Quality Assurance report - Health, disability and unpaid care

Background

This report accompanies the publication of Scotland’s Census 2022 health, disability and unpaid care topic data. It builds on the quality assurance reports published so far.  

Information on imputation rates for this topic have also been published on the Scotland’s Census website.   

Topic expert quality assurance panels 

We invited analytical colleagues from the Scottish Government to participate in quality assurance panels on the health data. Panel sessions assessed the coherence of 2022 Census statistics with previously published census estimates for Scotland, England & Wales and Northern Ireland as well as with other available data on the topics. The panel concluded that there were no remaining quality concerns which required investigation before publication. 

Age-standardisation 

Age is a risk factor in health outcomes, as many illnesses/conditions occur more frequently as people get older. Age-Standardised Percentages (ASPs) allow for comparisons to be made in health outcomes between populations living in different geographical areas and over time that may contain different age structures. ASPs adjust observed rates for a health outcome (e.g. disability) to a standard population with a known age structure. This means that the populations being compared are adjusted to have the same age structure as the standard population, accounting for any differences in their age structure. ASPs therefore allow for comparisons to be made using a single figure which accounts for different age structures, without the need to present and compare age-specific percentages. 

For example, Aberdeen City has a slightly higher raw percentage (observed count/population) of people with very good general health at 49.2% than Na h-Eileanan Siar at 48.7%. However, Aberdeen City has an ASP of 48.2%, lower than the ASP of 53.5% for Na h-Eileanan Siar. The raw percentage implies that the populations in both local authorities have similar health experiences/outcomes. Presenting the ASPs allows us to both identify the difference in health outcomes between Aberdeen City and Na h-Eileanan Siar and to say that this difference is due to prevalence of people with a very good general health, rather than a difference in the age of their populations.  

More information on the method used to produce age-standardised estimates for this topic are available on the Scotland’s Census website. 

Please note that some data in this report are not age-standardised because it was not possible to age-standardise published estimates from the Scottish Health Survey (SHeS) and Scottish Survey Core Questions (SSCQ). The age structure of the 2013 European Standard Population and Scotland’s population are very similar so any conclusions would be unlikely to change if age-standardised data were used.  

Quality information  

General health 

Individuals are asked to self-assess their health by answering the question ‘How is your health in general?’ with the response options very good, good, fair, bad and very bad. Scotland’s Census took place in March 2022 when there were limited COVID related restrictions in place outside of health and social care settings. The impact of the pandemic may still have influenced people's perception of their health. The England & Wales and Northern Ireland censuses took place a year earlier, in a different phase of the pandemic when more restrictions were in place. Users should consider this when comparing results across the UK. 

The Scottish Health Survey (SHeS) is an annual survey investigating the health of individuals living in private households. The survey topics vary year to year but always include questions on general health, unpaid care and long-term conditions. The adult responses contribute to the Scottish Survey Core Questions (SSCQ) dataset which aggregates survey responses to a set of core questions asked in the SHeS, the Scottish Household Survey and the Scottish Crime & Justice Survey. 

The census data on general health can be compared with both the SHeS and the SSCQ for people aged 16 and over only. The SHeS (28%) and the SSCQ (30.1%) have lower estimates of people in very good health compared with 41.0% in census. Combining very good/good health, the survey estimates are more similar to census, with 70% in SHeS and 72.1% SSCQ, compared with 75.2% in census (Figure 1). Note that these data are not age-standardised. 

The differences between the census and these sources may be partially due to the fact that the surveys are interviewer-led, so individuals can ask for clarification if any question is unclear. The SHeS also focusses exclusively on health meaning individuals are thinking deeply about their health when answering questions, rather than moving through a range of topics quickly whilst filling in the census. Indeed, among the three surveys that make up the SSCQ dataset, the SHeS consistently estimates poorer health than the other two surveys and this is attributed to the survey topic.  

Unpaid Care 

The data on unpaid care are broadly comparable between Scotland, England & Wales and Northern Ireland, although there were some small differences in the question and options included on the questionnaire that users should note when comparing results. 

In Scotland, the question asked was ‘Do you look after, or give any help or support to family members, friends, neighbours or others because of either: 

• long-term physical / mental ill-health / disability; or  

• problems related to old age?’

This wording was slightly different to England & Wales and Northern Ireland, where the following question was asked: ‘Do you look after, or give any help or support to, 

anyone because they have long-term physical or mental health conditions or illnesses, or problems related to old age?’ 

In Scotland and Northern Ireland, the following response options were presented: 

• No 

• Yes, 1 to 19 hours a week 

• Yes, 20 to 34 hours a week 

• Yes, 35 to 49 hours a week 

• Yes, 50 or more hours a week 

In England and Wales, the options were the same except instead of the ‘Yes, 1 to 19 hours a week’ category the following options were presented: 

• Yes, 9 hours a week or less 

• Yes, 10 to 19 hours a week 

For people aged 16 and over, census estimates for the provision of unpaid care in census (13.5%) is lower than those in the 2022 SHeS (16%) and SSCQ (19.3%). As mentioned in the general health section, there are reasons that may explain these differences. In addition, we see the largest difference between census and the survey estimates is in the category 0-19 hours of care provision (Census 2022: 55% of people providing some unpaid care, SHeS 2018-2022: 69% of people providing some unpaid care), whereas estimates for provision of more substantial care are similar between the two sources. SHeS has an additional category of 0 to 4 hours of care; almost half of the 69% providing 0-19 hours are in this category (48%). This additional category may capture small acts of care (e.g. bringing in someone’s shopping) and likely contributes to the higher overall estimate for care provision in the SHeS.  

Long-term health conditions 

For long-term conditions, the census asked people ‘Do you have any of the following, which have lasted, lasting or are expected to last, 12 months or more?’ and respondents tick which conditions they have from a list of nine options or fill in a write-in box which gets coded to one of the nine groups of conditions.

Scotland's Census 2022 long term health conditions question: Do you have any of the following which have lasted or are expected to last at least 12 months? (Tick all that apply)

• Deafness or partial hearing loss
• Blindness or partial sight loss
• Full or partial loss of voice or difficulty speaking (a condition that requires you to use equipment to speak)
• Learning disability (a condition that you have had since childhood that affects the way you learn, understand information and communicate)
• Learning difficulty (a specific learning condition that affects the way you learn and process information)
• Developmental disorder (a condition that you have had since childhood which affects motor, cognitive, social and emotional skills, and speech and language)
• Physical disability (a condition that substantially limits one or more basic physical activities such as walking, climbing stairs, lifting or carrying)
• Mental health condition (a condition that affects your emotional, physical and mental wellbeing)
• Long-term illness, disease or condition (a condition, not listed above, that you may have for life, which may be managed with treatment or medication)
• Other condition, please write in:
• No condition

The long-term conditions question changed between 2011 and 2022 with the addition of a new tick box to cover conditions involved with speech difficulty or loss of speech. In addition, following extensive consultation with users, descriptions were added to each category to provide a clear definition for each condition (Figure 2). If required, individuals could also access lists of the specific conditions that went into each category in additional question guidance. These changes halved the number of write-in responses provided in 2022 compared with 2011. 

Respondents could tick multiple conditions on the questionnaire, meaning people with multiple conditions are counted in the relevant category for each condition they have. This means that users should not sum categories together to get a total for people with a long-term health condition. 

The census question on long-term conditions included tick boxes for learning disabilities, learning difficulties and developmental disorders. However, there were changes to how these three conditions were presented on the census form in 2022 compared to 2011. We are doing additional work to understand the impact of these changes and will provide an update later in the year. This has also affected data on the number of long-term conditions, which we will also not be releasing at this time. 

Disability and health problems which limit day-to-day activities

Data on disability are collected by asking all people ‘Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months?’. This question is unchanged from 2011 and the data are comparable with previous censuses. 

105,800 people (1.9%) indicated they had no long-term health condition, but activities were limited by a health problem or disability. This is similar to 2011 when this figure was 2.0%. Data users should note this when comparing census data on disability with other sources. 

In Scotland, 24.1% of people had a disability using this definition, slightly lower than 25.6% of people in Northern Ireland. Data are not comparable with England & Wales because their census had two linked questions about long-term conditions and disability. A lower percentage had a disability in England & Wales at 17.8%. Only individuals with a long-term condition were asked the disability question. Whereas in Scotland and Northern Ireland, the questions on long-term conditions and disability were unlinked and were both asked of everybody.