Information About the People of Fife

Public Health 2011/12

The Annual Report of the Director of Public Health

1 2 INTRODUCTION

This is my third report as Director of Public Health. This year’s report is shorter than my previous two where I set out the scope and domains used when considering the health of the public in Fife.

The main function of this year’s report is to maintain oversight of the public’s health by scrutinising information that may have a bearing on the health of the population.

The main chapter of the report considers recent surveys relating to reported behaviours that are known to have an effect on health. Alongside the regular reporting of trends in deaths, the report presents information on behaviours known to contribute to health and disease taken from the first four year period (2008-2011) of the new Scottish Health Survey. The survey for adults indicated higher levels of drinking alcohol above recommended limits and over a third of the adult population only undertaking a low level of physical activity. Smoking remains higher in Fife than in the Scottish population.

Another important survey that monitors health behaviours in young people is the 2010 Scottish Adolescent and Lifestyle and Substance Use Survey (SALSUS). This report found that 52% of 13-year olds had taken an alcoholic drink with more than half of 13-year olds and three-quarters of 15-year olds, who drank alcohol, reporting having been drunk.

However there are positive indicators of change with Scottish trend data showing a fall in alcohol consumption and Fife smoking rates continuing to fall.

A major policy concern in Scotland relates to the growing proportion of the population exceeding normal weight range and being classed as overweight or obese. This is a rising epidemic that is not expected to reduce until the late 2020s.

The second chapter relates to issues around teenage pregnancy, particularly to young girls under 16 years of age. Fife has had a persistently higher rate and this has been the subject of consideration at both the Fife Health Board and the Fife Community Planning Partnership. The reasons are complex and parents and carers have a crucial role. From the public service, a response requires coherent partnership working between health, social services, youth work and, of particular importance, is the provision of appropriate advice and education in schools through relationship and sexual health education.

The report also includes a detailed review of pharmaceutical services in Fife and the regular review of the Health Protection function.

DR EDWARD COYLE Director of Public Health NHS Fife

December 2012

3 4 CHAPTER 1 HEALTH INTELLIGENCE

Understanding the size of the population in Fife, its composition, patterns of births and deaths, the occurrence of disease and factors that influence health such as health behaviours provides the basis for improving health and wellbeing and reducing health inequalities. Health intelligence makes the most of the data we have available in Fife from routinely collected data as well as surveys to ensure we have robust information to assess the current situation, look at past trends and make judgements about future projections.

Population

The population of Fife continues to grow with an estimated 367,292 individuals living in the Fife Health Board area at June 2011.1 This represents an increase of 2,347 persons since June 2010 which is equal to the national annual growth rate of 0.6%.1

The median age of Fife residents is 41 years. 18% of the Fife population are children (0-15), 61% are of working age (16-64) and 21% are of pensionable age (65+). 1 The proportion of the Fife population who are aged 65 and over, 75 and over and 85 and over has steadily increased in the past 20 years (Chart 1.1).

Chart 1.1: Percentage of Fife population aged 65 and over, 75 and over & 85 and over; 1991 – 2011.

20 65 and over 18 75 and over 85 and over

14 n o i t a l 12 u p o p

f 10 o

n o i t r 8 o p o r P 6

0 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 Year Source: National Records of Scotland

6.6% of the population were over 75 in 1991 compared to 8.1% in 2011 with the number of those aged 85 and over increasing by more than 20% (almost 2,000 persons) since 2001 to now represent 2.3% of the population.1 Fife, in common with Scotland, has an ageing population and the proportion of the population aged 75 and over is projected to be 13% by 2030.2

5 During the same time period the number of young people aged 0-15 years in Fife has been decreasing from almost 80,000 in 1981 to a low point of 64,833 in 2010 and is now estimated at 64,988. Over the next few years, the number of young people is projected to increase slowly. By 2030 there will be an estimated 69,078 people aged 0-15 living in Fife representing 17.4% of the total population and an increase of 6.3% from 2011. This partly reflects the rise in birth rates seen recently.2

In next year’s report we will be able to look in detail at the results from the 2011 Census which will more accurately show the number of people living in Fife, provide detail about the characteristics of individuals and their households and show how Fife has changed since the last Census in 2001.

Births

4,206 babies were born to Fife residents in NHS hospitals during 2009/10. This is a small decrease on the 4,269 babies born in the previous year but is still the second highest annual number of births in the last 15 years.3

There has been a steady increase in the proportion of births to mothers aged over 35 years. During 2009/10 13% of births were to mothers aged between 35-39 and a further 3% to mothers aged 40 and over compared to 10% and 1.5% respectively during 1997/98. First births to older mothers are more common among women living within the least deprived areas in Fife.a 18% of all first births in these areas were to women aged 35 and over compared to 4% among the most deprived areas during 2009/10. Conversely 30% of first births among the most deprived areas were to mothers aged under 20 compared to 3.3% in the least deprived areas.3

The proportion of babies (live singleton births) born with a low birthweight (less than 2500 grams) was 5.8% in 2011, continuing a fluctuating trend between 5 and 6% each year since 2001. Low birthweight contributes to a number of health problems, both in the neonatal period and longer term. Proportions among those in the most deprived areas were higher than Fife as a whole at 7.8% with proportions among the least deprived reported as 4.8%.3

Life Expectancy

The latest figures released for life expectancy show that babies born during 2008-10 in Fife could expect to live 76.3 years for males and 80.7 years for females.4 This represents an increase in life expectancy of 2.3 years for males and 1.4 years for females in the last 10 years.4 Chart 2 shows that life expectancy has also increased among the most deprived in Fife but the values of 72.6 years for males and 77.9 years for females are considerably lower than those reported for the least deprived (80.7 and 84.2 years respectively).5 The gap in life expectancy for men living in the most and least deprived areas has decreased from a high of 9.9 years in 2002-04 to 8.1 years in 2008-10 (Chart 1.2). In contrast, the gap in life expectancy for women born in the least deprived areas compared to the most deprived has fluctuated between 6.3 and 6.8 years since 2002-04 with no obvious narrowing in the gap.

a Deprived areas are created by ranking the Fife population in each data zone by the SIMD index and creating five groups from most to least deprived each containing approximately 20% of the population. 6 Chart 1.2: Male and Female Life Expectancy at birth in most and least deprived SIMD 2009 Quintile; 1996-98 to 2008-10.

90 Most Deprived Females Least Deprived Females Most Deprived Males Least Deprived Males 85

6.3 years h t r i b

t 80 a

y c n a t c e

p 8.1 years x 75 E

e f i L

65 1996 - 1997 - 1998 - 1999 - 2000 - 2001 - 2002 - 2003 - 2004 - 2005 - 2006 - 2007 - 2008- 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Source: Information Services (NHS Fife)

Deaths

During 2011 there were 3,759 deaths of Fife residents.6 This was 86 more deaths than in 2010 but the second lowest number in the last 20 years. Nationally the number of deaths recorded was the lowest since registration began in 1855.6 Fife continues to have lower rates of death (all cause, all age) than Scotland with a rate of 610.1 per 100,000 population in 2011 compared to 640.8 per 100,000 population.b

There were 1,351 premature deaths of Fife residents (deaths before the age of 75) in 2011. Fife has lower premature mortality rates than Scotland, 317.3 per 100,000 population compared to 349.1 per 100,000 population.6 There is a strong relationship between increasing deprivation and higher mortality both for all ages and premature mortality.7 Rates of death for all causes were 1.8 times greater for all ages among the most deprived areas than the least deprived in 2011 and 2.5 times greater amongst those aged under 75.7

Main Causes of Death

In 2011 more than half of all deaths (53%) were due to the ‘big three’ causes; cancer, coronary heart disease (CHD) and stroke.8 There were 1,092 deaths from all cancers which represented 29 per cent of all deaths in 2011. 48% of all cancer deaths were to persons aged less than 75 years. Of cancer deaths lung cancer was the most common form among both males and females accounting for 27% of all cancer deaths.8 Breast cancer was the second most common type of cancer death among women and prostate cancer among men. Colorectal cancer was the third most common cancer death for both men and women accounting for 8% of all cancer deaths in 2011.8 b Rates are European age standardised rates which allow for differences in the age structures of different populations 7 Coronary heart disease was the cause of 509 deaths (13%) of Fife residents in 2011. A further 206 residents died from other forms of heart disease. A third of all CHD deaths were amongst residents aged under 75 years. Just over half of all CHD deaths were male (56%) but among premature CHD deaths this proportion rose to more than three quarters (77%). Stroke accounted for 182 deaths of Fife residents in 2011, 8% of all deaths.

- Alcohol related deaths

Alcohol related deaths are derived by counting deaths with a recording of at least one of 12 alcohol related causes as an underlying cause of death.9 Using this definition there were 1,247 alcohol related deaths in Scotland and 92 in Fife during 2011, just over 2% of all Fife deaths. The average number of alcohol related deaths in Fife in the period 2009-2011 (86) was more than double the number in 1996-1998 (40). 9 More men than women died from alcohol related conditions during 2009-2011 with 61% of these deaths occurring in men. There is a strong relationship with deprivation for deaths where alcohol is the underlying cause. Alcohol related mortality rates in the most deprived areas in Scotland are six times greater than those in the least deprived areas. 9

- Smoking related deaths

As described previously lung cancer is the number one cause of cancer deaths in Fife with an estimated 86% of all lung cancer deaths caused by smoking.10 Work published in 2010 estimated that 24.1% of all deaths in Fife were attributable to smoking. Using the 2011 number of deaths this would equate to 904 deaths.10 Figures for Scotland show that twice the proportion of deaths attributed to smoking are seen among people living in the most deprived areas compared to people living in the least deprived areas.10

Health Behaviours

Health behaviours such as smoking, drinking, eating habits and exercise play an important role in determining levels of health and wellbeing. All of these are the focus of national and local strategies to improve health and wellbeing and information collected about health and wellbeing enables us to monitor our progress towards a healthier Fife and Scotland and allows us to identify areas for development. This section presents information collected by the new Scottish Health Survey in its first four year period (2008-2011) for all health boards in Scotland. Due to previous surveys having a small sample size or different methodology, trend data are not yet available for Fife so Scotland data will be used to highlight changes from previous surveys where possible. Data for areas within Fife and updated data for the whole of Fife will be available in early 2013.

Alcohol Consumption

- Adults

Drinking to excess can lead to a range of health and social problems. Concern about the levels and patterns of drinking among the adult population has led to daily benchmarks being incorporated into sensible drinking advice. Current daily benchmarks are 3-4 units for men and 2-3 units for women, with two alcohol free days per week. Weekly drinking guidance remains at weekly limits of 21 and 14 units respectively for men and women.11

8 Figures from 2008-2011 showed that 23% of adults in Fife consumed a hazardous or harmful amount of alcohol (beyond sensible limits) in an average week. Average weekly consumption among the Fife sample was 12.3 units with men (17 units) consuming more than women (7.9 units).12 At a Scotland level both average weekly consumption in units and the proportion drinking to hazardous or harmful levels decreased between 2003 and 2011, from 14.1 to 11.1 units and 25% to 21% respectively.

43% of men and 33% of women in Fife reported consuming more than the recommended daily limit on their heaviest drinking day in the previous week with a fifth of adults consuming more than twice the daily limit. Alcohol was consumed on an average of 2.7 days each week by adults in Fife with 13% of adults reporting that they did not have two alcohol free days per week. 12

Adherence to both weekly and daily drinking levels (for example men who drink less than 21 units per week and did not drink more than four units on their heaviest drinking day) was reported amongst 44% of adults in Fife, 46% of women and 42% of men. Taking into account non drinkers this means that almost half of men and more than a third of women were drinking beyond sensible limits (Chart 1.3). 12

Chart 1.3: Percentage of adults drinking outwith alcohol consumption guidelines across Health Board areas and Scotland

45 Scotland s t i 40 m i l

n 35 i d e e

c 30 x e

l 25 u d a

f 20 o

a 15 t n e c

r 10 e P 5

y s y s d e e n e d n & & n r f r y

e e i e n d a i n a l l i i i a e s a l n a w F h a r s s l h l p d e r a I k t s t w o i r y

r h r k A V o e o m g o f a n l g r l O i r s L h a T B e h a r & m a e a t H S l d t n r u G e G y s a o l r G D i

e L F r C h e W s t r a y e A r G Source: Scottish Health Survey 2008-2011 - Children and young people

Alcohol consumption and other behaviours can be measured among young people through the Scottish Adolescent Lifestyle and Substance Use Survey (SALSUS) which collects information from young people aged 13 and 15 years and publishes results at a Fife level every four years.13 The 2010 survey found that 52% of 13 year olds and 76% of 15 year olds in Fife reported ‘ever having a proper alcoholic drink’, higher than the national average for 13 year olds (44%) but similar to it for 15 year olds (77%).13

Seven percent of 13 year olds and 22% of 15 year olds reported that ‘they usually drank alcohol at least once a week’ which is lower than the 14% and 31% reported among the same age groups in 2006. The same proportion of boys and girls (both 9 age groups combined) reported weekly drinking (15%) but the most commonly consumed alcohol among boys was ‘beer, lager or cider’ compared to ‘spirits or liqueurs’ among girls.13 More than half of 13 year olds (57%) and three quarters of 15 years olds (77%) who drank alcohol reported they had ‘been drunk’ at least once with 23% of 13 year olds and 36% of 15 year olds reporting having ‘been sick’ as a result of alcohol consumption in the last year.

Physical Activity

- Adults

National guidelines recommend that adults should aim to be active every day and achieve at least 150 minutes (2½ hours) of moderate intensity each week. 14 Thirty seven percent of adults in Fife met the weekly physical activity recommendation with men (43%) more likely to do so than women (32%),12 just lower than the 38% reported nationally.12

In 2008 changes were made to the way in which physical activity data were defined and collected meaning that data collected prior to this are no longer comparable. Trend data for Scotland will now use 2008 as the baseline year. There has been no change in the proportions achieving the physical activity recommendation between 2008 and 2011 (both 39%).12

Low activity, defined as participating in fewer than 30 minutes of moderate activity a week (including no activity), was reported by almost a third of adults in both Fife and Scotland (32%).12 45% of men and 42% of women in Fife reported participating in sport or exercise within the four weeks prior to being surveyed. The most frequently reported sports among men were cycling and ‘exercises’ (e.g. press ups, sit ups)’ compared to swimming and ‘exercises’ (e.g. press ups, sit ups)’ among women. 12

- Children and young people

Current national guidelines recommend that children and young people should accumulate 60 minutes of physical activity every day of the week. In addition to this, vigorous activities including those that strengthen muscle and bone should be undertaken on at least three days a week and all children and young people should minimise the amount of time they are sedentary for extended periods. 14

A survey of almost 6,500 young people who were in school year classes primary 7 through to year 3 of secondary in Fife was published in 2012. Results covered a range of information on physical activity including the proportion of children meeting the national targets, types of physical and sedentary activities undertaken and determinants of physical activity.15

Overall, 18% of young people met the national activity guidelines. Proportions were higher among those in primary 7 (age range 10-12) and lower among pupils in year 1 of secondary school (age range 11-13).15 Across all year groups proportions were higher among boys than girls (Chart 1.4).15

The three most frequently reported activities (undertaken at least twice a week) were active travel, team games and active video games.15 Within these categories cycling, football and playing ‘Wii fit’ were the most commonly reported. Other popular activities included walking and swimming. The most frequently reported sedentary activities were ‘sitting and talking with friends’, and ‘talking and texting on the phone’, more than a third of all pupils reported that they did these activities ‘a lot’. 15

10 Chart 1.4: Percentage of Fife pupils meeting activity guidelines by school year and sex

30 Boys Girls All pupils 25 s e n i l e d i

u 20 g

y t i v i t c a

g 15 n i t e e m

a 10 t n e c r e P 5

0 P7 S1 S2 S3 School Year Group Source: Fife Active 2012

Perceptions of the benefits of physical activity among pupils was high with 95% reporting that physical activity would help them become healthier and a similar proportion stating that physical activity is fun.15 Pupils were also asked to identify barriers to physical activity. Forty-one percent of pupils said that the weather was a barrier to taking part in physical activity, closely followed by motivation (39% would rather do other things) and logistics (38% reported it was difficult to get to places). Girls were more likely than boys to state they were embarrassed to participate in physical activity and didn’t have the right clothing or equipment. 15

Smoking

- Adults

Reductions in the number of smokers have been seen since the introduction of the ban on smoking in public places in 2006. Figures from the Scottish Health Survey still showed that 26% of adults in Fife and 25% in Scotland reported they were current smokers over the four-year period 2008-2011.12

Men were more likely to report being a current smoker than women, 28% to 25%, and have greater daily cigarette consumption. In Fife average daily cigarette consumption among smokers was 15.2 (16.4 for men and 13.2 among women) which was significantly higher than the Scottish average of 14.2.12

Data have been collected on smoking through the Scottish Health Survey since 1995. In 1995, 35% of adults aged 16-64 reported they were current smokers; this had reduced to 29% by 2008. The proportions of smokers did not change significantly in 2009 or 2010 (28%) but reduced to 26% in 2011.16

11 - Children and young people

In the 2010 SALSUS survey more than three quarters of 13 year olds (76%) and more than half of 15 year olds (58%) in Fife reported that they had never smoked.13 These proportions were an increase on the proportions reported in 2006 which were in turn greater than those reported in 2002.

Regular smoking was reported by three percent of 13 year olds and thirteen percent of 15 year olds in the Fife 2010 SALSUS sample which was the same as the national average in both age groups but lower than proportions recorded in 2006 and 2002 (Chart 1.5). Girls were slightly more likely to report being a regular and occasional smoker than boys, nine percent compared to five percent in 2010.13

Chart 1.5: Percentage of Fife SALSUS respondents reporting regular smoking by age; 2002, 2006 and 2010

13 year olds 15 year olds

20 s t n e d

n 15 o p s e r

e g a t 10 n e c r e P

0 2002 2006 2010 Survey Year Source: SALSUS

Regular smokers were more likely than non smokers to report having friends, or at least one parent and siblings who smoked. Awareness of the potential consequences of smoking was high with 98% of pupils agreeing that smoking can cause lung cancer and 94% agreeing that passive smoking can harm the health of non-smokers.13

Healthy Weight and Diet

- Adults

A poor diet with high levels of saturated fat, salt and sugar and low levels of fruit and vegetables has been shown to be a risk factor for many diseases including heart disease and type II diabetes.17 The recommendation to consume five portions of fruit and vegetables each day has become one of the best known health improvement messages since its inception more than ten years ago and is still a key message of health improvement campaigns.17

24% of adults in Fife consumed the recommended 5 portions per day in 2008-2011, with greater proportions of women (26%) reporting this than men (21%).12 These 12 figures were higher than reported nationally where 22% of adults met the recommendation. Consumption of no portions of fruit and vegetables in the day prior to completing the survey was reported by 8% of adults in Fife. On average adults in Fife consumed 3.3 portions per day with men consuming 3.2 portions per day and women 3.5 portions.12

There has been very little change in the proportion of adults consuming the recommended level of daily fruit and vegetable consumption in Scotland since 2003. Proportions were 21% in 2003 and 22% in 2011 and the number of mean portions consumed was 3.1 in 2003 and 3.2 in 2011.16

National food consumption and nutrient intake is measured through secondary analysis of the Living Costs and Food Survey to monitor progress towards dietary targets set in 1996.17 Results from the 2009 survey showed that people in Scotland are on average eating more fat, saturated fat and added sugar than is recommended. Consumption of fruit and vegetables, bread, cereals and fish (white and oily) are all lower than recommended levels.17, 19

Obesity and being overweight is a result of energy intake from food and drink consumption exceeding the energy requirements of the body over a prolonged period which results in an accumulation of excess body fat.18 Body Mass Index (BMI) is commonly used as a measure of obesity with a BMI of over 30 categorised as obese and between 25 and 30 as overweight. 18

Being obese significantly increases the risk of developing a range of serious diseases, including type 2 diabetes, hypertension, heart disease and premature mortality. It has been estimated that by 2030 over 40% of Scottish adults could be obese. This could result in the occurrence of 48,000 heart attacks and more than 150,000 people with type 2 diabetes in Scotland during 2030, which is a potential of more than 75% on levels recorded in 2003. 18

The figures from the Scottish Health Survey 2008-2011 showed that the majority of men (70%) and women (63%) in the Fife sample had a BMI which exceeded the normal weight range so were classed as overweight or obese.12 29% of male and 32% of female Fife respondents were obese compared to 27% of male and 28% of female Scottish respondents. The prevalence of obesity in Fife was significantly higher than the national average and the fifth highest of all health board areas (Chart 1.6). 12

13 Chart 1.6: Prevalence of obesity in NHS Boards and Scotland

30 Scotland y t i s

e 25 b o

e 20 c n e l a

v 15 e r P 10

y y s d e e e d s n n & & r n f r y

e e i n a d i a n e l i i i l e a a s l n a F w h a r s s l h p l d e a r k I t s w t o i r y

r h r k V A o m o e g o f a l n g r l O i s a r L h B T e h a r & m a t a e H S l d n t r u G e G y s a o l G r D i

e L F r C h e s W t r a y e A r G Source: Scottish Health Survey 2008-11

- Children and young people

We do not currently have information about fruit and vegetable consumption or other dietary habits for children and young people in Fife but we can draw on national results published by the Scottish Health Survey for children aged 2 to 15 years and work done in other parts of Scotland. In 2011 mean consumption of fruit and vegetables was 2.7 portions per day, with girls consuming more portions than boys. Younger children (aged 2-4) consumed on average more portions than older children (13-15).20

13% of children aged between 2-15 years met the recommended daily intake which did not vary by age. However the proportion consuming no daily portions increased with age from 5% of those aged 2 to 4 years to 14% of those aged 13-15 years.20, 21

As well as among adults the level of obesity among children is a continued concern and the height and weight measurements of children taken in the first year of primary school in Fife and other parts of Scotland through the child health programme are used to monitor the prevalence of overweight and underweight children.18 For Fife in 2010/11 10.5% of primary 1 children measured through the programme had a BMI which classified them as obese. This was a slight increase from the 10.2% recorded in 2009/10 but rates have fluctuated between 8.9% and 11.9% since 2000/01 (Chart 1.7).22

14 Chart 1.7: Percentage of P1 children classified as obese; Fife 2000/1 to 2010/11

e 10 s e b o

n e r 8 d l i h c

e 6 g a t n e c r e

P 4 Scotland Fife 2

0 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 School Year Source: CHSP (ISD)

References

1. National Records of Scotland. (2012) Mid-2011 Population estimates Scotland: population estimates by sex, age and administrative area. Edinburgh: NRS, available http://www.gro- scotland.gov.uk/statistics/theme/population/estimates/mid-year/2011/index.html (Accessed 2012, September 24)

2. National Records of Scotland. (2012) Population projections for Scottish areas (2010- based). Edinburgh: NRS, available http://www.gro-scotland.gov.uk/statistics/theme/population/projections/sub-national/2010- based/index.html (Accessed 2012, September 24)

3. Information Statistics Division (2012) Births in Scottish hospitals year ending March 2011. Edinburgh: ISD, available http://www.isdscotland.org/Health-Topics/Maternity-and- Births/Births/ (Accessed 2012, September 24)

4. National Records of Scotland (2011) Life Expectancy for areas in Scotland, 2008-2010. Edinburgh: NRS, available http://www.gro-scotland.gov.uk/statistics/theme/life- expectancy/scottish-areas/index.html (Accessed 2012, September 24)

5. NHS Fife (2012) Life expectancy estimates by Fife SIMD quintile. Information Services, NHS Fife

6. National Records of Scotland (2012) Deaths by sex, year and (post-April 2006) NHS Board area, 1991 to 2011. Edinburgh: NRS, available http://www.gro- scotland.gov.uk/files2/stats/time-series/deaths-sex-year-nhs-board-1991-2011.xls (Accessed 2012, September 24)

15 7. NHS Fife (2012) Premature mortality by Fife SIMD 2009 Quintiles. Information Services, NHS Fife

8. NHS Fife (2012) Deaths by cause, age and sex. Information Services, NHS Fife

9. National Records of Scotland. Alcohol-related deaths in Scotland, 1979 to 2011. Edinburgh: NRS, available http://www.gro-scotland.gov.uk/statistics/theme/vital-events/deaths/alcohol-related/index.html (Accessed 2012, September 25)

10. Peto, R., et al (2012) Mortality from smoking in developed countries 1950−2005 (or later): Scotland. Oxford: University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, available http://www.ctsu.ox.ac.uk/~tobacco/C4330.pdf (Accessed 2012, September 25)

11. The Scottish Government (2009) Changing Scotland's relationship with alcohol: a framework for action. Edinburgh: Scottish Government, available http://www.scotland.gov.uk/Publications/2009/03/04144703/0 (Accessed 2012, September 25)

12. The Scottish Government (2012) Scottish health survey 2008-2011, results by NHS Board. Edinburgh: Scottish Government, available http://www.scotland.gov.uk/Topics/Statistics/Browse/Health/scottish-health- survey/Publications/healthboard2011 (Accessed 2012, September 25)

13. Drug Misuse Information Scotland (2011) Scottish schools adolescent lifestyle and substance use survey (SALSUS): local reports 2010. Edinburgh: DMIS, available http://www.drugmisuse.isdscotland.org/publications/abstracts/salsus_local.htm (Accessed, 2012, September 25)

14. Department of Health (2011) Start active, stay active: a report on physical activity for health from the four home countries’ Chief Medical Officers. London: Department of Health, available http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidanc e/DH_128209 (Accessed 2012, September 25)

15. Rowe, D. & Murtagh, S. (2012). Physical activity participation in Fife schoolchildren: research report of current levels, modes, contexts, preferences and determinants. Glenrothes: Fife Physical Activity Steering Group, available http://www.paha.org.uk/Resource/physical- activity-participation-in-fife-schoolchildren (Accessed 2012, September 25)

16. Rutherford, L., Sharp, C., & Bromley, C. (2012) The Scottish Health Survey 2011: volume 1 adults. Edinburgh: Scottish Government, available http://www.scotland.gov.uk/Publications/2012/09/7854/0 (Accessed 2012, September 25)

17. Barton, K.L. & Wrieden, W.L. (2012) Estimation of food and nutrient intakes from food survey data in Scotland 2001-2009. Aberdeen: Food Standards Agency Scotland, available http://www.foodbase.org.uk//admintools/reportdocuments/749-1-1324_Final_Report_2001- 2009.pdf (Accessed 2012, September 25)

18. The Scottish Government (2010) Preventing overweight and obesity in Scotland: a route map towards healthy weight. Edinburgh: Scottish Government, available http://www.scotland.gov.uk/Publications/2010/02/17140721/0 (Accessed 2012, September 25)

19. Barton, K.L. & Wrieden, W.L. (2012) Tables of Food and Nutrient intakes from Expenditure and Food Survey Data in Scotland 2001 – 2010. Aberdeen: Food Standards Agency Scotland, available http://www.foodbase.org.uk//admintools/reportdocuments/749-1- 1325_Food_and_Nutrient_Tables_Interim_update_2001-2010.pdf (Accessed 2012, September 2012)

16 20. Rutherford, L., Sharp, C. & Bromley, C. (2012) The Scottish health survey 2011: volume 2 children. Edinburgh: Scottish Government, available http://www.scotland.gov.uk/Publications/2012/09/3327/0 (Accessed 2012, September 25)

21. Crawford, F. & Mackison, D. (2012). ‘Is eating out of school a healthy option for secondary school pupils?’ a feasibility study to explore the nutritional quality of ‘out of school’ foods popular with school pupils. Glasgow: Glasgow Centre for Population Health, available http://www.gcph.co.uk/publications/371_is_eating_out_of_school_a_healthy_option_for_seco ndary_pupils (Accessed 2012, September 25)

22. Information Statistics Division (2012) Primary 1 body mass index (BMI) statistics: school year 2010/11. Estimated data completeness - height and weight recording for Primary 1 School Children by NHS Board and Council Area. Edinburgh, ISD, available http://www.isdscotland.org/Health-Topics/Child-Health/Publications/2012-04- 24/P1_estdatacomp_2010_2011.xls?38607425 (Accessed 2012, September 25)

17 CHAPTER 2 – TEENAGE PREGNANCY

Local agencies in Fife are committed to reducing under 16 teenage pregnancy. The role of the Local Authority is key with Education delivering Relationships and Sexual Health Education appropriate for all pupils, Community Services working to address sexual health in its contacts with young people and Social Work in its contact with looked-after and other vulnerable young people.

Within NHS Fife, Executive Leadership is provided via the Director of Public Health. Each of the three CHPs has the responsibility for local sexual health services and assessing the needs of their populations. Kirkcaldy and Levenmouth Community Health Partnership (CHP) has lead responsibility for the specialist sexual health services, which encompasses Reproductive Health, Genito-urinary Medicine and specialist health promotion across Fife.

Recent rates in Fife

Teenage pregnancy refers to conceptions i.e. deliveries plus abortions. Generally there are more abortions than deliveries in the under 16s.

Due to the nature of the data, the most recent results are for 2010. In Fife, the rate was 9.2 conceptions per thousand girls aged 13-15 (57 events) compared to the Scottish average of 7.1 conceptions per thousand girls aged 13-15.

Across Scotland rates have been relatively stable over the last ten years and a small change in numbers can significantly affect rates from year to year. Fife rates for <16 teenage pregnancies are usually higher than the Scottish average and in 2009 and 2010 were highest of any NHS Board in Scotland. In 2010 Fife was also highest for <18 rates, 47 conceptions per thousand girls aged 15-17 compared to an average of 36 conceptions per thousand girls aged 15-17 in Scotland.

Evidence-based approach

Evidence from research has identified the following risk factors for teenage pregnancy:

Behaviour: Early sexual activity Poor contraceptive use Mental Health/Conduct Disorder/Crime Alcohol/Substance Misuse

Education–related: Low educational attainment Disengagement from school

Family/Background: Looked after children Daughter of a teenage mother Low parental aspiration

Health improvement work in this area involves addressing issues of self-esteem and self-worth, as well as negotiation skills in addition to other factors.

18 Evidence from research suggests these are the key areas to reduce a high teenage pregnancy rate:

 Senior local sponsorship from all key partners  Health, Education, Social Services, Youth Support Services, Voluntary Sector  Young people’s sexual health services  Sex education given high priority  Youth & Community Services  Target those at most risk especially looked after children.

Teenage pregnancies can be associated with adverse social outcomes or “cycles of deprivation”. While many are unplanned, they may be wanted and some are intended. It is important not to stigmatise mothers or children in this situation. The Young Mother’s initiative supports young people to remain in education after birth of a child and the area of parenting support is an important one. It is also important to address issues for boys or fathers in both prevention and parenting.

Sexual intercourse is reported by up to a third of young people under the age of 16. In a high proportion this is later regretted. While against the law, a proportionate response is expected in services in those aged 13-16 and staff must conduct risk assessments to determine whether child protection referral is appropriate under existing guidance. Sexual activity below the age of 13 would always be a child protection matter.

Chart 2.1: Teenage Pregnancy (Delivery Plus Abortion) Mother aged <16 at conception, Fife & Scotland (source ISD) 12

8 0 0 0 , 1

e t a R

4 Scotland Fife

0 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 9 9 9 9 9 0 0 0 0 0 0 9 0 0 0 0 1 9 9 9 9 9 0 0 0 0 0 0 9 0 0 0 0 0 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2

Response

Funding from the Fife Health & Wellbeing Alliance has been allocated for targeted secondary school areas to take forward actions to reduce the rates in partnership with local agencies. The target schools are Buckhaven High School, Kirkcaldy High School, Lochgelly High School and Auchmuty High School in Glenrothes.

19 As an example of good practice, health improvement staff working with Kirkcaldy High School staff and public health nurses are piloting new methods of delivering Sex and Relationship Education based on pupils' identified needs. The school guidance team and nursing team are working well together. The nursing team are planning to pilot a specific drop-in for sexual health concerns and will link with specialist services to fast track any pupils who need further medical input. The aim is to streamline the referral process to make it easier for young people to access these services.

Engaging with young people locally is crucial to ensure their views are integral to service design. A detailed literature review of interventions and qualitative research on the topic has been conducted and disseminated to local areas.

Selected existing initiatives

The aim of all Relationships and Sexual Health Education is to encourage young people not to engage in early regretted sex. Staff from Fife have been recently trained in a specific innovative programme 'Only when I'm ready', or 'Delay' and elements of this will be incorporated into local practice.

The Hubs are a network of young people’s drop-ins run by each CHP in Fife. They are run under a service level agreement with Community Services and address sexual health and other health issues for young people. Sustaining and developing these in or near schools in target areas is very important and continual development takes place to meet young people's needs.

A needs assessment for supporting parent and carers in approaching this topic with young people was completed in 2011 and actions from this will be taken forward.

The website www.urhealthfife.org.uk was jointly developed to give young people access to appropriate health information. It is available within schools in Fife.

Primary care staff provide contraception services and initiatives are in place to promote training and uptake of more reliable methods such as implants. Emergency Hormonal Contraception (morning after pill) is available in pharmacies throughout Fife.

Sexual Health Fife has introduced additional priority measures for under-16s and outreach work has taken place with vulnerable groups and drug and alcohol services.

Training was delivered in 2011 to 21 staff working with vulnerable young people who do not usually receive sexual health input; employability workers, social workers, youth justice, SACRO and staff who deal with missing children. This was in addition to the existing multi-agency training programme and condom distribution scheme training.

A DVD has been developed by Dunfermline and West Fife CHP for use with vulnerable young people linking sexual health risks and alcohol use.

The Health Psychology for Looked after Children project offers 1:1 support for those who are looked after and consultancy for workers and carers on sexual health and a range of other health behaviours.

The last two projects have received national awards for good practice.

20 Further Plans

Leadership across all agencies is key to addressing high teenage pregnancy rates. The new Fife Sexual Health Strategy 2012-15 will emphasise this. It will be important to maintain momentum in targeted schools, on a partnership basis, linking to drug and alcohol issues.

Using health psychology expertise, a technique called Implementation Intentions will be explored to reduce unwanted pregnancy. This involves a checklist of ‘what if’ scenarios for effective use of contraception and has been shown in a randomised trial to reduce unwanted pregnancy.

Sources of information:

The Scottish Government (2011) The sexual health and blood borne virus framework 2011- 2015. Edinburgh: Scottish Government, available http://www.scotland.gov.uk/Publications/2011/08/24085708/0 (Accessed 2013, January 8)

Hughes, B (2006) Teenage pregnancy next steps: guidance for local authorities and primary care trusts on effective delivery of local strategies. London: Department of Education and Skills, available http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolle agueletters/DH_4137536 (Accessed 2013, January 8)

ISD Scotland (2012) Teenage pregnancy: year ending 31 December 2010. Edinburgh: ISD Scotland, available http://www.isdscotland.org/Health-Topics/Sexual- Health/Publications/2012-06-26/2012-06-26-TeenPreg-Report.pdf (Accessed 2013, January, 8)

NHS Health Scotland Maternal and early years for early years workers web site at http://www.maternal-and-early-years.org.uk/topic/pregnancy/teenage-pregnancy (Accessed 2013, January 8)

NHS Health Scotland, Learning and Teaching Scotland (2009) Reducing teenage pregnancy: Guidance and self assessment tool. Glasgow: Learning and Teaching Scotland, available at http://www.educationscotland.gov.uk/Images/teenage%20pregnancy%20web_tcm4- 593480.pdf (Accessed 2013, January 8)

NHS Health Development Agency (2004) Teenage pregnancy: an overview of the research evidence. London: NHS HDA, available http://www.nice.org.uk/niceMedia/documents/teenpreg_evidence_overview.pdf (Accessed 2013, January 8)

21 CHAPTER 3 PHARMACEUTICAL PUBLIC HEALTH

NHS Pharmaceutical Care Services provided by community pharmacies are done so on a contractual basis between the NHS and the independent community pharmacy contractor. All applications to open a new NHS community pharmacy are considered by the Pharmacy Practices Committee in each Board area on the basis that a new pharmacy is necessary and desirable. The publication of NHS Pharmaceutical Services (Scotland) Amendment Regulations 2011 puts a duty on NHS Boards to formally develop and publish a report of Pharmaceutical Care Services (PCS) and annually update them. This document is to be made available to the Pharmacy Practices Committee as part of their considerations and be made available to the public.

While pilot work had taken place in previous years this was the first full year for production of a Board approved report. During 2011-12 the pharmaceutical public health team led on the development of this report for NHS Fife.

The report gives an overview of general health related to pharmaceutical care needs in NHS Fife, describes the provision of pharmaceutical care in NHS Fife and examines this for any gaps in provision.

The information held on the NHS Pharmaceutical List and use of national data and mapping were utilised to produce the report.

Community Pharmacies in NHS Fife (April 2011) Location Number Population (GRO Population per CHP of community 2009) community Pharmacies Pharmacy NHS Fife Total 83 363460 4379 Dunfermline and 33 142184 4308 West Fife Glenrothes and 27 124153 4598 North East Fife Kirkcaldy and 23 97123 4222 Levenmouth

Based on this information, each individual pharmacy can be estimated to be serving a population of around 4400 people. This is in line with figures found previously in neighbouring areas of NHS Lothian and NHS Tayside. There is no standard as to the size of population that should be served by a pharmacy but the table above shows that there are small differences in the average population served by each pharmacy between the three CHP areas. The wide access to the community pharmacies overall in Fife has been demonstrated by the distribution of the pharmacies across Fife.

In terms of location of pharmacies, it is traditionally assumed that pharmacies tend to exist near GP practices as in the past, prescriptions were the main business. Pharmacies now have a contract for a wider range of services. Mapping pharmacies and GP practices shows that they are still in close proximity but the location is perhaps not surprisingly associated with population density rather than with each other.

22 Chart 3.1: Population Density by InterZone – December 2011 (NHS Fife)

In terms of accessibility, all pharmacies are within 20 minute drivetime across Fife and many areas are within 5-10 minutes drivetime to a pharmacy. In fact, data have shown that 84% of the Fife population live within 1 mile of their nearest pharmacy and based on this information it has been calculated that the average distance that Fife residents live from a pharmacy is 0.65 miles. It cannot be assumed that the population will necessarily use the nearest pharmacy but location has been shown to be critical in the access to pharmaceutical services. The PCS Report 12/13 also highlighted the current resources/facilities within community pharmacies in NHS Fife e.g. 98% of pharmacies currently have either a private area or consultation room, and the majority also have induction loop facility (83%) and wheelchair access.

NHS pharmaceutical care services include 4 core services. Acute Medication Service for dispensing of prescriptions, Minor Ailment Service to allow self-limiting conditions to be treated at the pharmacy, Chronic Medication Service to manage patients on long term, stable medicines and the public health service. The public health service includes a stop smoking service and provision of emergency hormonal contraception. For the calendar year 2010, 47% of all quit attempts made in Fife came from the community pharmacy stop smoking service. This is only one part of the community pharmacy NHS service yet is an important contribution to health improvement in Fife.

There are several additional services agreed within NHS Fife. These are locally negotiated contracts and as such not all pharmacies participate in these services. It is the responsibility of the NHS Board to ensure that these additional services meet the needs of the population however this does not mean that the population requires these services equally across geographical areas or that it is necessary to provide

23 them from every community pharmacy. The services might also not entirely be provided by pharmacy alone and so provision must be looked at in the context of wider healthcare services.

The development of methods for assessing pharmaceutical care needs is being progressed in conjunction with other health boards and this will contribute to future planning.

For more information about this chapter, contact Mr William John, Public Health Pharmaceutical Advisor.

References

Scottish Government (2011) NHS (Pharmaceutical services) (Scotland) amendment regulations 2011 (SSI 2011/32). Edinburgh: Scottish Government, available http://www.sehd.scot.nhs.uk/pca/PCA2011(P)07.pdf (Accessed 2013, January 17)

NHS Fife (2012) Pharmaceutical care services in NHS Fife 2012/13 report. Kirkcaldy: NHS Fife, available http://www.nhsfife.org/nhs/index.cfm? fuseaction=publication.pop&pubID=2CC4FD97-FA09-3DB0-7D8E4D32CBB31FB5 (Accessed 2013, January 17)

24 CHAPTER 4 HEALTH PROTECTION

Health protection stocktake

The Scottish Government, as part of its continual improvement process, established the Health Protection Stocktake Working Group in 2010. The remit of the Group was to consider:

- Current structures for health protection in Scotland including the roles of the Scottish Government, Health Protection Scotland and NHS Boards; - Capacity and resilience, including any issues related to immunisation, surveillance, communicable disease outbreaks, public health and major incident responses; - The health protection workforce and how this might be developed, with particular reference to multi-disciplinary approaches; - Standardised protocols, including the HPS role in producing guidance and standards; - Governance, including a review of the Health Protection Advisory Group (HPAG); - Existing and required links at EU and UK level, including with the Health Protection Agency, at both an administrative and professional level; - Relationships and behaviours.

The Group has prepared a Final Report which is currently being considered by the NHS Scotland Chief Executives’ Group.

Immunisation

Uptake rates for primary immunisation in Fife continue to be encouraging with over 98% of children having received their primary immunisation for Diphtheria, Tetanus, Pertussis (whooping cough), Polio, Haemophilus Influenzae and Type B (HiB), with 96% receiving Meningococcal C (MenC) and 97% receiving PCV by 24 months. The update rates for 1 dose of MMR at 24 months is 93% and 92% of 6 year olds having received 2 doses of MMR.

Chart 4.1 – Uptake rates for primary immunisations (source ISD)

n 96 e r d l i h C

f o 94 e g a t n e c r e

88 Dip Tet aP Pol Hib MenC PCV MMR1 Vaccines

25 Human Papilloma Virus (HPV)

Human Papilloma Virus causes 99% of cervical cancers and it is estimated that immunisation will reduce the number of cases of cervical cancer by up to 77%. In Scotland cervical cancer claims around 100 lives every year.

The HPV immunisation programme commenced in September 2008. Up to August 2011 60% of all eligible girls had received 3 doses of the vaccine. Of those, 85% were vaccinated within the schools programme, 27% were immunised outwith this programme. The uptake for the HPV vaccine in eligible girls in Fife is below the Scottish average.

From September 2012 the Gardasil vaccine will be used in the national vaccination programme. A significant advantage of Gardasil is that it is highly effective against the two strains of HPV that cause around 90% of genital warts as well as protecting against the two types of HPV responsible for more than 70% of cervical cancers in the UK.

Seasonal Flu Vaccination

The flu vaccine for 2011/2012 did not differ from that supplied in 2010/2011 which included H1N1 within the trivalent vaccine. Pregnant women with no risk factors continued to be offered the flu vaccine at any point in their pregnancy.

Vaccine uptake for the season 2011/2012 up to the beginning of March was 76% for the over 65 years age group and 56% for at risk groups which is less than the Scottish average. Efforts continue to improve the uptake of vaccine in high risk groups and also with health and social care staff.

Communicable Diseases

The Public Health Department receives notifications on a wide range of communicable diseases to assess the risk of spread of infections and instigate control measures to avoid this. Much of this work is undertaken jointly with Fife Council and where relevant other agencies such as Scottish Water, Scottish Environment Protection Agency and Animal Health. The Public Health etc (Scotland) Act 2008 requires that Health Boards develop Joint Health Protection Plans (JHPPs) to enhance this joint working to tackle the challenge of communicable disease and also other health threats such as environmental pollution. The most recent JHPP is available from Fife Council and NHS Fife websites.

Areas of activity in 2011 which continue into 2012 include mumps, measles and whooping cough (pertussis) reinforcing the message that vaccination is still the best form of protection from these infections.

Tuberculosis (TB) 2011

There were 29 new TB cases notified to NHS Fife in 2010. 12 of these were confirmed as Mycobacteria tuberculosis. From these 12 cases, 39 contacts were identified for screening.

161 new entrants were notified to Fife from Port Health control at Heathrow Airport in 2011. Eight of these required follow up by the TB service.

26 Weekly BCG clinics are carried out at the Victoria Hospital Kirkcaldy for all newborn babies from at risk groups. A BCG school catch-up programme was completed in November 2012. In 2012, the BCG service was re-designed and it is now delivered by the paediatric service within the Operational Division.

In response to the publication of the TB Action Plan for Scotland, a multi-disciplinary team comprising respiratory physicians, public health, microbiology and pharmacy meet twice a year to review management of TB cases and learn wider lessons for improving the quality of response in line with best practice guidance.

Emergency planning

Planning, exercising and training both internally and with our partner agencies is essential to ensure that we can respond appropriately should any major adverse event take place in our area and also contributes to making Fife a safer place and a more resilient community.

In 2011 NHS Fife were involved in the emergency planning for all the major public events in Fife and in particular, the airshow at RAF Leuchars.

As well as participating in training and exercise days for major events the health protection team were also involved in events organised by our partner agencies, commercial organisations and also exercises and training led by ourselves. The topics covered in the exercises and training included multi-agency response, the setting up of rest centres, reviewing Fife flooding arrangements, testing hospital water plans and public health topics such as zoonoses (infections in animals which can spread to humans).

For more information about this chapter, contact Dr Margaret Hannah, Deputy Director of Public Health.

References

Health Protection Scotland (2012) Notification of seasonal flu vaccination uptake. [Online] Email to Dr Charles Saunders ([email protected]) 2012, July 12.

Information Statistics Division (2012) Childhood immunisations – Fife. Edinburgh: ISD, available http://www.isdscotland.org/Health-Topics/Child- Health/Publications/2012-12-14/child_imms_Fqtr312.xls (Accessed 2013, January 18)

Information Statistics Division (2012) HPV immunisation uptake statistics HPV immunisation programme - school year 2011/12 and HPV immunisation uptake statistics for the catch-up programme 1 September 2008 - 31 August 2011. Edinburgh: ISD, data tables by NHS board and CHP available at http://isdscotland.org/Health-Topics/Child-Health/publications/data-tables.asp? id=718#718 (Accessed 2013, January 18)

NHS Health Scotland (2012) HPV vaccine. Edinburgh: NHS Health Scotland, available at http://www.immunisationscotland.org.uk/vaccines-and- diseases/hpv.aspx#whatspread (Accessed 2013, January 13)

Scottish Parliament (2008) Public health etc. (Scotland) act 2008 (asp 5). Edinburgh: The Stationery Office Limited, available http://www.legislation.gov.uk/asp/2008/5/contents (Accessed 2013, January 17)

27 PUBLIC HEALTH DEPARTMENT – STAFF LIST

NAME DESCRIPTION EMAIL ADDRESS

COYLE, Eddie Director of Public Health [email protected] ARCHIBALD, Bryan Information Analyst [email protected] BALL, Graham Consultant in Dental Public Health [email protected] BROWN, George Emergency Planning Officer [email protected] BROWN, Jeanne Office Manager [email protected] CAMPBELL, Clare Public Health Scientist [email protected] CAMPBELL, Karen Health Protection Nurse Specialist [email protected] CHALMERS, Kim Childsmile Regional Programme Manager [email protected] CLIFFORD, Cheryl Personal Secretary [email protected] CONAGLEN, Philip Specialty Registrar in Public Health [email protected] COOKE, Cathy Public Health Scientist [email protected] DUANE, Brett Specialty Registrar in Dental Public Health [email protected] EAVES, Jenny Regional Childsmile Researcher [email protected] FISSENDEN, Liz Personal Secretary (Childsmile) [email protected] GILMOUR, Mhairi Public Health R&D Officer (Older People) [email protected] GHATTAS. Mike Public Health Dataset Co-ordinator [email protected] HAMLET, Neil Consultant in Public Health [email protected] HANNAH, Margaret Consultant in Public Health Medicine [email protected] HUNTER, Janice Personal Secretary [email protected] HYLAND, Jackie Consultant in Public Health Medicine [email protected] JOHN, William Public Health Pharmacist [email protected] LINYARD, Alison SHINE Project Manager [email protected] LUMSDEN, Shona Personal Secretary [email protected] MACDONALD, Sandra Personal Secretary [email protected] MCALLISTER, David Specialty Registrar in Public Health [email protected] MCLAREN, Gordon Consultant in Public Health [email protected] MOHAMMED, Ishtiaq Principal Pharmacist - Clinical Effectiveness [email protected] MUIR, Aileen Consultant in Pharmaceutical Health [email protected] NEALON, Sarah Personal Secretary [email protected] O’KEEFE, Emma Specialty Registrar in Dental Public Health [email protected] PEARCE, Trisha Personal Secretary [email protected] QUINN, Mary Health Protection Nurse Specialist [email protected] SAUNDERS, Charles Consultant in Public Health Medicine [email protected] SHIELS, Karen Personal Secretary [email protected] SIMPSON, Wendy Public Health Scientist [email protected] VALENTINE, Jo-Anne Health Improvement Manager – Health Inequalities [email protected] WATSON, Lorna Consultant in Public Health Medicine [email protected] WILLIAMS, Nicola Research Assistant, Childsmile [email protected] WOOLLEY, Dorothy Librarian [email protected] WILSON, Natalie Personal Secretary [email protected]

28 29 For further information please contact: Public Health Department NHS Fife Cameron House Cameron Bridge LEVEN KY8 5RG

01592 226459

ISBN No: 978-0-9566285-3-4