Scottish Government

10 Health and Caring

INTRODUCTION AND CONTEXT

Improving health is one of the Scottish Government's five strategic objectives: ⁸¹Help people to sustain and improve their health, especially in disadvantaged communities, ensuring better, local and faster access to health care.

This is supported by the national outcome: 'we live longer, healthier lives'. A series of 45 national indicators and targets has been devised to help assess progress towards achieving these national outcomes and strategic objectives. A number of these indicators are directly related to health and health-related behaviours. For example, the following target has been set in relation to smoking: Reduce the percentage of the adult population who smoke to 22% by 2010. The Scottish Household Survey ( SHS) will be used to monitor progress towards this target.

Although other sources of data on health in Scotland exist, such as the Scottish Health Survey ( SHeS), the long time-series and relatively large sample sizes available from the SHS mean that it is currently better placed than other surveys to monitor progress towards the smoking reduction target and to provide data on self-assessed health status to proxy healthy life expectancy. These measures are both explored in this chapter, alongside the prevalence of long-standing illness or disability in households in Scotland and arising need for regular care and support.

The health and caring experiences of men and women are examined, as well as the experiences of younger and older adults in different types of household. The influence of other factors such as housing tenure, household income and area deprivation is also explored.

The section on adult smoking looks at trends in smoking prevalence between 1999 and 2008 and examines the influence of age, sex and deprivation. This section includes multivariate analysis of smoking behaviour to identify the factors most associated with being a current smoker.

Some commentary is provided throughout this chapter based on more in-depth analysis than actually presented. The actual analysis will be presented as accompanying web tables on the SHS website.

SMOKING IN ADULTS

Figure 10.1 shows the trend in proportion of adults saying they smoke between 1999 and 2008, with smoking among adults seeing a gradual decline from 30.7% in 1999 to 25.2% in 2008. ⁸² This compares against the target of reducing the proportion smoking to 22% by 2010.

Figure 10.1: Whether respondent smokes by year
1999-2008 data, Adults (2008 base: 9,505)

From June 2007, this question was asked of three quarters of the sample. From January to May 2007, it was asked of all random adults.

Legislation to prohibit smoking in public places came into effect in late March 2006. The primary intention of the legislation was to reduce the harm from environmental tobacco smoke in the general population and, in particular, among employees exposed to smoke in the course of their work (e.g. bar workers). The legislation might, as an additional consequence, have encouraged some people to give up smoking.

Figure 10.1 shows that the smoking rate declined every year between 1999 and 2008, except in 2007 where there was a slight increase. The size of the decline was 1.3 percentage points between 2005 and 2006, the year in which the legislation banning smoking in public places was introduced and when most awareness raising activity about it was carried out. The figure continues to fall, from 25.7% in 2007 to 25.2% in 2008. The average reduction across the period is around half a percentage point each year. If this average reduction continued, the 2010 figure is likely to be around 24%, above the 22% target.

Analysis of the number of cigarettes smoked each day suggests a clustering of respondents based on pack size. The median number of cigarettes smoked in 2007 and 2008 is 15 while at the lower quartile the number smoked is 10 and at the upper quartile this is 20.

Over the period from 1999 to 2008, there has been no change in the median number of cigarettes smoked per day. Since the introduction of legislation prohibiting smoking in public places in 2006, and since the start of the SHS in 1999, there has been no obvious change in the number of cigarettes current smokers report smoking. The median number of cigarettes smoked per day is 15.

Figure 10.2 shows the proportion of men and women who smoke, and the prevalence of smoking in different age groups. Overall, slightly more men than women smoke, at 26% and 25% respectively. Younger men more commonly smoke than younger women, with the gap widest (four percentage points) between the ages of 25 and 44 years. This relationship is reversed among those aged 45 to 74 years, with a higher prevalence of female smokers to male smokers by a percentage point at this age. Men smoke more, on average, smoking a median of 15 cigarettes, compared with a median of 12 a day for women.

Younger people more commonly smoke, although there is little variation overall in the younger age groups, varying by only three percentage points. More significant is the reduced smoking prevalence among those aged over 60 years. Among the 60-74 year old group, the proportion smoking is down to 1 in 5, reducing to a little over 1 in 10 among those aged 75 or over. The average number of cigarettes peaks at a later age, with those aged 16 to 24 years smoking a median of 10 cigarettes per day, compared with 15 among those aged between 35 and 74 years, dropping to 10 again among those aged 75 years or older.

Figure 10.2: Percentage of respondents who smoke by age and gender
2007/2008 data, Adults (base 19,917)

Figure 10.3 shows the variation in smoking behaviour by economic status, with those at school least commonly smoking (just 3%) followed by those permanently retired from work (17%) and those in Higher or Further Education (18%). The adults who most commonly smoke are those unable to work due to short-term ill-health (64%) those unemployed and seeking work (58%) those coded as 'other' and those who are permanently sick or disabled (46% and 45% respectively).

Figure 10.3: Percentage of respondents who smoke, by economic status
2007/2008 data, Adults (base: 19,919)

To examine how these respondent characteristics work together to influence smoking behaviour, CHAID analysis was performed. ⁸³CHAID enables the survey respondents to be segmented into the groups most and least likely to smoke. When respondent age, sex and working status are all included in a CHAID model, the most influential factor is working status, followed by respondent age and then respondent sex.

The groups most likely of all to smoke are unemployed people and those unable to work due to short-term ill-health; over half of these respondents (59%) smoke. ⁸⁴ There is no statistically significant difference along gender or age lines within this group. Smoking prevalence amongst these groups was 56% in 1999/2000, but the increase is not statistically significant.

Another group with a similarly high smoking prevalence are those looking after the home or family who are aged 16-24 years, with 56% smoking. This was 54% in 1999/2000, but again, this increase is not statistically significant. This is likely to be an important group for initiatives targeted at younger smokers. Although likely to be mainly women, gender did not emerge as significant (presumably due to the small number of men in this category).

Older respondents within the 'looking after the home or family' category are also more likely than average to smoke, with 36% aged 25-44 years smoking. The prevalence is reduced with age, with 28% of those aged 45 and older in this category smoking. These figures were 40% and 29% in 1999/2000, not significantly different.

Overall, one in four full time employees smoke and this is one instance where females more commonly smoke compared with their male counterparts. These are middle-aged and older women (those aged over 35 years old) who work full time (25% smoke, compared with 22% of men). For slightly younger full time workers, the relationship is reversed, with 30% of men aged 25-34 years smoking, compared with 21% of women. There is no significant difference between younger full-time working men and women, with 33% of those aged 16-24 years smoking. A similar pattern is observed in 1999/2000, though figures were higher in 1999/2000 for all these groups. There is a significant improvement among full-time working women aged 25-34 years, of whom 30% smoked in 1999/2000, compared with 21% in 2007/2008.

Figure 10.4 illustrates the relationship between smoking prevalence and area deprivation. ⁸⁵ Adults in the 15% most deprived areas of Scotland are considerably more likely than those in the rest of Scotland to say that they are current smokers (42% and 23% respectively). Looking across from the 10% most deprived to the 10% least deprived shows a more marked difference between the most deprived and second most deprived group (eight percentage points), then a more gradual reduction in smoking at each decile, with just 11% smoking in the 10% least deprived data zones.

Figure 10.4: Percentage of respondents who smoke by Scottish Index of Multiple Deprivation
2007/2008 data, Adults (base: 19,920)

From June 2007, this question was asked of three quarters of the sample. From January to May 2007, it was asked of all random adults.

To understand how living circumstances influence smoking behaviour alongside respondent characteristics, a tenure indicator and an area deprivation measure were added to the CHAID model alongside respondent age, sex and working status.

In the combined model, tenure is the most influential measure, ⁸⁶ followed by working status for private renters and owner-occupiers and age for social renters. Area deprivation emerges as a lower level indicator than tenure and economic status. In the combined model, three groups emerge as particularly prevalent smokers - social renters aged 16-24 years who are self-employed or unemployed (73% smoke), private renters who are permanently disabled or unable to work due to short-term ill health (63% smoke) and social renters aged between 25 and 59 years living in the 15% most deprived of areas (61% smoke). Two other groups where more than 50% smoke are social renters aged 16-24 years who are looking after the home or family or on a Government training scheme (58% smoke) and social renters aged between 25 and 59 not living in the 15% most deprived of areas (51% smoke). Those least likely to smoke are owner-occupiers who are permanently retired or in higher or further education who do not live in the 15% most deprived of areas (only 12% smoke).

The smoking rates of young self employed or unemployed people have increased - 55% smoked in 1999/2000 while 73% say this in 2007/2008. Other groups show smaller fluctuations in smoking behaviour.

Figure 10.5 compares the self-assessed health status of non-smokers and smokers. Smoking causes and exacerbates a number of chronic respiratory diseases and cardio-vascular disease, and can worsen the health of people with long-term conditions such as asthma. Smokers are less likely than non-smokers to describe their health as 'good' (48% and 59% respectively) while 17% of smokers say their health is 'not good' compared with 11% of non-smokers. The determinants of self perceived health are examined further towards the end of the chapter.

Figure 10.5: Self perception of health by smoking status
2007/2008 data, Adults (base: 19,919)

From June 2007, this question was asked of three quarters of the sample. From January to May 2007, it was asked of all random adults.

LONG-STANDING ILLNESS OR DISABILITY

The SHS asks participants whether anyone in their household, including children, has:

Any long-standing illness, health problem or disability that limits your/their daily activity or the kind of work that you/they can do?

By disability as opposed to ill-health, I mean a physical or mental impairment, which has a substantial and long-term adverse effect on their ability to carry out normal day to day activities.

The question is therefore a subjective measure of long-standing illness, disability and health problems and is not subject to any verification. In addition, this wording does not capture all forms of disability covered by the legal definition within the Disability Discrimination Act 2005, though this is being explored for future years of the survey. ⁸⁷

Figure 10.6 shows that about a third of households in Scotland (33%) contain at least one person with a long-standing illness, health problem or disability. This figure covers all members of the household, including children. Households comprised of older people are more likely to contain someone with a long-standing health problem or disability, with over half of 'older smaller' ⁸⁸ (53%) and 'single pensioner' households (52%) doing so compared with only 16% of small family households and 23% of single parent households.

Figure 10.6: Households where someone in the household has a long-standing illness, health problem or disability by household type
2007/2008 data, Households (base: 27,238)

In Figure 10.7 between 41% and 49% of households with net annual incomes below £15,000 contain someone with a long-standing illness, health problem or disability. The corresponding figure for households with a net annual income of over £40,000 is 13%. These findings are partly explained by the income profile of older households, with almost half of older smaller households (47%) and 84% of single pensioner households having incomes below £15,000 (see Chapter 6).

Figure 10.7: Households containing anyone with a long-standing limiting illness, health problem or disability by net annual income
2007/2008 data, Households (base: 26,267)

* Includes all adults for whom household income is known or has been imputed.
Household income in the SHS is that of the highest income householder and their partner only.

Owner occupier households (28%) and those who rent from the private sector (19%) ⁸⁹ are less likely to contain someone with long-standing health problems or disabilities than those living in the social rented sector (52%) (see Figure 10.8). The discussion above noted that many pensioners and single pensioners in particular have low incomes. However, although they can have lower incomes, older people are more likely to be owner occupiers than people in other age groups, so the association between disability, health status and living in the social rented sector is likely to be explained by factors other than just the age of the householders.

Figure 10.8: Households containing anyone with a long-standing limiting illness, health problem or disability by tenure
2007/2008 data, Households (base: 27,220)

Figure 10.9 shows the age and gender profile of those with a long-term health issue or disability. The gender split of those with a long-term health issue or disability is 55% female and 45% male overall, with proportionately more ill or disabled women than men in the over 70 age group (37%, compared with 28% of ill or disabled men). Men are more prevalent in the slightly younger group, with 22% of ill or disabled men in the 60-69 age group compared with 19% of ill or disabled women.

There is evidence of a greater concentration of males with health issues or disabilities in their youth. A total of 9% males aged less than twenty years, compared with 5% of females are reported as having a disability or long-term illness.

Figure 10.9: Household members with a long-standing limiting illness, health problem or disability by age and gender
2007/2008 data, Household members with a disability and/or long-term illness (base: 11,046)

CARE NEEDS WITHIN THE HOME

This section looks at the care needs of household members in Scotland, including children's needs. Figure 10.10 shows that while 14% of all households contain at least one person who requires regular help or care, one in four single pensioners and one in five older smaller households have care needs. Looking across different types of household, we also see that almost half (45%) of those households with care needs contain only one adult ⁹⁰ so more likely to need care from outside the household. Indeed, looking at who provides care, although outside care is provided to half of the households with care needs (50%), this figure is 85% for single pensioners, 77% of single adults and 49% of single parents. This compares with around a quarter of smaller households and large adult households, and less than one in five large families (18%) .

One person households are least likely to receive the care they need. Overall, 5% of those who need care do not receive any, with 6% of single pensioners and 12% of single adults receiving no care compared with around 3-4% of other households.

Figure 10.10: Those households containing someone who needs regular help or care by household type
2007/2008 data, Households (base: 27,238)

There is also a significant pattern between needing care and household income, with the highest income households being the least likely to contain someone in need of regular care or help. Between 17% and 22% of households with a net annual income of £20,000 or below contain someone who requires regular help, compared with around one in ten with incomes between £20,001 and £30,000, and around 5% of households with an annual income above £30,000 (Figure 10.11).

Figure 10.11: Whether anyone in the household needs regular help or care by net annual income
2007/2008 data, Households (base: 26,267)

*Includes all adults for whom household income is known or has been imputed.
Household income in the SHS is that of the highest income householder and their partner only.

In Figure 10.12, just one in ten owner occupiers and less than one in ten private renters have someone in the household with care needs, compared with one in four social renters and less than one in four of those in other tenures.

Figure 10.12: Whether anyone in the household needs regular help or care by tenure
2007/2008 data, Households (base: 27,220)

SELF-PERCEPTION OF HEALTH

Over half of adults (56%) say their own health is 'good', 32% say it is 'fairly good' and 13% say it is 'not good' (see Table 10.1). Women more commonly say their health is not good compared with men (14%, compared with 11%). However, more striking is how the proportion rating their health favourably is far lower among the two oldest groups in particular. Although a significant proportion of those aged over 60 years still say their health is good, one in five aged 60 to 74 years and one in four aged over 75 say their health is not good.

Table 10.1: Self perception of health by gender and age
Column percentages, 2007/2008 data

There is a significant relationship between income and perceived health - one in which age may be a contributory factor - with one in five of those with a net annual household income of £15,000 or less saying they have 'not good' health compared with 1 in 20 with an income in excess of £30,000, as referenced in Table 10.2.

Table 10.2: Self perception of health by net annual income
Column percentages, 2007-08 data

*Includes all adults for whom household income is known or has been imputed.
Household income in the SHS is that of the highest income householder and their partner only.

Looking at tenure, almost one in four social renters (24%) say their health is not good, compared with around one in 10 owner occupiers and private renters (10% and 8% respectively).

Table 10.3 also shows that people living in the 15% most deprived of areas in Scotland ⁹¹ are around twice as likely to say their health is 'not good' compared with those living elsewhere (20%, compared with 11%). Looking across the whole area distribution, we see a gradual increase in the proportion saying their health is not good with each 10%, from the least deprived to most deprived areas.

Table 10.3: Self perception of health by Scottish Index of Multiple Deprivation
Column percentages, 2007/2008 data

Figure 10.13 shows that smokers are less likely than non-smokers to describe their health as 'good'. They are more likely to say their health is 'not good' (17%) compared with 11% of non-smokers. However, it is unclear how smoking works alongside age - since older people less commonly smoke but more commonly report not having good health, while smokers tend to be younger but also tend to report less good health.

A CHAID model including a number of these main explanatory variables (age, sex, deprivation, tenure ⁹² and smoking behaviour) was tested to identify the ordering of the factors and to identify key groups or 'nodes' of interest. In the model, respondents are first separated on the basis of age, followed by tenure and then smoking behaviour or deprivation. Smoking and area deprivation have a different level of influence depending on the group involved.

Since the proportion of people saying that their health is 'not good' is low overall, much of the CHAID model is driven by the weight of factors governing 'good' responses. Important groups with a strong relationship to perceived good health are:

• Aged 60-74, an owner occupier, not in a deprived area, non-smoker - 51% say they are in good health. ⁹³
• Middle-aged (45-59), owner occupier, doesn't smoke, not in a deprived area - 64% say they are in good health.
• Slightly younger, (35-44), own with help of mortgage, non-smoker - 70% say they are in good health.
• Aged 75+, an owner occupier, not in a deprived area - just 22% say their health is not good, compared to 42% of social renters of this age who smoke.
• Aged 60-74, a social renter - 24% say they are not in good health while 35% say they are.

Two sets of respondent characteristics were excluded from the model because of their very strong correlation to health, as these would obscure the other factors. These are having a health issue or disability and taking part in sports or other activities, which are compared to smoking and health perceptions in Figure 10.13.

Figure 10.13: Self perception of health by smoking, illness or disability and whether has done physical activity in the past four weeks
2007/2008 data, Adults (base: 24,399)

The strongest association is found between rating health as 'not good' and having a long-term illness or disability, followed by not being physically active ⁹⁴ then being a smoker. Almost half of adults with a long-term illness or disability say their health is not good (45%), compared with 27% of those who have not walked, cycled or done other sports in the past four weeks and 17% of smokers. The corresponding figures for those without a long-term illness or disability, those who have been active and those who do not smoke are 4%, 7%, and 11% respectively.