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The Scottish Health Survey: Volume 1: Main Report

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1 GENERAL HEALTH AND MENTAL WELLBEING

Lisa Given

SUMMARY

  • In 2009, 77% of adults described their health in general as 'good' or 'very good' and 7% described it as 'bad' or 'very bad'. Perceptions of health varied significantly with age. Nine in ten adults aged 16-24 had 'good' or 'very good' health compared with half of those aged 75 and over.
  • The general health of most children aged 0-15 was reported to be 'good' or 'very good' (95%) in 2008/2009, with no significant difference between boys and girls.
  • 69% of boys and 67% of girls were described as having 'very good' health; this declined with age and was lowest for those aged 14-15 (60% of boys and 53% of girls). The decline in 'very good' health was generally matched by a corresponding increase in children in 'good' health.
  • The proportion of children with 'good' or 'very good' general health was very similar in 1998, 2003 and 2008/2009. However, the proportion reporting 'very good' health as opposed to 'good' health appears to have increased over time, particularly for boys. In 1998 60% of boys had 'very good' health and 34% had 'good' health compared with 69% and 27%, respectively, in 2008/2009.
  • Four in ten adults (42% of women and 37% of men) reported having a long-standing physical or mental condition or disability in 2009. Women were also more likely than men to have a limiting long-term condition (27% and 23%, respectively).
  • The prevalence of limiting long-term conditions increased with age. 9% of men and 12% of women aged 16-24 had a limiting long-term condition compared with 58% of men and 55% of women aged 75 and over.
  • 24% of adults had one long-term condition while 16% reported having two or more. Just 3% of adults aged 16-24 had two or more long-term conditions compared with 37% of those aged 75 and over.
  • 15% of children aged 0-15 had a long-term condition; 9% were non-limiting, while 6% were limiting. Long-term conditions were more common in boys (17%) than girls (14%).
  • Children under 4 were the least likely to have a long-term condition. Rates were higher for boys aged 4 to 15 (between 17% and 25%), and for girls aged 12 to 15 (18%-19%).
  • In 2009, the mean scores on the Warwick-Edinburgh Mental Wellbeing Scale were 49.9 for men and 49.7 for women. These were not significantly different to the scores in 2008.
  • 8% of adults were assessed as having depression symptoms of moderate to high severity and 9% had anxiety symptoms of this level (measured using the Revised Clinical Interview Schedule). Women were more likely than men to have symptoms of moderate to high severity for both depression and anxiety.
  • The prevalence of depression and anxiety symptoms varied by socio-demographic group. Moderate to high levels of anxiety or depression were generally more common among people in lower supervisory and semi-routine and routine households, the lowest income households and those living in the most deprived areas in Scotland. These differences tended to be more pronounced among women.
  • 3% of women in the two highest income quintiles had depression symptoms of moderate to high severity compared with 27% of those in the lowest income quintile. Women in the most deprived 15% of areas were more than twice as likely to have depression symptoms of moderate to high severity as women in the rest of Scotland (20% versus 8%). The patterns for men were similar but with less steep gradients.
  • The majority of adults (96%) in Scotland reported that they had never attempted suicide, 1% reported a suicide attempt in the previous year while 4% said they had attempted suicide longer ago than this. Women were more likely than men to have ever attempted suicide (6% compared with 3%).
  • Men in lower supervisory and semi-routine and routine households were more likely than men in other household types to have attempted suicide, whereas women in managerial and professional households were less likely than women in other types to have done so. Suicide attempts were also more commonly reported by people in the lowest income households and in the most deprived areas.
  • The prevalence of deliberate self-harm was low; 3% of adults reported this (4% of women and 2% of men). Self-harm did not vary by household income or area deprivation for men or women, or by socio-economic classification among men. Women in intermediate and own account worker households (6%) were more likely to report self-harming than those in managerial and professional households (2%).
  • 51% of adults in paid employment or a government training scheme reported their job to be 'not at all' or 'mildly' stressful; 35% said it was 'moderately stressful' and 14% said it was 'very' or 'extremely' stressful. Men and women's assessments of job stress were not significantly different.
  • Social, emotional and behavioural problems in children aged 4-12 in 2008/2009 (measured via the Strengths and Difficulties Questionnaire) were more common in boys (7%) than girls (4%). 90% of children had no such problems while 4% were assessed as borderline. The proportion of children with these problems had decreased since 2003 (10% of boys and 7% of girls).
  • Children from semi-routine and routine households, the lowest income households and those living in the most deprived areas were the most likely to have social, emotional and behavioural problems. For example, just 1% of girls and 3% of boys in the highest income quintile had these problems compared with 10% in the lowest quintile.

1.1 INTRODUCTION

This chapter is in two parts. The first section looks at self-assessed general health and long-term conditions in adults and children. These are critical measures of the population's overall health status and key markers of health inequalities. 1 The second presents data on adult and child mental health and wellbeing. The following sets out the recent policy context for both these topics.

1.1.1 General health

As noted in the introduction to the general health and wellbeing chapter in the 2008 Report, 2 health features strongly within the Scottish Government's National Performance Framework. 3 Two of its national outcomes are: "we live longer, healthier lives" and "we have tackled the significant inequalities in Scottish society". The latter outcome is supported, in part, by a Ministerial Taskforce on health inequalities. 4 These outcomes underpin the following strategic objective:

Healthier: Help people to sustain and improve their health, especially in disadvantaged communities, ensuring better, local and faster access to health care

In turn, this objective supports the purpose 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

In addition to the objectives and outcomes set out above, the National Performance Framework also includes objectives, targets and indicators that relate specifically to children and young people. Much of the information collected in the survey relate directly to these. For example, the measures of children's physical health, mental wellbeing, and health-related behaviours such as diet and physical activity can be used to help assess the outcome "our children have the best start in life and are ready to succeed". By looking at results over time, the outcome "we have improved the life chances for children, young people and families at risk" can also be assessed. The Scottish Government's commitment to improving outcomes for children and young people has led to an increasing emphasis being placed on the early years, for example via the 2008 Early Years Framework published jointly with COSLA. 5 This emphasis not only aims to improve children's lives in the present, but it also explicitly acknowledges the evidence that outcomes in later childhood, and well into adulthood, are strongly linked to very early experiences. 6,7,8 The 2006 Getting It Right for Every Child programme also underpins the approach to child health, wellbeing and wider development that all agencies in Scotland are committed to follow. 9

1.1.2 Mental wellbeing

As well as addressing general health and long-term conditions, this chapter also reports a number of mental health and wellbeing measures. These include the prevalence of depression, anxiety, suicide attempts, self-harm and work-related stress in adults. It also looks at psychosocial health in children.

A new policy and action plan for mental health improvement in Scotland was launched on 7th May 2009: Towards a Mentally Flourishing Scotland ( TAMFS). 10 This policy and action plan outlines 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. The following Scottish Government national indicator is monitored using data on mental wellbeing collected in the survey:

Increase the average score of adults on the Warwick-Edinburgh Mental Wellbeing scale by 2011

The Government's Choose Life strategy includes a target to reduce the rate of suicide by 20% between 2002 and 2013. 11 The NHS is supporting this via a HEAT12 target to educate and train 50% of its frontline staff in suicide prevention awareness techniques by the end of 2010. By June 2009, 22% of staff in NHS Scotland had received such training. 13 Figures from the Registrar General for Scotland show that suicide rates increased in the 1980s and 1990s, but have followed by a downward trend since 2000, with a possible levelling off in recent years. 14

As part of its wider programme of action on improving mental health and wellbeing, 15 the then Scottish Executive commissioned NHS Health Scotland to "establish a core set of national, sustainable mental health indicators." 16 The resulting indicator set, published in 2007, is intended to allow national monitoring of adult mental health and the contextual factors (at the individual, community and structural level) associated with it. SHeS is the data source for 28 of the 54 indicators, 9 of which had been included in the survey previously while a further 19 were added in 2008. Many of the items reported in this chapter are drawn from these high level and contextual mental health and wellbeing indicators.

A parallel exercise to develop mental health indicators is also being conducted for children and they are due to be published in 2011. 17 As the only national survey covering children of all ages in Scotland, SHeS is likely to be used to as a baseline for some of the child mental health wellbeing indicators.

1.2 SELF-ASSESSED GENERAL HEALTH

1.2.1 Introduction

This section reports self-assessed general health for adults and children separately. All participants were asked to rate their health in general as either 'very good', 'good', 'fair', 'bad' or 'very bad'. For children aged 12 or under this question was asked of the parent completing the interview on the child's behalf and used the same answer options presented to those aged 13 and above.

This question is part of the adult mental health indicators set. The indicator is: "percentage of adults who perceive their health in general to be good or very good".

Responses are based on recall and as such are subject to distortion due to variations in individual perceptions. 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. 18,19

1.2.2 Self-assessed general health - adults

Self-assessed general health for adults remains unchanged from 2008. In 2009, 77% described their health in general as 'good' or 'very good'; one in six (16% of men and 17% of women) described it as 'fair' and 7% (8% of men and 7% of women) described it as 'bad' or 'very bad'.

As in previous reports, prevalence of self-reported good health declined with age and coincided with an increase in self-reported bad health. Nine in ten adults aged 16-24 described their health as 'good' or 'very good' compared with half (50% of men and 54% of women) of those aged 75 and over. Conversely, while almost no-one aged 16-24 assessed their health as 'bad' or 'very bad', 17% of men and 12% of women aged 75 and over did so. There was some fluctuation between 2008 and 2009 in how particular age groups assessed their general health, but there was no clear pattern in these relatively small differences. Table 1.1

1.2.3 Self-assessed general health - children

Note that the results for children reported here (and in the rest of the chapter) are based on the data from the 2008 and 2009 surveys combined. This combined dataset includes more child interviews and therefore provides greater accuracy for the figures for different age or socio-demographic groups.

Table 1.4 shows that most children's general health was reported to be 'good' or 'very good' (95%) in 2008/2009. There was no difference between boys and girls' general health, for example 69% of boys and 67% of girls were described as having 'very good' health.

Prevalence of 'bad' or 'very bad' health was very low across all age groups. The proportion of children reported as having 'very good' health declined with age. In boys, there was a linear decline from 75% in those aged 0-1, to 66%-67% of those aged 8 to 13, before a further decrease to 60% for those aged 14-15. The pattern for girls was broadly similar, though with a less consistent pattern. Around 7 in 10 girls aged 0-11 had 'very good' health, which decreased to 53%-57% for girls aged 12-15. These decreases with age could be caused by the change in respondent (from parent to child at age 13), or by developmental changes at the onset of adolescence. However, it should be noted that the decline in very good health was generally matched by a corresponding increase in children in 'good' health, rather than increasing levels of bad health.

Table 1.4 also includes results for self-assessed health in children in the 1998 and 2003 surveys. 20 While the proportion with 'good' or 'very good' general health changed very little over this period (94% in 1998, 92% in 2003 and 95% in 2008/2009) there was some evidence of an increase in the proportion reporting 'very good' health as opposed to 'good'. This was particularly true for boys, in 1998 60% of boys had 'very good' health and 34% had 'good' health. In 2008/2009 the equivalent figures were 69% and 27% respectively. Table 1.4

1.3 LONG-TERM CONDITIONS

1.3.1 Introduction

All participants were asked if they had any long-term conditions or disabilities that had affected, or were likely to affect them for at least twelve months (parents were asked this of children aged 0-12). Those who reported having such a condition were asked to say whether it limited their daily activities in any way so that conditions could be further classified as limiting or non-limiting. As the question did not specify that conditions had to be doctor-diagnosed, responses are subject to some distortion due to variation in individuals' perceptions.

This question is also part of the adult mental health indicators set. The indicator is: "percentage of adults who have a long-standing physical condition or disability".

1.3.2 Prevalence and number of long-term conditions - adults

As Table 1.2 shows, four in ten adults reported having a long-standing physical or mental condition or disability in 2009. The prevalence of long-term conditions in adults was the same in 2008 and 2009. Women were more likely than men to have a long-term condition (42% compared with 37%). Women were also more likely than men to have a limiting long-term condition (27% and 23%, respectively).

19% of adults aged 16-24 had a long-term condition, this rose steadily with age to 69% of those aged 75 and over. The association with age was stronger for limiting conditions than for non-limiting ones. For example, 9% of men and 12% of women aged 16-24 had a limiting long-term condition which increased sharply to 58% of men and 55% of women aged 75 and over. In contrast, non-limiting conditions ranged between 8% and 21% in men, and the rate in the oldest group was 12%. The same pattern was evident among women.

24% of adults had one long-term condition while 16% reported having two or more. The mean number of long-term conditions in 2009 was 1.6. There was no difference in the number of long-term conditions reported by men and women. As would be expected from the results discussed above, age was strongly associated with the number of conditions reported. Adults aged 75 and over were twelve times more likely than those aged 16-24 to have two or more long-term conditions (37% compared with 3%). The mean number also increased in line with age for both men and women. Table 1.2 and Table 1.3

1.3.3 Prevalence and number of long-term conditions - children

Long-term conditions were much less common in children than adults. 15% of children aged 0-15 had a long-term condition; 9% were non-limiting, while 6% were limiting. Boys were more likely than girls to report a long-term condition (17% compared with 14%); although small, this difference was statistically significant, and was accounted for by higher rates in boys than girls aged 4-11.

The prevalence of long-term conditions in children increased with age but with different patterns for boys and girls. For boys, long-term conditions were less common in the under 4 age group, and then ranged between 17% and 25% in those aged 4 to 15 (with the highest rate at age 8-9). Long-term conditions in girls were also lowest in the under 4s, and then were generally higher for those aged 4 to 11, before increasing to around 18%-19% for those aged 12 to 15. Table 1.5 , Figure 1A

Table 1.5, Figure 1A

1.4 ADULT MENTAL HEALTH AND WELLBEING

1.4.1 Introduction

In Scotland, a broad definition of mental health that encompasses both positive mental wellbeing and mental health problems has been adopted in policy circles and beyond. 21 The adult mental health indicators set was designed to include measures that allowed national monitoring of both wellbeing and mental health problems, as well as contextual factors associated with mental health. This section concerns all these aspects. It presents results from a number of measures, all of which were included in the survey for the first time in either 2008 or 2009. The first measure presented is based on the WEMWBS scale, 22 which is used as both a mental health indicator, and a National Performance Framework national indicator. WEMWBS comprises 14 positively worded statements with a five item scale ranging from '1 - None of the time' to '5 - All of the time'. The lowest score possible is therefore 14 and the highest is 70; the tables present mean scores.

The prevalence of anxiety and depression symptoms is explored using data collected in the nurse visit via a standardised instrument, the Revised Clinical Interview Schedule ( CIS-R). The CIS-R is a well-established tool for measuring the prevalence of mental disorders 23. The CIS-R comprises 14 sections, each covering a type of neurotic symptom and asks about presence of symptoms in the week preceding the interview. Prevalence of two of these neurotic symptoms - depression and anxiety - were introduced to the survey in 2008. Questions about suicide attempts and self-harm were also asked, and are reported below. Given the potentially sensitive nature of these topics, these questions were included in the nurse interview part of the survey. 24 Because only a sub-sample of adults was invited to participate in the nurse interview the results that follow are based on data from both 2008 and 2009. This allows for greater accuracy when figures are presented for different age or socio-demographic groups.

This section ends with some results about stress at work based on a new question introduced to the main interview in 2009, which will be repeated again in 2011.

1.4.2 WEMWBS mean score

The mean WEMWBS score for adults in 2009 was 49.8 (49.9 for men and 49.7 for women). The corresponding figures in 2008 were not significantly different, indeed they were identical for women. There was a significant association between age and mean WEMWBS scores, but there were no clear patterns. For example, men aged 45-54, and women aged 75 and over, had the lowest mean scores. Table 1.6

1.4.3 Prevalence of symptoms of depression and anxiety

The following two mental health indicators are reported here:

Percentage of adults who have a symptom score of 2 or more on the depression section of the Revised Clinical Interview Schedule

Percentage of adults who have a symptom score of 2 or more on the anxiety scale of the Revised Clinical Interview schedule

The majority of adults in 2008/2009 had a symptom score of zero for depression (89% of men and 84% of women) while 8% had a score of two or more, which is indicative of symptoms of moderate to high severity. Women were more likely than men to have a depression symptom score of two or more (10% compared with 7%), and this difference was statistically significant. Symptom scores for anxiety were similar to those for depression, 9% of adults had symptoms of moderate to high severity and, as with depression, prevalence was higher in women (10%) than men (7%).

The proportion of adults with a symptom score of two or more for depression or anxiety varied somewhat by age. The patterns appeared to differ for men and women, for example no men aged 16-24 had depression symptoms of moderate to high severity, whereas the prevalence of this among women was generally similar across all age groups and ranged from 9% to 12% (with one exception in the 64-75 age group, where it was lower at 5%). The equivalent pattern for anxiety symptoms of moderate to high severity by age was broadly similar to that for depression. However, it should be noted that the sample sizes for the youngest age groups are quite small so a fuller examination of the association with age should be conducted when the 2010 and 2011 data have been collected. Table 1.7

1.4.4 Prevalence of symptoms of depression and anxiety by socio-demographic characteristics

Tables 1.8 to 1.10 present the depression and anxiety symptom scores, including summary measures of moderate to severe symptoms, by socio-economic classification ( NS-SEC of the household reference person), equivalised household income and the Scottish Index of Multiple Deprivation (descriptions of each of these measures are available in the Glossary at the end of this volume). To ensure that the comparisons presented in this section are not confounded by the different age profiles of the sub-groups, the data have been age-standardised (age-standardisation is also described in the Glossary). Only age-standardised figures are presented in the tables.

Socio-economic classification

Men and women living in lower supervisory and technical, and semi-routine and routine households were more likely to report depression symptoms of moderate to high severity than those in the other two household types. For example, 9% of men and 15% of women in these households had depression symptoms of moderate to high severity compared with 5% of men and 7% of women in professional and managerial households. This was also true for anxiety in men (9% versus 5%). However, for women, rates of anxiety were similar in intermediate and own-account worker households (13%), and lower supervisory and technical, and semi-routine and routine households (12%) while those in managerial and professional households had a lower rate (8%). Table 1.8

Equivalised household income

Household income was associated with symptoms of both depression and anxiety, with prevalence highest among those in the lowest income households. The pattern was much more pronounced for women than for men. For example, 3% of women in the two highest income quintiles had depression symptoms of moderate to high severity, this then increased sharply to 27% of those in the lowest income quintile. In men, the rates ranged between 4% and 6% in the first three quintiles and were higher (10% and 11%) in the bottom two income quintiles. The patterns for anxiety symptoms were similar, but the gradient for women was much less steep (6%-8% in the first three quintiles compared with 17% in the lowest quintile had anxiety symptoms of moderate to high severity).

Although the patterns were similar for men and women, it is clear that the burden of depression and, to an extent, anxiety is greater for women in the lowest income households than it is for men in the lowest income households. Table 1.9

Scottish Index of Multiple Deprivation

Two measures of SIMD are being used throughout this report. The first, which uses quintiles, enables comparisons to be drawn between the most and least deprived 20% of areas and the intermediate quintiles. The second contrasts the most deprived 15% of areas with the rest of Scotland (described in the tables as the "85% least deprived areas").

As with NS-SEC and household income, there was some evidence of a relationship between area deprivation and prevalence of symptoms of both depression (Figure 1B) and anxiety (Figure 1C). For men, the association was only significant for anxiety symptoms. Women in the most deprived quintile were almost four times as likely as those in the two least deprived quintiles to have depression symptoms of moderate to high severity (19% versus 5% and 6%, respectively). Women in the most deprived 15% of areas were more than twice as likely to have this level of depression symptoms as women in the rest of Scotland (20% versus 8%). The patterns for anxiety symptoms were the same as those for depression symptoms for men and women, but with slightly less steep gradients (and men in the most deprived 15% of areas had similar rates of symptoms to those in the rest of Scotland).

As with household income, women in the most deprived areas experience a higher burden of moderate to high severity depression and anxiety symptoms than men in similarly deprived areas. In contrast, men and women in the least deprived areas have very similar rates. Table 1.10, Figure 1B, Figure 1C

Figure 1B

Figure 1C

1.4.5 Factors associated with depression or anxiety symptoms

Logistic regression was used to examine the factors associated with symptoms of moderate to high severity for depression or anxiety. Moderate to high severity was defined as a symptom score of two or more on either the CIS-R depression scale, the CIS-R anxiety scale, or both. The usual convention in SHeS reports is to run separate regression models for men and women. However, as the nurse sample size is still fairly small this analysis was run for all adults, with sex as one of the factors explored in the model. As the strength of the socio-demographic associations outlined above differed notably by gender, separate models should be run in future when a larger sample is available to further examine this topic. 25

The factors found to be significant were: sex, age, economic activity, marital status and equivalised household income. Household and parental NS-SEC, SIMD and educational attainment, were also explored but were not found to be significant.

Logistic regression compares the odds of a reference category (shown in the table with a value of 1) with that of the other categories. In this example, an odds ratio of greater than one indicates that the group in question is more likely to have depression or anxiety symptoms of moderate to high severity than the chosen reference category; an odds ratio of less than 1 means they are less likely. For more information about logistic regression models and how to interpret their results see the Glossary.

Sex was significantly associated with depression or anxiety symptoms of moderate to high severity. The odds of women having a symptom score of two or more were 1.6 times higher than for men.

Age was also significant. When compared with those aged 16-24, the odds of having a symptom score of two or more were significantly higher among those aged 35-44 and 45-54 (odds ratios of 3.3 and 3.5, respectively compared with those aged 16-24).

Compared with those in paid employment, self-employed or on a Government training programme, the odds of having moderate to severe depression or anxiety symptoms were significantly higher for people permanently unable to work because of ill health (odds ratio of 4.7), people who were either looking for, or intending to look for paid work (2.8), those who were retired (2.5), and those looking after the home or family (2.2). The small sample sizes for the unemployed and long-term sick groups mean that the confidence intervals around their odds ratios are quite wide.

Single people had higher odds of moderate to severe depression or anxiety symptoms than those who were either married or in a civil partnership (odds ratio of 1.9). The odds were also significantly higher for people who had previously been married/in a civil partnership but had since separated, divorced or had the partnership dissolved (1.7).

Overall, household income was significantly associated with having depression or anxiety symptoms of moderate to high severity, but the nature of the relationship was not clear. Table 1.11

1.4.6 Suicide attempts

In addition to being asked about symptoms of depression and anxiety, those who took part in the nurse visit were also asked whether they had ever attempted to take their own life. The question was worded as follows:

Have you ever made an attempt to take your own life, by taking an overdose of tablets or in some other way?

Those who said yes were asked if this was in 'the last week, in the last year or at some other time.' Table 1.7 differentiates between attempts that took place in the 12 months preceding interview and those that happened longer ago. Note that this question is likely to underestimate the prevalence of very recent attempts as people might be less likely to agree to take part in a survey immediately after a traumatic life event such as this.

Table 1.7 shows that the majority of adults (96%) in Scotland reported that they had never attempted suicide. One percent reported a suicide attempt in the previous year while 4% said they had done so longer ago than this. Women were more likely than men to have ever attempted suicide (6% compared with 3%) and this difference was significant.

Among men, only two age groups (45-54 and 75 and over) contained someone who had attempted suicide in the previous year (1% in both groups). 2% of women aged 16-24, and 1% aged 25 to 54, reported this, while no women aged 55 and over did so. There was more variation by age when all those who had ever attempted suicide were considered, although this was only true among women (because fewer men had ever attempted suicide). Although differences were small overall, women in the two oldest age groups were the least likely to report a suicide attempt. This might reflect a difference in behaviour in older age groups, or it could be that older generations are less comfortable disclosing information such as this than are their younger counterparts. Table 1.7

1.4.7 Suicide attempts by socio-demographic characteristics

Tables 1.8 to 1.10 also present the prevalence of all suicide attempts by NS-SEC, equivalised household income and SIMD. Despite the low overall prevalence in suicide attempts, there was some evidence of differences by socio-demographic characteristics. Attempts in the previous year were considered too rare to be compared in this way so this section focuses on the proportions that have ever attempted suicide.

Socio-economic classification

With NS-SEC, 6% of men in lower supervisory and technical, and routine and semi-routine households had ever attempted suicide compared with 2% and 1% of those in the other two household types. Among women, 3% of those in professional and managerial households had ever attempted suicide but the rates were higher (8% and 7% in the two other household types. Table 1.8

Equivalised household income

The relationship between suicide attempts and equivalised household income generally showed a linear pattern with the proportion reporting ever attempting suicide increasing in line with household income. 1% of adults in the highest income quintile had ever attempted suicide compared with 10% of men and 15% of women in the lowest quintile. Table 1.9

Scottish Index of Multiple Deprivation

There was also some evidence of a relationship between area deprivation and suicide attempts with people living in more deprived areas more likely to have ever attempted suicide than those in the least deprived areas. The pattern was a little clearer for men than women. No men living in the least deprived quintile said they had ever attempted suicide, in contrast 8% of those in the most deprived quintile had. The corresponding rates for men in the most deprived 15% of areas and the rest of Scotland showed a slightly smaller difference (8% versus 2%, respectively). While the proportion of women in the most deprived quintile that had ever attempted suicide (10%) was higher than in the three least deprived quintiles (3%-5%) the difference was not as big as was the case with men. Similarly, the difference in the rates of ever attempting suicide was smaller between the 15% most deprived areas and the rest of Scotland (10% and 5%, respectively). Table 1.10

1.4.8 Deliberate self-harm

Participants in the nurse visit were also asked whether they had ever deliberately harmed themselves 'but not with the intention of killing themselves'. Again, as Table 1.7 shows, prevalence of deliberate self-harm was low with 3% of adults reporting this (4% of women and 2% of men). For men, deliberate self-harm varied across age groups with no obvious pattern and was highest for those aged 35-44 (5%). The pattern was a little clearer for women: prevalence was greatest among those aged 16 to 34 (7%) and then declined to less than 1% from 65 onwards. Table 1.7

There was a significant association between NS-SEC and deliberate self-harm (Table 1.8). The figures for men did not vary, but women in intermediate and own account worker households (6%) were more likely to report self-harming than those in managerial and professional households (2%) Table 1.8

Although men in the two lowest household income quintiles had the highest rates of self-harm (4% and 3%) compared with 1% in the other groups, these differences were not statistically significant. Sample size could be an in issue here. There was no significant association between deliberate self-harm and area deprivation for men or women. Table 1.9 and Table 1.10

1.4.9 Stress at work

The 2009 survey included a series of questions on working life from the adult mental health indicators set. As work is considered to be an important contextual factor associated with mental health, adults in paid employment or on a government training scheme were asked questions about their job, including the following one about stress at work:

Some people tell us that their jobs are stressful. In general, how do you find your job?

Answer options ranged from 'not at all stressful' to 'extremely stressful'. Table 1.12 shows that 51% of adults in paid employment or a government training scheme reported their job to be 'not at all' or 'mildly' stressful'; 35% said it was 'moderately stressful' while 14% considered they had a 'very' or 'extremely' stressful job. Men and women's assessments of job stress were not significantly different.

Assessments of stress at work varied by age, though note that the sample sizes for those aged 16-24 are quite small (as many in this age group were in education rather than work). Men aged 35 to 54 and women aged 45 to 64 were more likely to say their job was stressful than those in other age groups. Table 1.12

1.5 PSYCHOSOCIAL HEALTH IN CHILDREN

1.5.1 Introduction

Children's social, emotional and behavioural development was measured via the Strengths and Difficulties Questionnaire ( SDQ) 26 in both 2003 and 2008/2009. The SDQ is a brief behavioural screening questionnaire designed for use with the 3-16 age group. The SDQ was completed by a parent on behalf of all children aged 4-12.

The SDQ comprises 25 questions covering themes such as consideration, hyperactivity, malaise, mood, sociability, obedience, anxiety, and unhappiness. It is used to measure five aspects of children's development: emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems and pro-social behaviour.

A score was calculated for each of the five aspects, as well as an overall 'total difficulties' score which was generated by summing the scores from all the domains except pro-social behaviour. The total difficulties score ranged from zero to forty with a higher score indicating greater evidence of difficulties. There are established thresholds indicating 'normal' (score of 13 or less), 'borderline' (14-16) or 'abnormal' scores (17 or above). Much of the discussion in this section focuses on the total difficulties score. It looks at patterns by age and sex, compares scores in 2003 and 2008/2009, and looks at scores by socio-demographic characteristics.

1.5.2 SDQ scores by age and sex

The majority (90%) of children aged 4-12 had a normal total difficulties score on the SDQ and the mean score was 7.1. The proportion of boys and girls with normal scores were very similar, however boys were slightly more likely than girls to have an abnormal score (7% compared with 4%). The mean total difficulties score was also higher in boys (7.6) than girls (6.7). These gender differences in abnormal and total mean scores were significant and are consistent with other published studies. 27

Boys and girls had similar scores for emotional symptoms, peer problems and pro-social behaviour. At all ages, boys had significantly higher abnormal scores than girls for hyperactivity (18% versus 7%), and conduct problems (13% versus 9%).

There were some fluctuations in SDQ scores with age. Boys and girls aged 4-5 had a lower mean score for total difficulties than those aged 6-12, and were also less likely to have an abnormal total difficulties score. For example, 8% of boys and 5% of girls aged 10-12 had an abnormal total difficulties score compared with 2% of boys and 1% of girls aged 4-5.

The increase with age in abnormal scores was not uniform across all five domains of the SDQ. For example, abnormal pro-social behaviour and hyperactivity did not increase notably with age, though hyperactivity in boys hit a peak of 23% in the 8-9 age group. The pattern for conduct problems appeared to follow different directions for boys and girls. Boys aged 4-5 were at least half as likely as older boys to have an abnormal score in this domain whereas the youngest and oldest girls had similar rates. Table 1.13

1.5.3 SDQ scores in 2003 and 2008/2009

Table 1.13 also shows the 2003 SDQ scores for children. The mean score for all children was lower in 2008/2009 than 2003 (7.1 versus 8.2). This was true for both boys (7.6 versus 8.6) and girls (6.7 versus 7.8). The proportion of children with abnormal total difficulties scores has also declined since 2003, from 9% to 5% (from 10% to 7% for boys, and 7% to 4% for girls). It is difficult to interpret trends from a table with just two time points as the estimate for a particular year may be an outlier at the extreme of the sampling distribution. The 2010 and 2011 data will help to assess whether this represents a genuine improvement in children's psychosocial health over time. Table 1.13

1.5.4 SDQ scores by socio-demographic characteristics

Tables 1.14-1.16 present the mean total difficulties scores, and the percentage of children with abnormal scores, in 2008/2009 by NS-SEC, household income and SIMD.

Socio-economic classification

NS-SEC was significantly associated with abnormal total difficulties scores. Boys living in semi-routine and routine households were more likely than those in all the other household types to have an abnormal total difficulties score (11% compared with 3%-6%). Mean total difficulties scores were also significantly higher in boys in semi-routine and routine households. The pattern was similar for girls, with higher prevalence of abnormal scores (7% compared with 1-2% of girls living in other household types), and higher mean scores, found in those living in semi-routine and routine households, and lower supervisory and technical households. Table 1.14

Equivalised household income

There was a significant association between household income and total difficulties scores. Both the mean total difficulties score, and the proportion of children with abnormal scores, increased as household income decreased. For example, 10% of boys and girls in the lowest income quintile had an abnormal score compared with just 3% of boys and 1% of girls in the highest. Table 1.15, Figure 1D

Figure 1D

Scottish Index of Multiple Deprivation

There was also a significant association between area deprivation and total difficulties scores, and this was particularly apparent among boys. As deprivation increased, mean total difficulties scores and the proportion of children with borderline or abnormal scores increased. For example, just 1% of boys living in the least deprived quintile had an abnormal total difficulties score compared with 13% in the most deprived quintile. The corresponding pattern for girls was less clear as the rates were highest in the middle and lowest quintiles (7% and 5%). However, looking at abnormal and borderline rates for girls combined, there was a clear increase in total difficulties scores in line with increasing deprivation.

The association was confirmed when the scores of children living in the 15% most deprived areas were compared with those in the rest of Scotland. Again, the gap was greater for boys than for girls, and the difference in girls' borderline scores was also notable. Boys in the 15% most deprived areas were 3 times as likely as those living elsewhere to have an abnormal total difficulties score. Table 1.16