Survey 2003

Psychosocial health - General Health Questionnaire ( GHQ12)

5.10 Psychosocial health was assessed using the 12-item version of the General Health Questionnaire ( GHQ12), which is designed to identify short-term changes in mental health (depression, anxiety, social dysfunction and somatic symptoms) (Goldberg 1972, 1978). Compared to all other adults, those with a limiting long-standing condition were markedly more likely to record a GHQ12 score ³⁰ which would put them at higher risk of mental distress and psychological ill-health. ³¹ Thirty per cent of this group recorded a GHQ12 score of 4 or more, which indicates a possible psychiatric disorder, compared to only 9.4% of other adults. Further analysis on the relative likelihood of a high GHQ12 score (4+) found the presence of a long-standing health condition to be the strongest predictor of a high GHQ12 score. (Table 8.6 in Appendix).

Health-related quality of life - Medical Outcomes Study 12-Item Short Form ( SF-12) ³²

5.11 This measure questioned respondents about aspects of their physical functioning, limitations to their normal activities because of physical or mental health problems, bodily pain, general health, vitality, social functioning, and psychological distress and psychological well-being. Higher scores on the physical ( PCS-12) and mental ( MCS-12) sub-scales indicate a higher health-related quality of life. Average (mean) quality of life on both the physical and mental sub-scales was lowest for those with limiting long-standing conditions. Adults who reported a non-limiting long-standing condition had lower average physical quality of life as compared to adults with no long-standing conditions, but did not differ in terms of mental quality of life (consistent with GHQ12 scores) (Table 5.3). Once again when age, sex and deprivation (as an indicative socio-demographic measure) were controlled for, those with limiting long-standing conditions still reported lower quality of life. (Tables 8.7 and 8.8 in Appendix.)

Table 5.3: Health-related quality of life

Mean (standard deviation ³³)

Source: Scottish Health Survey 2003
Note: bases are low because of high numbers of missing responses.

Use of services

GP consultations

5.12 Respondents were asked how many times they had spoken to a GP on their own behalf (either by person or telephone) within the fortnight prior to the survey. Adults with long-standing limiting conditions were most likely to have made at least one consultation. Nearly one third (32.4%) made one or more consultation in the fortnight prior to the survey. Of these, 78% had one consultation (Figure 5.3).

Figure 5.3: GP consultations in fortnight prior to survey

5.13 Analysis was conducted to control for the effects of age, sex, socio-demographic status, self-assessed general health and whether or not the respondent had been ill during the fortnight ( SHeS Report, 2005: 203 and 205). Taking these into account, the odds of respondents with long-standing conditions (both limiting and non-limiting) consulting their GPs were still higher than for those without long-term conditions (Table 8.9 in Appendix). Respondents were also asked about the total number of GP consultations over the past year. Although analysis suggests that the average (mean) number of consultations was significantly higher amongst those with long-standing conditions, the data also showed a wide variation of frequency of GP consultations among those adults with long-standing conditions, ranging from none to over 200.

Hospital attendance

5.14 Adults with limiting long-term conditions were more likely to have attended hospital in the previous year, either as outpatients (including day-patients or visits to casualty) or as inpatients (Table 5.4). Of those admitted to hospital as inpatients, half (50.1%) had limiting long-standing conditions, while 41.5% of those attending as outpatients had limiting long-standing conditions (table not shown).

Table 5.4: Hospital attendance in year prior to survey

Percentages

Source: Scottish Health Survey 2003

5.15 Analysis, controlling for age, sex, deprivation, general health and acute illness showed that adults with long-standing conditions (both limiting and non-limiting) were significantly more likely than those with no long-term condition to have attended hospital in the past year as an outpatient. However, only those with a limiting long-standing condition were more likely to have attended as inpatients. See Tables 8.10 and 8.11 in Appendix for details.

Medication

5.16 The majority of adults (84.3%) reporting a limiting long-standing condition were also taking prescribed medication ³⁴. Nearly three-quarters (72.7%) of those with a non-limiting condition were taking prescribed medication, compared to just over one quarter (26.7%) of those with no long-term health conditions. Of those taking prescribed medicines, 45.6% were adults with long-standing health conditions, 22.3% had non-limiting conditions and 32.1% did not have a long-term condition. Once again these differences were robust enough to hold up in the analysis which controlled for age, sex, socio-demographic factors, acute illness and self-assessed general health (Table 8.12 in Appendix).

5.17 Scrutiny of the number of prescribed medicines taken showed marked differences according to whether or not the respondent had a long-standing condition (Figure 5.4).

Figure 5.4: Number of prescribed medicines taken

Prevalence of long-standing conditions by health board

5.18 Use of health services is likely to differ between health boards as locational analysis at health board level ³⁵ shows a difference in terms of prevalence of limiting and non-limiting long-standing conditions. Lowest prevalence of limiting conditions was found in Orkney, Lothian, Forth Valley, Fife, Borders and Grampian, while lowest prevalence of non-limiting conditions was seen in Glasgow, Grampian and the Western Isles. The relative incidence of limiting conditions was highest in Argyll and Clyde, Glasgow and Lanarkshire, and that of non-limiting conditions was highest in Argyll and Clyde, Lanarkshire, Ayrshire and Arran, Borders and Orkney ³⁶. See Figures 8.4 and 8.5 in the Appendix.

5.19 Locational analysis at health board level also confirmed the strong association between higher prevalence of long-standing conditions and deprivation as measured using SIMD divided into quintiles ³⁷ For example, almost two-fifths (39.4%) of adults in the Greater Glasgow Health Board were categorised in the most deprived SIMD quintile.

Lifestyle

Diet

5.20 Portions of fruit or vegetables consumed during the day prior to the survey was examined as a key indicator of a healthy diet and general health status ³⁸. Overall, just over one-fifth (21.1%) of all adults reported that they ate five or more portions of fruit/vegetables in the day preceding the survey, and 9.5% ate none. The figures varied little according to whether or not the individual reported a long-standing health condition. For example, 9.8% of adults with a limiting condition ate no fruit/vegetables, compared to 9.9% of adults without a long-term condition. The respective figures for 5 or more portions were 18.3% and 21.9%.

Smoking

5.21 Nearly one-third of adults with limiting long-standing conditions (32.1%) reported themselves to be current smokers. This compares to 34% of those with non-limiting conditions, and 27.9% of those without any long-term conditions. Analysis was conducted to control for factors associated with likelihood of cigarette smoking (age, sex, deprivation), and the effects of health status remained (although the level of deprivation was the largest predictor). See Table 8.13 in Appendix for details of analysis. Among those who classed themselves as current smokers, adults with limiting long-standing conditions were the group least likely to be 'light' smokers (fewer than 10 cigarettes per day) but most likely to be heavy smokers, smoking 20 or more cigarettes daily.

Drinking

5.22 Information on alcohol consumption in the week prior to the survey was gathered. The average (mean) number of units consumed varied little between groups of men, but the mean number of units consumed by women with limiting long-standing conditions was significantly lower (5.1 units) than that for women with non-limiting or no long-term conditions (7.1). However, there was wide variation in the alcohol consumed by men and women within each group. As such, differences in means are not helpful in differentiating levels of alcohol consumed by adults with long-standing conditions compared to those without long-standing conditions. Another derived variable calculated alcohol consumption in relation to official 'low-risk' weekly limits of up to 14 units for women and 21 units for men. Analysis (controlling for age, sex and deprivation) of the relative likelihood of drinking to excess was lower amongst men and women who had limiting long-standing conditions. (Table 8.14 in Appendix)

Physical activity

5.23 SHeS questioned respondents about a number of aspects of physical activity (Table 5.5). The responses were used to calculate a summary measure of physical activity: whether or not the respondent undertook 30 or more minutes of at least moderate physical activity in the four weeks prior to the survey, also shown in Table 5.5. Adults with limiting long-standing conditions were least likely to have undertaken any forms of physical activity. Differences between those with non-limiting conditions and those without long-standing conditions were not as marked, and in some aspects (e.g. housework or manual work), activity levels were lower amongst those reporting no long-standing health condition.

Table 5.5: Proportions of each group undertaking physical activity in the four weeks prior to the survey

Percentages

Source: Scottish Health Survey 2003

5.24 Further analysis on the summary measure indicates that, taking other key variables (including age) into account, adults with limiting long-standing conditions were least likely to have taken 30 minutes or more exercise on any day within the month prior to the survey (Table 8.15 in Appendix). A further summary measure was derived which reflected the Scottish Executive's recommended minimum levels of physical activity (at lest 30 minutes of moderate activity on most days of the week) ³⁹. According to this measure, adults with long- standing conditions (especially those with limiting conditions) were less likely to meet the minimum levels. 18.3% of adults with limiting long-standing conditions, and 34.1% of adults with non-limiting conditions took at least 30 minutes of moderate exercise on 'most' days (i.e. 5 or more days per week), as compared to 40.8% of adults without long-standing conditions (Figure 5.5).

Figure 5.5: Number of days per week of at least 30 minutes of moderate physical activity

Summary of key points

5.25 SHeS estimated that in 2003, 26.5% of adults in Scotland had a long-standing ⁴⁰ illness, disability or infirmity which limited their activities in some way (limiting long-term conditions). This is comparable with the SHS figures for the prevalence of long-term conditions. A further 14.7% reported long-term conditions that were not limiting.

5.26 Adults with long-standing conditions, especially those with limiting conditions, had a poorer health-related quality of life across a range of measures. They reported poorer physical and mental health; were more likely to experience acute illness; were more likely to attend GP or hospital; and were more likely to be taking medication.

5.27 Adults with limiting long-term conditions were more likely to report less healthy lifestyles. Compared to adults with no long-term conditions, and also to those who defined their long-term conditions as non-limiting, those with limiting long-term conditions were more likely to be current and heavier smokers; were less likely to be physically active; and were more likely to be obese.

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