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Working Together for a Healthier Scotland |
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Chapter 3 - Influences on Scotland's Health48. Many different factors account for Scotland’s relatively poor health record and for the large inequalities in health that exist in Scotland. Lifestyle factors have been shown to be associated with a range of diseases. These aspects of our behaviour are strongly linked to underlying social and economic circumstances. Prominent among these are poverty, unemployment, and inadequate housing. Environmental factors, like pollution and access to health services and amenities, also bear on health. Life Circumstances49. The circumstances in which we live closely affect our risk of poor health and our prospects of good health and well-being. So, too, do culture, fashion, the mass media, peer influences and social isolation or marginalisation. Good general education - not just health education - is a foundation for good health. 50. Unemployment - standing currently at some 6% in Scotland and involving over 147,000 people - can bring with it despair, poverty and resentment. It develops a culture of hopelessness, and it undermines self-esteem. The knowledge and means to choose a balanced diet are often lacking. Consolation found in tobacco and alcohol misuse has detrimental effects on physical, mental and social well-being, and family income. 51. Housing conditions can affect health in many ways. As well as being demoralising and impairing well-being, cold and dampness can worsen respiratory illnesses. In 1996, 25% (534,000) of all dwellings in Scotland were judged to suffer from problems of dampness or condensation. Drinking water supplied through lead plumbing may affect the intellectual development of small children. Poorly designed houses increase the risk of accidents within the home: such accidents are a major cause of death or injury among children and the elderly. Local problems of naturally recurring radon gas at high levels, if not addressed, can substantially increase the risk of lung cancer. Where there are problems, their impact will generally be greatest for those who spend most time at home. There are, of course, other risks for those who are homeless. 52. A clean, well maintained environment, free from pollutants and dereliction, helps safeguard physical and mental health. Local amenities, including parks and recreational facilities, are also important. Not only do they improve the environment and support well-being, but they increase the incentive to take physical exercise, which, in turn, contributes to better health. Conversely, a lack of local amenities encourages recourse to other pursuits such as smoking, alcohol misuse and drug taking. 53. Areas of multiple deprivation pose a particular threat to health. The combined problems of low incomes, unemployment, poor housing, a degraded environment, and high levels of crime impose an additional burden of ill-health on many families. Each of these problems can, in isolation, affect our risk of poor health, but this combination of social ills can place extreme stress on communities, families and individuals. 54. Regeneration of these areas is required to transform the housing stock, improve the environment, provide training and employment, tackle crime, bring new amenities, and build a sustainable community infrastructure. The Government are determined to take action to regenerate our most deprived urban communities. At the same time, the Government recognise that disadvantage can also be found in rural areas, where local solutions can address inequalities on similar concerted lines. 55. A safe and healthy workplace is important. For people who work, the working environment is a significant influence on their health. For many, going to work is a positive part of their lives, and it helps them stay healthy. But we need to make sure that work does not injure people or make them ill, and that they leave work at the end of the day at least as healthy as when they arrived. 56. The Government are concerned about the impact of social exclusion on health. There are growing numbers of people who lack the means - material and otherwise - to participate in mainstream economic, social, cultural and political life in Scotland. Long-term unemployment, poor housing, homelessness, poverty and low educational achievement can all contribute to ill-health. Some health problems may also contribute to social exclusion. Some people may face stigma and prejudice as a consequence of a particular health problem, such as mental illness or HIV/AIDS. Some may face practical barriers to opportunity through disability. And high levels of long-term illness can suppress economic activity and employment in many communities. 57. An important aspect of people’s life circumstances is the extent to which a wide range of services and facilities is easily reachable, affordable and user-friendly. Health services, including health centres, health visitors, and pharmacies, are not only about treating illness: they promote and support health. Adequate shopping facilities are also important so that people, especially in deprived and remote communities, can have easy access to purchase the foods which are necessary for a balanced diet. So are safe and accessible places for taking exercise. A good transport system brings such provision within the reach of all, while reducing pollution and accidents. LifestyleSmoking 58. Tobacco smoking is the most important preventable cause of disease and premature death in Scotland. Each year smoking accounts for more than 10,000 deaths - approximately one in 6 of all deaths - and the cost to NHS hospitals in Scotland of treating smoking-related disease is around £87 million each year. Lung cancer causes the death of more men, and women, in Scotland than any other form of cancer, and Scottish death rates from lung cancer are among the highest in the world. Smoking is a major risk factor for CHD and is also implicated in chronic bronchitis, high blood pressure, stroke, peripheral vascular disease, a number of types of cancer and osteoporosis. Women who smoke are less likely to conceive and more likely to lose their babies before or soon after birth. Children of smokers are more likely to be of small stature and to develop respiratory infections, while more than 25% of the risk of sudden infant death syndrome is attributable to maternal smoking. There is increasing awareness of the dangers of passive smoking in relation to lung cancer, asthma and respiratory infection. Since 1982 there has been little decrease in the number of children smoking, particularly among girls. Sadly, smoking will kill many of today’s teenagers in their later years. Table 2: Percentage of Secondary Schoolchildren (aged 12-15) Smoking Regularly or Occasionally Scotland 1982-1994 (Source: OPCS)
59. Apart from the direct effects of smoking on health, thousands of fires are caused each year by carelessness with cigarettes or other smokers’ materials, some with fatal consequences. Of the 88 deaths resulting from fires in dwellings in 1996/97, 39 resulted from fires so caused, as did 731 injuries. 60. The recent Scottish Health Survey suggests that limited progress has been made in reducing the level of smoking among adults aged 25-64. The proportion of people in this age group who smoke has fallen from 40% in 1986 to 36% in 1995. But it seems unlikely that the target of reducing the level of smoking in this age group to 32% by the year 2000 will be achieved. Other surveys indicate that no significant progress has been made in reducing smoking levels in the 12-24 age group. Eating for Health 61. The link between diet and health is well established. The James Report on Scotland’s diet, published in 1993, confirmed unequivocally the very poor balance of our diet and its highly damaging impact on the population’s health. In short, the average Scottish diet is deficient in certain vitamins and fibre and contains too much saturated fat, sugar and salt. Children’s diets are particularly bad with many never eating fruit and vegetables and some eating almost exclusively crisps, chips, snack foods, sweets and fizzy drinks. The rate of breastfeeding by Scottish women is very low despite the well-known benefits of breast milk, which provides children with a healthy start to life by reducing the risk of certain potentially serious illnesses in infancy and childhood. The Scottish Health Survey found that, among the adult population:
62. Such is the extent of our poor diet that it ranks second to smoking as the cause of Scotland’s high mortality rate from CHD, stroke and cancer (evidence suggests that our diet influences the incidence of almost one-third of cancers in men and nearly half of those in women); is directly responsible for much of our poor dental health, particularly among children; and contributes to our comparatively poor life expectancy. Unless the Scottish people change their present diet, they are likely, despite advances in healthcare, to continue to have a high rate of mortality and disability from CHD, stroke and cancer and a lower life expectancy than most other western countries. 63. Improving diet has to be at the heart of improvements in Scotland’s health. We want to encourage and enable the Scottish people to adopt a better and healthier balance in their diet. This means much more fruit and vegetables, bread, cereals, potatoes, rice, pasta and fish, especially oil rich fish; and much less of foods containing high levels of fat, salt and sugar. Lifelong food preferences are established at an early age; and so the eating habits of young children are an important start. 64. Most Scots are aware of the beneficial impact of a balanced diet on the quality of health and well-being. The task is to help each of us to act on that information. Dietary targets for the year 2005 have been set, therefore, and a Diet Action Plan: Eating for Health, was published in 1996. The Plan, for action over a 10 year period, provides a coherent framework for tackling our dietary shortcomings. It examines the changes required in the diet of the population in general and of particular groups, notably pregnant women and children, and those in deprived communities to whom low income and unavailability of healthy food choices present particular barriers to achieving a balanced diet. It identifies ways in which the various interests in a position to influence what we eat can contribute to helping people choose, and enjoy, a healthy diet. 65. With the support of Government funds of £1m, implementation of the Plan is now underway across the spectrum of interests. The Scottish Community Diet Project, led by a national project manager to co-ordinate dietary strategy and develop initiatives in deprived communities, has already awarded £60,000 to fund innovative diet projects in these communities. Constructive discussions with the major food retailers have explored ways of increasing the contribution they can make to improving Scotland’s diet as a whole and within deprived communities. A Scottish Healthy Choices award scheme is open to all catering interests in Scotland. A healthy eating leaflet has been issued to all Scottish households. A short practical cooking skills course for schoolchildren is being developed. Many initiatives, particularly within communities, are also being taken forward at local level. Physical Activity 66. Physical activity can help protect against heart disease, strokes and a number of other health problems and promote physical, social and mental well-being and fitness. It also helps prevent obesity. Around one-third of all CHD and one-quarter of all strokes could be avoided if regular physical activity was undertaken by all, while programmes of physical activity can reduce mortality after a heart attack by 20%. Exercise taken in Scotland falls well short of the levels regarded as beneficial to good health. A key recent development has been the identification of the benefits of regular moderate activity, not just vigorous exercise. This is true for all age groups, and regular activity, continued into older age, has been shown to prevent falls and diseases such as osteoporosis as well as improving mental health. Of those interviewed in the Scottish Health Survey, 53% of men and 62% of women acknowledged that they did not get sufficient regular exercise, while 23% of men and 26% of women undertook no moderate or physical activity in an average week. Low levels of physical activity in children in Scotland are a cause for concern. Alcohol Misuse 67. Over 90% of the adult population drink alcohol. It can be a part of a healthy lifestyle if taken in moderation and at the right time and place, and, indeed, there is evidence of physical health benefits of regular moderate alcohol consumption for men over 40 and women after the menopause. Both excessive consumption over long periods and heavy spasmodic drinking cause damage to health, accidents, and anti-social behaviour. The costs of alcohol misuse in personal, social and economic terms are great, and are all too often hidden or unheeded. 68. Some 8% of men and 1% of women in Scotland - about 200,000 people - are drinking at levels which are definitely harmful. The 1994 General Household Survey showed alcohol consumption levels in Scotland to be broadly similar to those in other parts of the UK. There has been a greater tendency, however, towards binge drinking in Scotland and this may be the most significant variation in the patterns of alcohol consumption in the UK. Misuse of alcohol is a major risk factor associated with disease, homelessness, unemployment, criminality, mental breakdown, domestic violence and child abuse. Many working days are lost each year due to alcohol misuse. Heavy drinking contributes to high blood pressure; increases the chances of stroke; and is linked to cancer of the throat and mouth. A quarter of the men and a tenth of the women admitted to general hospitals will be problem drinkers. 69. There has been a steady increase in deaths attributable to alcohol. According to the Office for National Statistics, there has been a small increase in the 1990s in the proportion of children in Scotland aged 12-15 who drink alcohol at all (from 59% in 1990 to 64% in 1996). However, there has been a more marked increase in the amount consumed by those who drink. The average number of units a week drunk by children of this age has more than doubled - from 0.8 units in 1990 to 1.9 units in 1996. Alcopops, which were first introduced into the market in 1995, accounted for about 18% of all alcohol consumed by this age group in 1996. Consumption by women has increased in the last two decades. Their smaller average physical size means that a given amount of alcohol may cause more damage to women than men. 70. The target set for alcohol consumption was to reduce the 1986 figures for men drinking more than 21 units per week and for women drinking more than 14 units per week by 20% by the year 2000. The heavier the drinking above this level, the greater the hazard to physical and mental health. Findings from the Scottish Health Survey are that 33% of men and 13% of women drank more than these recommended levels. This indicates an increase compared with the 1986 levels of 24% and 7% respectively. To be effective, preventative policies have to focus on the moderately heavy drinkers as well as those at the extreme end of the range. 71. The Government are fully committed to tackling alcohol misuse on a broad front. Alcohol development officers have been appointed throughout Scotland, co-ordinating action at local level. The licensing framework in Scotland works well and can react to particular problems, for example, licensing boards are required to refuse late night extensions unless satisfied of their community benefit. Regulation has recently been strengthened. Local authorities can now have recourse to byelaws prohibiting the consumption of alcohol in designated public areas. Under Scots law, it is already an offence for adults to buy alcohol for supply to children and recent legislation allows the police to confiscate alcohol from under 18s who are drinking in public. 72. The Government have made clear that, if their current measures to bolster the action taken by the drinks industry towards better self-regulation do not bear fruit, they will take further action which could include legislation in areas which have traditionally been left to self-regulation. The Government have also made very clear their determination to tackle alcohol misuse by young people - which can lead not only to crime but also to under-achievement, poor health and poor employment prospects. 73. A high proportion of adult fatalities from fire in dwellings (where the cause of fire was carelessness with smokers’ materials, pans left on cookers, or misuse of electrical apparatus, for example) has been linked with excessive intake of alcohol. Drug Misuse 74. All the indicators show that drug misuse continues to grow in Scotland. Surveys of young people regularly show half or more reporting that they have taken an illicit drug at some time in their lives. In surveys about 1 in 4 young people acknowledge having taken drugs within the preceding 12 months, and figures for drug misuse in young age groups - for example those pupils starting secondary school - are of especial concern. While these figures also remind us that drug taking is not part of the day-to-day lives of most Scots, the upward trends dispel complacency. With growing concern about the medium to long-term effects of drugs taken freely in dance settings, mixing of hard and recreational drugs, and drugs and driving, a sustained effort is needed to stop drug misuse acquiring the malign grip of tobacco and alcohol in Scotland. Early adolescent solvent abuse continues to be associated with a significant risk of brain damage and accidental death. 75. The figures for those with a serious drug problem reported to the Scottish Drug Misuse Database show that heroin-users increased significantly during 1996/97. Comparing these figures with those for other parts of the UK provides evidence that Scotland is one of the worst areas for heroin misuse. A similar pattern emerges in the illicit misuse of certain prescription drugs, together with injecting and "polydrug" misuse. Drug-related deaths in Scotland rose from 251 in 1995 to 267 in 1996, following a steeper rise from 151 in 1992. There is a damaging link between injecting drug use and the spread of HIV/AIDS and hepatitis B and C. The most serious harm from drug misuse is concentrated in areas of deprivation. 76. Drug misuse and crime are closely linked. Some police forces operate on the basis that 50-70% of crime is drug related. It can take many forms, from petty thefts and burglaries, to fund drug purchase, through anti-social behaviour induced by drug taking to intimidation and violence spawned by drug dealing. An ongoing study suggests that around 2.5 million crimes may be committed annually in Glasgow by heroin injectors. Substantial costs fall on local communities, public services and industry. Inequalities77. Just as there are inequalities in health, so there are marked differences in lifestyle between socio-economic groups, geographical location and other groupings. For example, levels of smoking are closely associated with social class (Figure 16). Less than a quarter of men and women in social classes I and II smoke cigarettes, but in social classes IV and V the percentage of smokers among both men and women is almost 50%. 78. Diet is also closely associated with social class. Thus the percentage of people who eat fresh fruit only once a week or less is significantly higher in social classes IV and V than in social classes I and II (Figure 17). 79. Differences in lifestyle do not fully account for inequalities in health. Disadvantaged life circumstances, although having a major bearing on lifestyle, have in themselves, a harmful effect on health. Low income or poorly located housing can affect access to a range of health promoting venues and facilities. There is evidence that the availability of general medical care tends to vary inversely with health need in the population served. 80. In order to take stock of current knowledge on inequalities in health and to identify the best areas on which to concentrate efforts, the Government have established an independent inquiry under Sir Donald Acheson, the former Chief Medical Officer in England, into inequalities in health, drawing on international experience. Together with responses to this Green Paper, Sir Donald’s report will help inform the development of our health strategy. Priorities81. The effects of life circumstances and lifestyle on health are readily apparent, well documented and have been accepted by the Government. Tackling them is important in health terms, and, more broadly, in support of social cohesion and community safety. We propose that the priorities should be:
In identifying a range of priorities, an overarching objective must be to reduce inequalities. Views are invited on the priorities proposed. |
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| © Crown Copyright 1998 | Prepared 3rd February 1998 |