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Do housing conditions influence respiratory morbidity and mortality in children?
PlcbL Hhh, Lond. (1979) 93, I57-162
Do Housing Conditions Influence Respiratory Morbidity and Mortality in Children? A St~xdy o f H o s p i t a l A d m i s s i o n s and R e s p i r a t o r y D e a t h s ~n S e v e n D i s t r i c t s in S o u t h Wales. J. W. G. Yarnell M.B.. D.P.H.
M.R.C. Epidemiology Unit, 4 Richmond Road, Cardiff A study was conducted of the deaths and hospital admissions of children due to respiratory disease in seven districts with widely differing housing standards. No relationship betwc~n the inadequate housing amenities and respiratory mrrbidity and mortality was found but a close relationship between respiratory mortality and overcrowding and o~her socio~economic variables was suggested.
Intr~lnction Inadequate housingstandards have been suggested ~, = as an important contributory cause o f respiratory mortality and morbidity in early childhood. The present study examines morbidity, measured by hosp/tal admissions, and mortality during a six-year period in seven health districts with widely differing housing standards in South Wales. In order to compare the admissions for bronchitis and pneumonia with other hospital admissions which were unlikely to be related to housing conditions, two other diagnostic categories were also examined: asthma and whooping cough. Method Data were obtained from Hospital Activity Analysis (HAA) Section o f the Welsh Office: complete data were available for the hospitals serving the selected districts during the years 1970-5. Data were obtained for the foUowing International Classification of Diseases (ICD) codes (eighth revision) in children aged 0--11 years for each of the abov e years: 033, whoopihg cough; 466, acute bronchitis and bronchiolitis; 470-4, influenza; 480-6, pneumonia; 493, asthma; 51 I, pleurisy; 519, other diseases o f the respiratory system. Cases in which the above code was only a subsidiary diagnosis Were excluded from the analysis. The H A A clerk was contacted in the major admitting hospital for each district in order to obtain an assurance on the completeness of the data; the response was satisfactory. However, one area, Ogwr, recorded a high proportion of diagnoses as ICD code 519 (other diseases o f the respiratory system). This was reported to be due co the tendency o f admitting doctors to record "respiratory infection" as the principal diagnosis. For the purposes of the present analysis this diagnosis has been recorded in the category "bronchitis or pneumonia". In all other hospitals the major contribution to the acute respiratory admissions were recorded as "bronchitis, bronchiolitis or pneumonia". 0038-3506/79/030157+06 $01:00/0
~) 1979 The Society of Community Medicine
.
.
.
,
,,
,
,,,
,
I
II
I
I
~ l i
I
I l
617 8 115 18 13,320 t6,375
Cynon
III
III
IIIIIIII
IIII
727 18 124 20 12,205 i5,050
Mcrthyr
illlilii
lili i
i
ii
-
~
I
373 39 76 15 17,675 21,450
I
III I
I
Illl
il
.
.
.
.
.
533 .
.
.
11"2 5.7
7.9 3'9 .
6.6 0.57 52.5 32-7
4.5 0"55 60.2 23.9
5"33
2"/.~,
Mcrthyr
31.9
Cynon
.
552 ~
6.2 4.3
4.7 0.57 57.8 28.4
14.1
Ogwr
=
544
9.7 9.2
4.8 0'54 67,S 15-8
43.7.
Rhondda
544
6.9 5.0
4.9 0.57 53.5 34.t
16.5
TdffEly
I
IIIIIIIIIII
I
IIIIIIII III
II
I
.
424 15 146 14 20,590 25,320 IIIIII
Vale of Glamorgan
..................................................
607
10'4 5.8
5.9 0'59 49.3 31"4
23.2
496
4"5 3.5
4-4 0"55 56.6 22.9
8.7
Rhymney Valeof Glamorgan
m mllllll
374 23 100 24 22,485 27,295
*Figares available only for health districts: Cynon and Merthyr = Single District; Rhondda and Tail"Ely similarly,
i"
476 56 107 12 15,970 19,895
Rhondda Taft"Ely Rhymney
TABLE 2. Selectedhousing indicesnnd demographic variab[csby district
(
837 53 140 12 25,310 30,890
Ogwr
*Rates are based on population 0-11 years for admissions, 0-14 years for deaths.
Per cent liouseswith 4 or more persons lackingamenities Per cent houses with more than one person per room Average no. of persons per room Per cent houses owned by occupier Per cent hoases rented from council Per cent economically active males out of employment Population density (persons per hectare) Average no. of children 0-14 years per ~'eneral practitioner*
~ 1
Bronchitis and pneumonia Whooping cough Asthma Death rates (all acute respiratory infections) Population aged 0-11 years Population aged 0-14 years
.
Hospital admission rates
TABIo~.I. Mean annual hospital admissions for selected respiratory diagnoses and respiratory disease deaths in children per 100,000child population* by district
*P
Admissions Bronchitisetc, Whoopingcough Asthma Deaths 0,14 0,1I -0,43 0,17
-0,11 0,29 -0,54 0,56
--0,10 0,06 --0,22 0,63
0,36 0,21 0,21 -0,74*
-0,21 -0,04 -.0'43 0,56
0,07 0,04 -0,43 0,63
-0,14 0,64 -0,61 0,15
-0'09 0+66 -0'50 0'07
Houses Housm No, children lacking I+ persons No, persons owncd rentedfrom UnemployedPopulation 0-14 yrs amenities per room per room by occupier council males density per G,P,
Houses Houseswith
TABLE3, Valuesof Spearman'srankcorrelationcoemcientsfor variablesof Tables I and 2,
160
d.W.G.
Yarnell
The address codes conformed to the reconstituted local authority districts following the Local Government Act 1972. Because of day-to-day changes in the catchment areas of some hospitals all eligible child admissions were scrutinized in all hospitals in South Wales. Mortality data were obtained from the Office of Population Censuses and Surveys; deaths due to acute respiratory disease were extracted from the ICD "B" lists available for local areas. Demographic and housing data were taken from the 1971 Census County Reports for the reconstituted local authorities. The Family Practitioner Committees provided the numbers of general practitioners for each district. Results Table 1 shows the average annual respiratory disease admissions and deaths per I00,000 child population. Both admissions and death rates show wide variation from district to district with at least a twofold difference between ~he districts with the highest and lowest admissions or deaths. Admissions for whooping cough show a sevenfold difference between the districts with the highest and lowest admission rates. Ther~ is no obvious relationship between admissions and deaths from respiratory disease. The patterns for admissions and deaths are also similar in each area if separate age groups of children (0-4 years and 5-14 years) are considered. ~a~le 2 shows housing indices and other demographic variables which were believed to be relevant to admissions and deaths from respiratory disease. The first index, houses with four or more persons lacking amenities, was chosen to maximize the possibility that such houses contained young children, since it was found that in. all districts the greatest proportion of houses without amenities were inhabited by one or two persons only, i.e. typically the elderly. Certain other variables such as the availability o f paediatric beds were also examined but were rejected since reliable data could not be obtained for all districts. The figures reflect the character of each district: Rhondda, Merthyr and Cynon--depopulating mining valleys with a large stock of older houses; Rhymney, Ogwr and TaffEly-growth areas with new industrial development; and the Vale of Glamorgan--a rural residential area. Table 3 shows the valiJes of the rank correlation coefficients for the deperLdent (Table t) and independent (Table 2) variables. Although only one value reaches the conventional level of statistical significance the pattern of valuers for each of the dependent variables is of interest. Admissions for bronchitis and pneumonia do not correlate with any o f the independent values, except weakly and positively with the percentage of houses owned by the occupiers. Whooping cough admissions correlate weakly with the percentage of "overcrowded" houses but strongly with increasing population density and average child population per general practitioner. Asthma admissions seem to be correlated with factors associated with decreased socio-economic status but more strongly ..,:,~.~,~,, i~.~,.,.oo,~,-.,o,,,Ja . . . . 1. . . . .v.v. i s u t a t e. d ' . .(i.e. . .more . . ~u~,,,~ hahltats.___ Finally, deaths due to respiratory disease show little relation to lack of amenities but are correlated with overcrowding. Even stronger are the correlations with other socio-economic factors: owner-occupancy, council tenancy and level of unemployment. Discussion The findings support the view that socio-eeonomie factors and overcrowding play art importartt contributory role in acute respiratorY deaths o f children. This is in agreement with other work. For example, children aged one to four years from social class V families are known to
Respirator)" morbidit.v attd mortality in children
161
have over twice the death rate from respiratory disease (largely pneumonia) than children from social classes I and 1I.3 Parental and social factors have been stated to be responsible for 71 ~ of avoidable post-neonatal deaths, which were predominantly due to respiratory disease? Similarly, overcrowding has been shown to be associated with arl increased incidence of tuberculosis, 5, ~ and measles, 7 and also with mortality principally due to respiratory infection.8. From the present results it appears that inadequate housing amenities do not significantly influence respiratory morbidity a n d mortality in children. Although this index represents only one possible index o f dilapidation other such indices would seem to be less reliable as an indication of general standards. For example, figures derived from local housing dearance programmes and grant improvement areas (GIAs under the 1968 Housing AeQ are dependant on the policies and financial resources of individual district councils. In support o f the present results other workers have also failed to incriminate dilapidation of the home as a significant contributory cause of respiratory morbidity 1° or infant mortality, a~ This is in apparent contrast to the findings of Brennan & Lancashire 12 who studied childhood mortality (from all causes) in the county boroughs of England and Wales during the year 197I. These authors demonstrate that overcrowding and inadequate housing amenities have highly significant associations with child mortality under five years o f age when the effects of social class and unemployment are eliminated. They do not demonstrate (by the use of partial correlation coefficients) independant associations between overcrowding on the one hand and inadequate housing amenities on the other, and childhood mortality. It is also worth noting that, in England and Wales among children under five years of age, accidents account for approximately 6 ~o and respiratory disease for 13 ~o of all deaths, a3 Adelstein & White ~ have demonstrated very steep social class gradients in deaths due to accidents in children aged one to four years; other authors 1~havenotedthat the incidence of accidents to children is much lower among families rehoused in modern accommodation. It is suggested that, where possible specific causes of mortality should be examined, since these relationships are likely to shed" most light on the mechanisms by which socio-economic factors contribute to childhood mortality. Hospital admissions for bronchitis and pneumonia were not correlated significantly with any factors included in the present study. H A A data has been validated elsewhere and the percentage of missing information and errors found to be low. ~s The admissions for whoop~ng cough and asthma also support this since the pattern of admissions accord with prior expectations; whooping cough admissions are associated with high population density and possibly with the extent of immunization by general practitioners; asthma is more common among families of social classes I and IP" and in rural areas.
Acknowledgements The author is grateful to Mrs D. J. Folwell (OPCS) and Mrs J. Evans (HAA Section, Welsh Office) for supplying the basic data; to Mrs Marjorie Smith for clerical assistance, to Dr A. S. St. Leger for statistical advice and to Mrs B. K. Mahoney for typing the manuscript.
References 1. Ph~'oah, P. O. D. (1976). International comparisons of perinatal and infant mortality rates. Proceedings o f the .Royal Society o f Medicine 69, 335-8. 2. Sims, D. G., Downham, M. A. P. S., McQuillin, J. & Gardner, P. S. (1976). Respiratory syncitial virus infection in north-east England. British Medical Journal ii, 1095-8.
162
J . ltt,'. G. Yarnell
3. Adelstein, A. M. & \Vhite, G. C. (1976). Causes of children's deaths analysed by social class (t959-63). OPCS Studies on Medical aid Population Subjects, No. 31. (Study No. 3).+ London: H.M.S.0. 4. Depart merit of Healtla and Social Security. (1970). Confidential enquirylnto postneonatal deaths 1964-66. Report on Pt~blic Health and Medical Subjects, No. 125. London: H.M.S.O. 5. Benjamin, B. (1953). Tuberculosis and social conditions in the Metropolitan Boroughs o f London. British )auroraloJ" Tuberculosis attd Diseases of the Chest 4'7, 4-17. 6. Stein, L. (1950). A study of respiratory tuberculosis in relation to housing conditions in Edinburgh. British Joun2al of Social tlledichte 4, 143-69. 7. Halliday, J. L. (1928). An inquiry into the relationship between housing conditions and the incidence and fatality of measles, llIedical Research Council, Special Report Series, No. 120. London: Ft.M.S.O. 8. Stocks, P. (1934). The association between mortality and density of housing. Proceedings of the Royal Society o f Medicble 27, 1 127-46. 9. Woolf, B. & Waterh~ause, J. (1945). Studies on Infant mortality. Part I. Influence of social conditions in counly boroughs o f England and Wales. Journal of H)~iene 44, 67-98. 10. Smith, C. M. (1934). Housing conditions and respiratory disease: morbidity in a poor class quarter and in a rehousing area of Glasgow. Medical Research ColotCil, Special Report Series, No. 19. London: H.M.S,O1 I. Schmitt, R. C. (1955). Housing and health on Oahu. American Journal of Public Health 45, 1538-40, 12. Brennan, M. E. & Lancashire, R. (1978). Association o f childhood mortality wilh housing status and unempl0yrraent. Jourttal of Epideraiology and CommtmiO, Health 32, 28-33. i 3. Office o f Population Censuses and Surveys (1977). Mortality statistics; childhood. Review of the Registrar General ondeaths ht England and Wales, 1975. (Series DH3 no. 2). London: H.M.S.O. 14. Wilner, D. M., Price ~Valkley, R., Pinkerton, T. C. & Tayback, M. (1962). The Housing Environment altd Fantily Life. A longitudinal Stud), of the Effects of Housing on Morbidity and Mental Health. Baltimore: John Hopkins Press. 15. Martini, C. J. M., Hughes, A. O. & Patton, V. A. (1976). A study o f the validity o f hospital activity analyst5 information. British Journal af Preventil,e attd Social Medicine 30, 180-6. 16. Haraman, R. F., Haiti, T. & Holland, W. W. (1975). Asthma in schoolchildren: demographic associations and peak expiratory flow rates compared in children with bronchitis. British Jottrnal of Preventfi,e attd Social lt4edicine 29, 228-38.
Do Housing Conditions Influence Respiratory Morbidity and Mortality in Children? A St~xdy o f H o s p i t a l A d m i s s i o n s and R e s p i r a t o r y D e a t h s ~n S e v e n D i s t r i c t s in S o u t h Wales. J. W. G. Yarnell M.B.. D.P.H.
M.R.C. Epidemiology Unit, 4 Richmond Road, Cardiff A study was conducted of the deaths and hospital admissions of children due to respiratory disease in seven districts with widely differing housing standards. No relationship betwc~n the inadequate housing amenities and respiratory mrrbidity and mortality was found but a close relationship between respiratory mortality and overcrowding and o~her socio~economic variables was suggested.
Intr~lnction Inadequate housingstandards have been suggested ~, = as an important contributory cause o f respiratory mortality and morbidity in early childhood. The present study examines morbidity, measured by hosp/tal admissions, and mortality during a six-year period in seven health districts with widely differing housing standards in South Wales. In order to compare the admissions for bronchitis and pneumonia with other hospital admissions which were unlikely to be related to housing conditions, two other diagnostic categories were also examined: asthma and whooping cough. Method Data were obtained from Hospital Activity Analysis (HAA) Section o f the Welsh Office: complete data were available for the hospitals serving the selected districts during the years 1970-5. Data were obtained for the foUowing International Classification of Diseases (ICD) codes (eighth revision) in children aged 0--11 years for each of the abov e years: 033, whoopihg cough; 466, acute bronchitis and bronchiolitis; 470-4, influenza; 480-6, pneumonia; 493, asthma; 51 I, pleurisy; 519, other diseases o f the respiratory system. Cases in which the above code was only a subsidiary diagnosis Were excluded from the analysis. The H A A clerk was contacted in the major admitting hospital for each district in order to obtain an assurance on the completeness of the data; the response was satisfactory. However, one area, Ogwr, recorded a high proportion of diagnoses as ICD code 519 (other diseases o f the respiratory system). This was reported to be due co the tendency o f admitting doctors to record "respiratory infection" as the principal diagnosis. For the purposes of the present analysis this diagnosis has been recorded in the category "bronchitis or pneumonia". In all other hospitals the major contribution to the acute respiratory admissions were recorded as "bronchitis, bronchiolitis or pneumonia". 0038-3506/79/030157+06 $01:00/0
~) 1979 The Society of Community Medicine
.
.
.
,
,,
,
,,,
,
I
II
I
I
~ l i
I
I l
617 8 115 18 13,320 t6,375
Cynon
III
III
IIIIIIII
IIII
727 18 124 20 12,205 i5,050
Mcrthyr
illlilii
lili i
i
ii
-
~
I
373 39 76 15 17,675 21,450
I
III I
I
Illl
il
.
.
.
.
.
533 .
.
.
11"2 5.7
7.9 3'9 .
6.6 0.57 52.5 32-7
4.5 0"55 60.2 23.9
5"33
2"/.~,
Mcrthyr
31.9
Cynon
.
552 ~
6.2 4.3
4.7 0.57 57.8 28.4
14.1
Ogwr
=
544
9.7 9.2
4.8 0'54 67,S 15-8
43.7.
Rhondda
544
6.9 5.0
4.9 0.57 53.5 34.t
16.5
TdffEly
I
IIIIIIIIIII
I
IIIIIIII III
II
I
.
424 15 146 14 20,590 25,320 IIIIII
Vale of Glamorgan
..................................................
607
10'4 5.8
5.9 0'59 49.3 31"4
23.2
496
4"5 3.5
4-4 0"55 56.6 22.9
8.7
Rhymney Valeof Glamorgan
m mllllll
374 23 100 24 22,485 27,295
*Figares available only for health districts: Cynon and Merthyr = Single District; Rhondda and Tail"Ely similarly,
i"
476 56 107 12 15,970 19,895
Rhondda Taft"Ely Rhymney
TABLE 2. Selectedhousing indicesnnd demographic variab[csby district
(
837 53 140 12 25,310 30,890
Ogwr
*Rates are based on population 0-11 years for admissions, 0-14 years for deaths.
Per cent liouseswith 4 or more persons lackingamenities Per cent houses with more than one person per room Average no. of persons per room Per cent houses owned by occupier Per cent hoases rented from council Per cent economically active males out of employment Population density (persons per hectare) Average no. of children 0-14 years per ~'eneral practitioner*
~ 1
Bronchitis and pneumonia Whooping cough Asthma Death rates (all acute respiratory infections) Population aged 0-11 years Population aged 0-14 years
.
Hospital admission rates
TABIo~.I. Mean annual hospital admissions for selected respiratory diagnoses and respiratory disease deaths in children per 100,000child population* by district
*P
Admissions Bronchitisetc, Whoopingcough Asthma Deaths 0,14 0,1I -0,43 0,17
-0,11 0,29 -0,54 0,56
--0,10 0,06 --0,22 0,63
0,36 0,21 0,21 -0,74*
-0,21 -0,04 -.0'43 0,56
0,07 0,04 -0,43 0,63
-0,14 0,64 -0,61 0,15
-0'09 0+66 -0'50 0'07
Houses Housm No, children lacking I+ persons No, persons owncd rentedfrom UnemployedPopulation 0-14 yrs amenities per room per room by occupier council males density per G,P,
Houses Houseswith
TABLE3, Valuesof Spearman'srankcorrelationcoemcientsfor variablesof Tables I and 2,
160
d.W.G.
Yarnell
The address codes conformed to the reconstituted local authority districts following the Local Government Act 1972. Because of day-to-day changes in the catchment areas of some hospitals all eligible child admissions were scrutinized in all hospitals in South Wales. Mortality data were obtained from the Office of Population Censuses and Surveys; deaths due to acute respiratory disease were extracted from the ICD "B" lists available for local areas. Demographic and housing data were taken from the 1971 Census County Reports for the reconstituted local authorities. The Family Practitioner Committees provided the numbers of general practitioners for each district. Results Table 1 shows the average annual respiratory disease admissions and deaths per I00,000 child population. Both admissions and death rates show wide variation from district to district with at least a twofold difference between ~he districts with the highest and lowest admissions or deaths. Admissions for whooping cough show a sevenfold difference between the districts with the highest and lowest admission rates. Ther~ is no obvious relationship between admissions and deaths from respiratory disease. The patterns for admissions and deaths are also similar in each area if separate age groups of children (0-4 years and 5-14 years) are considered. ~a~le 2 shows housing indices and other demographic variables which were believed to be relevant to admissions and deaths from respiratory disease. The first index, houses with four or more persons lacking amenities, was chosen to maximize the possibility that such houses contained young children, since it was found that in. all districts the greatest proportion of houses without amenities were inhabited by one or two persons only, i.e. typically the elderly. Certain other variables such as the availability o f paediatric beds were also examined but were rejected since reliable data could not be obtained for all districts. The figures reflect the character of each district: Rhondda, Merthyr and Cynon--depopulating mining valleys with a large stock of older houses; Rhymney, Ogwr and TaffEly-growth areas with new industrial development; and the Vale of Glamorgan--a rural residential area. Table 3 shows the valiJes of the rank correlation coefficients for the deperLdent (Table t) and independent (Table 2) variables. Although only one value reaches the conventional level of statistical significance the pattern of valuers for each of the dependent variables is of interest. Admissions for bronchitis and pneumonia do not correlate with any o f the independent values, except weakly and positively with the percentage of houses owned by the occupiers. Whooping cough admissions correlate weakly with the percentage of "overcrowded" houses but strongly with increasing population density and average child population per general practitioner. Asthma admissions seem to be correlated with factors associated with decreased socio-economic status but more strongly ..,:,~.~,~,, i~.~,.,.oo,~,-.,o,,,Ja . . . . 1. . . . .v.v. i s u t a t e. d ' . .(i.e. . .more . . ~u~,,,~ hahltats.___ Finally, deaths due to respiratory disease show little relation to lack of amenities but are correlated with overcrowding. Even stronger are the correlations with other socio-economic factors: owner-occupancy, council tenancy and level of unemployment. Discussion The findings support the view that socio-eeonomie factors and overcrowding play art importartt contributory role in acute respiratorY deaths o f children. This is in agreement with other work. For example, children aged one to four years from social class V families are known to
Respirator)" morbidit.v attd mortality in children
161
have over twice the death rate from respiratory disease (largely pneumonia) than children from social classes I and 1I.3 Parental and social factors have been stated to be responsible for 71 ~ of avoidable post-neonatal deaths, which were predominantly due to respiratory disease? Similarly, overcrowding has been shown to be associated with arl increased incidence of tuberculosis, 5, ~ and measles, 7 and also with mortality principally due to respiratory infection.8. From the present results it appears that inadequate housing amenities do not significantly influence respiratory morbidity a n d mortality in children. Although this index represents only one possible index o f dilapidation other such indices would seem to be less reliable as an indication of general standards. For example, figures derived from local housing dearance programmes and grant improvement areas (GIAs under the 1968 Housing AeQ are dependant on the policies and financial resources of individual district councils. In support o f the present results other workers have also failed to incriminate dilapidation of the home as a significant contributory cause of respiratory morbidity 1° or infant mortality, a~ This is in apparent contrast to the findings of Brennan & Lancashire 12 who studied childhood mortality (from all causes) in the county boroughs of England and Wales during the year 197I. These authors demonstrate that overcrowding and inadequate housing amenities have highly significant associations with child mortality under five years o f age when the effects of social class and unemployment are eliminated. They do not demonstrate (by the use of partial correlation coefficients) independant associations between overcrowding on the one hand and inadequate housing amenities on the other, and childhood mortality. It is also worth noting that, in England and Wales among children under five years of age, accidents account for approximately 6 ~o and respiratory disease for 13 ~o of all deaths, a3 Adelstein & White ~ have demonstrated very steep social class gradients in deaths due to accidents in children aged one to four years; other authors 1~havenotedthat the incidence of accidents to children is much lower among families rehoused in modern accommodation. It is suggested that, where possible specific causes of mortality should be examined, since these relationships are likely to shed" most light on the mechanisms by which socio-economic factors contribute to childhood mortality. Hospital admissions for bronchitis and pneumonia were not correlated significantly with any factors included in the present study. H A A data has been validated elsewhere and the percentage of missing information and errors found to be low. ~s The admissions for whoop~ng cough and asthma also support this since the pattern of admissions accord with prior expectations; whooping cough admissions are associated with high population density and possibly with the extent of immunization by general practitioners; asthma is more common among families of social classes I and IP" and in rural areas.
Acknowledgements The author is grateful to Mrs D. J. Folwell (OPCS) and Mrs J. Evans (HAA Section, Welsh Office) for supplying the basic data; to Mrs Marjorie Smith for clerical assistance, to Dr A. S. St. Leger for statistical advice and to Mrs B. K. Mahoney for typing the manuscript.
References 1. Ph~'oah, P. O. D. (1976). International comparisons of perinatal and infant mortality rates. Proceedings o f the .Royal Society o f Medicine 69, 335-8. 2. Sims, D. G., Downham, M. A. P. S., McQuillin, J. & Gardner, P. S. (1976). Respiratory syncitial virus infection in north-east England. British Medical Journal ii, 1095-8.
162
J . ltt,'. G. Yarnell
3. Adelstein, A. M. & \Vhite, G. C. (1976). Causes of children's deaths analysed by social class (t959-63). OPCS Studies on Medical aid Population Subjects, No. 31. (Study No. 3).+ London: H.M.S.0. 4. Depart merit of Healtla and Social Security. (1970). Confidential enquirylnto postneonatal deaths 1964-66. Report on Pt~blic Health and Medical Subjects, No. 125. London: H.M.S.O. 5. Benjamin, B. (1953). Tuberculosis and social conditions in the Metropolitan Boroughs o f London. British )auroraloJ" Tuberculosis attd Diseases of the Chest 4'7, 4-17. 6. Stein, L. (1950). A study of respiratory tuberculosis in relation to housing conditions in Edinburgh. British Joun2al of Social tlledichte 4, 143-69. 7. Halliday, J. L. (1928). An inquiry into the relationship between housing conditions and the incidence and fatality of measles, llIedical Research Council, Special Report Series, No. 120. London: Ft.M.S.O. 8. Stocks, P. (1934). The association between mortality and density of housing. Proceedings of the Royal Society o f Medicble 27, 1 127-46. 9. Woolf, B. & Waterh~ause, J. (1945). Studies on Infant mortality. Part I. Influence of social conditions in counly boroughs o f England and Wales. Journal of H)~iene 44, 67-98. 10. Smith, C. M. (1934). Housing conditions and respiratory disease: morbidity in a poor class quarter and in a rehousing area of Glasgow. Medical Research ColotCil, Special Report Series, No. 19. London: H.M.S,O1 I. Schmitt, R. C. (1955). Housing and health on Oahu. American Journal of Public Health 45, 1538-40, 12. Brennan, M. E. & Lancashire, R. (1978). Association o f childhood mortality wilh housing status and unempl0yrraent. Jourttal of Epideraiology and CommtmiO, Health 32, 28-33. i 3. Office o f Population Censuses and Surveys (1977). Mortality statistics; childhood. Review of the Registrar General ondeaths ht England and Wales, 1975. (Series DH3 no. 2). London: H.M.S.O. 14. Wilner, D. M., Price ~Valkley, R., Pinkerton, T. C. & Tayback, M. (1962). The Housing Environment altd Fantily Life. A longitudinal Stud), of the Effects of Housing on Morbidity and Mental Health. Baltimore: John Hopkins Press. 15. Martini, C. J. M., Hughes, A. O. & Patton, V. A. (1976). A study o f the validity o f hospital activity analyst5 information. British Journal af Preventil,e attd Social Medicine 30, 180-6. 16. Haraman, R. F., Haiti, T. & Holland, W. W. (1975). Asthma in schoolchildren: demographic associations and peak expiratory flow rates compared in children with bronchitis. British Jottrnal of Preventfi,e attd Social lt4edicine 29, 228-38.