Joanne McLean, Lisa Rutherford and Victoria Wilson
As a study of public health, the Scottish Health Survey (SHeS) plays an important role in assessing health outcomes and challenges in Scotland. With aims to reduce health inequalities and improve Scotland’s life expectancy status, currently one of the lowest in Western Europe (including in the UK), improving the health and wellbeing of Scotland’s population continues to be a key policy focus both at local and national level.
In 2018, the Scottish Government launched six inter-related public health priorities designed to improve the health of the population and reduce health inequalities. These priorities were accompanied by the publication of a revised National Performance Framework (NPF) which covers the eleven National Outcomes that help to describe the kind of Scotland the Framework aims to create. The NPF also links with a number of the United Nation’s Sustainable Development Goals and helps to measure progress towards the NPF vision for Scotland, including that ‘we are healthy and active’.
The context for public health in 2020 presented unique and unprecedented challenges with the emergence of the COVID-19 pandemic. Flexible, fast-paced and responsive health guidance and initiatives were required given the continuously changing circumstances and developing scientific understanding of the virus. This was guided by the Chief Medical Officer and through liaison with the governments within the UK, the World Health Organisation (WHO) and the international community, both following the initial nationwide lockdown and during the subsequent route map out of lockdown as restrictions were eased or reintroduced as necessary.
COVID-19 has resulted in unprecedented disruption to healthcare services and life in general. All areas of society have been affected as individuals, teams and communities have had to adapt to meet these new challenges. Many services have been necessarily paused, stepped down or have undergone significant reconfiguration during the period of the COVID-19 pandemic. While safe and incremental resumption of many of these services began over the summer period, the resurgence in cases over the autumn alongside the concurrent risks associated with winter have meant that the balance between COVID and non-COVID services has had to be kept under constant review, with a need to measure restarting paused services against the need to keep the virus under control.
The Scottish Government is following an evidence-based, cautious and phased approach to achieving that balance and re-mobilising NHS services, working closely with Health Boards and their partners to minimise the impact on patients going forward while also being able to respond to ongoing COVID-19 requirements as necessary.
The effects of the COVID-19 pandemic are likely to be felt for some time, not only in relation to physical health but also mental and emotional wellbeing, as well as existing health inequalities. In such a context, continuing to collect data on the health of Scotland’s population remained paramount. However, the circumstances of lockdown and associated physical distancing requirements meant that an alternative way of sourcing such information was needed than the face-to-face approach previously used. As such, the decision was taken to collect data for key measures from SHeS via a telephone survey, whereby potential respondents aged 16 and over were contacted by letter and asked to opt-in to an interview conducted over the phone. No interviews were conducted with or about children aged 15 and under.
At the time of interviewing (5th August to 23rd September 2020) COVID-19 cases had reduced after the first wave of the pandemic and restrictions relating to time outside of the home, social interactions and businesses that could open had been eased. Those previously advised to shield had been told they no longer had to from 1st August.
This shorter SHeS 2020 telephone survey was undertaken in order to capture data on key survey measures as quickly as possible and to add to the growing evidence base on public health during the pandemic. Of particular interest were the national indicators relevant to health including:
Each of the chapters included in this volume addresses an aspect of health that relates either directly or indirectly to the Scottish Government’s objective that ‘we are healthy and active’.
The accompanying technical report for the SHeS 2020 telephone survey provides further information on the method used for this survey. While every effort was made to retain questions that were consistent with the face-to-face surveys as far as possible, it should be noted that due to a change in the mode used to collect the data (from face-to-face to telephone collection) and the shorter data collection period (August – mid September 2020), this data is not directly comparable with the previous findings from face-to-face SHeS surveys. It is, however, a useful snapshot into the health of the population during the COVID-19 pandemic and a useful exercise in aiding the development of the SHeS approach for data collection in 2021
The SHeS Series
SHeS has been carried out annually since 2008 and prior to this was carried out in 1995, 1998, and 2003. Fieldwork for SHeS 2020 (the sixteenth face-to-face survey in the series) was suspended towards the end of March 2020 as the UK went into a nationwide lockdown at the outset of the COVID-19 pandemic.
Commissioned by the Scottish Government Health Directorates, the SHeS series aims to provide regular information on aspects of the public’s health and factors related to health which cannot be obtained from other sources. The specific aim of the telephone survey was to provide national level data on health, health conditions and the prevalence of certain risk factors associated with these health conditions for adults over a specified period of time during the COVID-19 pandemic.
The SHeS 2020 telephone survey methods differ from the usual SHeS methods in a number of ways which are likely to impact the responses received and so affect comparability with previous SHeS data. For more information on the questions and measures covered by the SHeS series using the face-to-face approach, see the SHeS 2019 Technical report.
The SHeS 2020 Telephone Survey
The SHeS 2020 telephone survey was undertaken by ScotCen Social Research. Due to the testing of a new methodology for SHeS (already a well-established survey programme) within the context of the COVID-19 pandemic, the survey results in this report are presented as experimental statistics. This means that the survey reported upon was in a testing phase and that users should be aware of the mode differences and potential impact on results (see individual chapters and section 1.1.4 in the technical report for more detail).
Analysing and publishing this experimental statistics allows the method and data reported to be evaluated for its suitability as a potential method for use in the future and an assessment to be made on whether the survey vehicle delivers data that meets the needs of the Scottish Government and other users of the SHeS data, particularly in light of ongoing restrictions related to the COVID-19 pandemic.
The results of the telephone survey are not directly comparable to SHeS results for previous years for three main reasons. Firstly, the difference between levels of response by deprivation was greater than usual, with fewer people in deprived areas taking part than is usually the case. The survey weighting was amended to adjust for this as far as possible but the indication is that there were an insufficient number of interviews amongst the very deprived to make the results fully representative. Hence, for some indicators that are generally higher in deprived areas it is possible that the telephone survey results may underestimate true prevalence.
The second reason is that some of the more sensitive questions in the survey (such as those on mental health, food insecurity and loneliness) are usually included in a self-completion form which participants complete themselves rather than the interviewer asking the questions. Self-completion formats may illicit a more accurate response from some participants who feel more comfortable answering sensitive questions privately. Hence, for these indicators the telephone survey may less accurately reflect true prevalence (see Volume 2: Technical Report for more information).
Lastly, the short data collection period, selected to facilitate rapid data collection, means that it was not possible to monitor changes in indicators that can occur as a result of seasonality or whether changes occurred as restrictions have been eased or reintroduced.
The SHeS 2020 Telephone Survey was intended to provide a snapshot of the health of Scotland’s population, both physical and mental, during a short period within the COVID-19 pandemic. The questionnaire was shorter than the usual SHeS survey and, as such, the scope of the survey was broad rather than permitting a detailed focus on particular topic areas. In addition to interest in general health, long-term conditions and health risk behaviours, mental health (including social capital and loneliness) has also been a topic of particular interest throughout the pandemic and in turn, featured in the SHeS 2020 telephone survey. Cardiovascular disease (CVD) and related risk factors (smoking, poor diet, lack of physical activity, obesity and alcohol use) remained a key focus of the survey, as covered in chapters 4-7. The main components of CVD are ischaemic heart disease (or coronary heart disease) and stroke, both of which are clinical priorities for the NHS in Scotland[14,15].
The other chapters in this report focus on health conditions and experiences which have the potential to influence health outcomes in the short-term and in later life - general health, long-term conditions and caring (Chapter 1), mental wellbeing (Chapter 2), social capital and loneliness (Chapter 3) and dental health (Chapter 8).
It is important to note that the data presented in this report is for a short period in 2020 and that it was not possible to capture data at the very start of the lockdown period when restrictions were at their most wide-ranging.
The Scottish Health Survey series was designed to yield a representative sample of the general population living in private households in Scotland every year. Due to the opt-in approach for the telephone survey (see Fieldwork), achieving a representative sample was harder to control for. See sections 1.6.4 and 1.7 of the technical report for more information on variations in the sample profile and the weighting approach used to attempt to adjust for these differences.
In line with annual surveys in the series, a random sample of addresses (11,000 addresses) was selected from the Postcode Address File (PAF), using a multi-stage stratified design. The number of addresses in the sample was more than would usually be sampled for a survey of this length as it was estimated that the response rate would be lower when using an opt-in method. Participating households included in the survey were those from which a respondent or respondents contacted ScotCen to opt in to taking part. All adults aged 16 and over within these opt-in households were also given the opportunity to take part once initial telephone contact had been made.
As for the Scottish Health Survey in previous years, those living in institutions were outwith the scope of the survey. This should be borne in mind when interpreting the survey findings as respondents living in these settings are more likely to be older and, on average, in poorer health than those in private households.
A letter stating the purpose of the survey was sent to each sampled address inviting all adults aged 16 and over to opt in to the telephone survey, either via an online portal, by email or by calling the survey freephone number. An interviewer from ScotCen then contacted, by telephone, those who opted in to complete the interview. Any adult living in a household where someone opted in to take part was eligible to participate. As a thank you, each participating adult received a £10 Love2Shop gift voucher.
Interviewing was conducted using Computer Assisted Telephone Interviewing (CATI), where the questionnaire answers were input directly to a laptop. The content of the interview and full documentation are provided in the accompanying technical report.
Towards the end of the interview self-reported height and weight measurements were taken from those who were willing to provide them. Unlike the face-to-face survey (where blood pressure, waist circumference and saliva samples are taken for a subset of the adult sample), no interviewer-administered biological measurements were taken as part of the telephone survey.
Between 5th August 2020 and 23rd September 2020, interviews were conducted with 1,920 adults (aged 16 and over) across 1,384 households. Although the issued sample was much larger than for the usual face-to-face surveys to allow for the lower levels of response generally achieved by opt-in surveys, response levels were particularly low for those living in the most deprived areas and amongst younger adults. Further details on survey response are presented in the technical report.
Ethical approval for the 2020 SHeS telephone survey was obtained from the Research Ethics Committee (REC) for Wales (reference number 17/WA/0371). Approval was sought from REC Wales as this is the Committee which approved SHeS under the current contract.
Since addresses and individuals did not all have equal chances of selection and respondents self-selected by opting in to the survey, the data had to be weighted for analysis. A detailed description of the weights is available in the accompanying technical report.
Weighted and unweighted data and bases in report tables
All data in the report are weighted. For each table in the report both weighted and unweighted bases are presented. Unweighted bases indicate the number of participants involved. Weighted bases indicate the relative sizes of sample elements after weighting has been applied.
Standard analysis variables
As in all previous SHeS reports, data for men and women are presented separately where possible. Survey variables are tabulated by age groups and where possible, by other questions in the survey. This includes presentation of several key indicators by whether or not respondents had received a letter/text advising them to shield. The age profile of the shielding group is generally older and the majority of people in this group have at least one long-term condition. This should be borne in mind when comparing results with those for people who have not received a shielding letter or text.
The SHeS 2020 telephone survey used a stratified multi-stage sample design. In addition, weights were applied when obtaining survey estimates. One of the effects of using the complex design and weighting is the standard errors for the survey estimates are generally higher than the standard errors that would be derived from an unweighted simple random sample of the sample size. The calculations of standard errors shown in tables, and comment on statistical significance throughout the report, have taken the stratifications and weighting into account. Full details of the sample design and weighting are given in the technical report.
Presentation of results
Commentary in the report highlights differences that are statistically significant at the 95% confidence level. Statistical significance is not intended to imply substantive importance. A summary of findings is presented for each chapter, along with a visual infographic summary. A description of the methods and key definitions can be found in the accompanying technical report. A link to the tables showing the results discussed in the text is included at the end of each chapter.
Due to the change in mode of administration and the different approach to sampling, no trends have been presented in this report since data collected in these different ways are not directly comparable. See section 1.1.4 of the technical report for more information on the differences in survey modes that are likely to impact on the responses received and comparability with previous SHeS data.
Availability of further data and analysis
As with surveys from previous years, a copy of the SHeS 2020 telephone survey data will be deposited at the UK Data Archive.
Content of this Report
This volume contains chapters with a summary of results from the SHeS 2020 telephone survey, and is one of two volumes based on the survey, published as a set as ‘The 2020 Scottish Health Telephone Survey’:
Volume 1: Main Report
1. General Health, Long-term Conditions & Caring
2. Mental Wellbeing
3. Social Capital & Loneliness
4. Diet, Obesity & Food insecurity
5. Physical Activity
8. Dental Health
Volume 2: Technical Report
Volume 2 includes a description of the survey methods including: survey design and response and sampling and weighting procedures.
Both volumes are available on the Scottish Government website.
References and notes
1. Scottish Government: Population Health Directorate. Health improvement. [Online].
2. Scottish Government: Population Health Directorate. Scotland’s Public Health Priorities. [Online].
4. United Nations (2015). Transforming Our World: The 2030 Agenda for Sustainable Development. [Online].
5. Scottish Government. Coronavirus in Scotland. [Online].
6. Scottish Government (2020). Coronavirus (COVID-19): Scotland’s route map through and out of the crisis. Edinburgh.
7. Coronavirus (COVID-19): Scotland’s route map. Edinburgh: Scottish Government (2020).
10. Dong W and Erens B. The 1995 Scottish Health Survey. Edinburgh: The Stationery Office. 1997.
11. Shaw A, McMunn A and Field J. The 1998 Scottish Health Survey. Edinburgh: The Stationery Office. 2000.
12. Bromley C, Sproston K and Shelton N [eds]. The Scottish Health Survey 2003. Edinburgh: The Scottish Executive. 2005.
13. McLean, J and Wilson, V [eds]. The Scottish Health Survey 2019 edition: Volume 2 Technical Report. Edinburgh: The Scottish Government. 2020.