Consumers' views of the maternity services: implications for change and quality assurance.

The feasibility and usefulness of consumer surveys for quality assurance and planning maternity services were assessed in a postal survey of 1807 women in four health districts representing a range of social and demographic characteristics. A response rate of 79 per cent was achieved. Scope was identified for some reduction in length of stay: 43 per cent of postnatal women wished for a shorter stay than they have actually experienced. The Domino system and a 1-2 days stay were the preferred options (25 and 24 per cent respectively). Six per cent of postnatal women would have preferred a longer stay than experienced and consisted mainly of women with birth complications including caesarean deliveries, women with lack of help at home and Afro-Caribbeans. Schemes to increase continuity of care and make the delivery suite more home-like would be favoured by a large proportion of women. Sixty-five per cent of women regarded continuity of midwifery care and familiarity with the delivering midwife as important. Seventy-five per cent considered a home-like environment in the delivery suite as important, and gave specific suggestions of how this might be achieved. The results show that consumers' surveys are feasible, with a good response rate and range of views expressed by the study population. They can assist in monitoring quality and provide guidance for planning at local and regional levels.

A health visitor investigation of home accidents in pre-school children.

The incidence and characteristics of home accidents in pre-school children were investigated in the northern part of Lambeth with the help of health visitors. Accidents were identified using the notification system from accident and emergency departments to health visitors. The study shows that there is not an easily identifiable group of high risk children so all must be regarded as potentially at risk. It also highlights how important it is that accidents treated at hospital are notified to health visitors and some ways for improving the system are suggested.

Respiratory illness and home environment of ethnic groups.

Factors contributing to differences in the prevalences of respiratory symptoms and diseases among ethnic groups were studied in primary schoolchildren living in 20 inner city areas of England in 1983. The raised prevalences of respiratory symptoms in these groups were compared with results from a national representative sample of children studied in 1982. Data on age, sex, respiratory illness, and social and environmental variables were obtained by questionnaire for 4815 children living in inner cities. The children were classified as white, Afro-Caribbean, Urdu, Gujarati, Punjabi, other Asian, or "other." Significant differences in the prevalence of respiratory conditions were found among the ethnic groups after allowance was made for the effects of interfering variables. Except for asthma all conditions were most prevalent in Afro-Caribbeans and whites. In these two ethnic groups respiratory illness was significantly associated with belonging to a one parent family and the combined use of gas cookers and paraffin heaters at home. Respiratory illness was found to vary in prevalence among ethnic groups but may be perceived differently by different groups. Further studies, measuring lung function, are necessary.

Investigations into the relations between respiratory illness in children, gas cooking and nitrogen dioxide in the U.K.

In 1977 an association was reported between the prevalence of respiratory illness and use of gas for cooking at home in a national sample of six to 11 year olds living in England and Scotland (p less than .10). Other variables such as social class and number of cigarette smokers at home did not seem to explain the association. As the gas cooker is an unflued appliance emitting a variety of pollutants during gas combustion it was suggested that indoor air pollution might explain the finding. Nitrogen dioxide (NO2) was suspected so a series of studies was conducted to investigate the distribution of levels of NO2 in the home, the relative contribution of sources of NO2 to indoor exposure and the relation between respiratory illness in six to 11 year olds and levels of NO2 in the home. The gas cooker was found to be one of the main sources of NO2 in the home. Winter weekly averages in kitchens with gas cookers had a mean of 112.2 ppb (n = 428, range 5-317 ppb). Levels in electric cooking kitchens were significantly lower (n = 87, mean 18 ppb, range 6-188 ppb). Studies of health indicated a relation between respiratory illness and bedroom levels of NO2 over the range 4-169 ppb (p .10). Results for living room levels of NO2 suggested a similar but non-significant relationship (p greater than .10). No relation was found for kitchen levels of NO2. For schoolchildren any effect on health from indoor NO2 is likely to be weak. However other sections of the population such as infants and the elderly who may spend more time indoors and are particularly susceptible to respiratory illness need to be studied to assess fully the impact that NO2 may be having on health.

Suitability of a new turbine spirometer for epidemiological surveys in children.

The performance of a new turbine spirometer, which has several advantages over equipment previously used to measure lung function, was compared with that of a conventional spirometer (Vitalograph) in a cross-over trial on 368 children six to 11 years old. On average, slightly higher values of forced expiratory volume at 0.75 s and forced vital capacity were recorded on the turbine spirometer. These differences occurred mainly in children aged less than eight years. Assuming the Vitalograph remained accurate, there appeared to be a slight tendency for readings on the turbine spirometer to drift downwards at a rate of 0.04 1 per 100 children measured but this was not statistically significant (p greater than 0.10). In conclusion, the machines differed mainly in the youngest age group. Until a recording of the complete expiration curve can be made using the turbine spirometer, it is not possible to assess whether this effect of age arose because of errors in the breath manoeuvre by younger children undetectable in the turbine spirometer or because the simpler design of the spirometer makes it easier than the Vitalograph for young children to use it correctly.

Childhood respiratory illness and the home environment. I. Relations between nitrogen dioxide, temperature and relative humidity.

The relation between the use of gas for cooking, nitrogen dioxide (NO2), temperature and relative humidity was investigated in an urban area of northern England. In a pilot study conducted in a random sample of 40 homes measurements of temperature and relative humidity were not significantly different between homes with a gas cooker and homes with an electric cooker but weekly average levels of NO2 were higher in bedrooms (p less than 0.005) and living rooms (P less than 0.01) of gas homes. In the main study conducted in gas cooking homes only, access was gained to 183 (54.3%) of 337 randomly selected homes. No correlation was found in children's bedrooms between with weekly average level of NO2 (range 4.7 to 160.8 ppb) and weekly average temperature (ranged 7.7 to 22.0 degree C; r = 0.05, p greater than 0.10) or relative humidity (range 37.0 to 98.1%; r = 0.07, p greater than 0.10). Levels of NO2 in the bedroom were positively correlated with those in the living room (range 9.0 to 292.2 ppb; r = 0.39, p less than 0.01). Factors which tended to be associated with high levels of NO2 in the home included gas fires, paraffin heaters and use of the cooker for heating and drying clothes.

Childhood respiratory illness and the home environment. II. Association between respiratory illness and nitrogen dioxide, temperature and relative humidity.

The relation of respiratory illness to nitrogen dioxide (NO2), temperature and relative humidity in homes with a gas cooker was investigated in five and six year old children living in an urban area of the northern England. NO2 was measured for one week in the child's bedroom and living room of each home, and temperature and relative humidity were measured in the bedroom only. Information on respiratory conditions experienced by the child and characteristics of the home was collected in a self-administered questionnaire completed by the child's mother. Access was gained to 183 homes (54.3% of 337) where only gas was used for cooking. Complete information was obtained for 179 (93.7%) of 191 children who lived in the 183 homes. After allowing for the effects of age, sex, social class, and number of cigarette smokers in the home and temperature or relative humidity, no statistically significant relation was found between the prevalence of having one or more respiratory conditions and weekly average levels of NO2 in the bedroom (range 4.7 to 160.8 ppb) or living room (range 9.0 to 292.2 ppb). However, the prevalence of having one or more respiratory conditions tended to be highest in homes with high levels of NO2 and lowest in homes with low levels, consistent with earlier findings. A significant positive association was found between the prevalence of respiratory conditions and relative humidity (p less than .05). A harmful effect on health from NO2 cannot be totally dismissed but if it exists it is weak and difficult to detect in small samples of children.

Respiratory illness in British schoolchildren and atmospheric smoke and sulphur dioxide 1973-7. I: cross-sectional findings.

The relation between respiratory illness and atmospheric smoke and sulphur dioxide (SO2) was investigated from 1973 to 1977 in children aged 6 to 11 from a random sample of 28 areas in England and Scotland. Cross-sectional results are presented for 1975, and results from other years briefly summarised. In 1975 there were 19 areas with data on pollution and in these areas the sample included 5787 children of white ethnic origin of whom 4116 (71%) had complete information of respiratory illness and other variables considered in the analysis. After allowing for the effects of age, social class, population density, type of fuel used for cooking in the home, and season of examination, the prevalence of respiratory illness in both sexes was in the home, and season of examination, the prevalence of respiratory illness in both sexes was positively associated with the levels of smoke over the range of annual means 8 to 51 microgram/m3 )P less than or equal to 0.05). No relation was found between illness and annual means of SO2 ranging from 12 to 114 microgram/m3. Similar results were found in other years, and in 1977, when information of tobacco smoking at home was collected, the association between illness and atmospheric smoke appeared to be independent of smoking within the home. The levels of smoke were much lower than those at which effects on health hve previously been reported so the association is unlikely to be causative. We postulate that higher levels of atmospheric pollution at an earlier period in some areas may have predisposed children living there to respiratory illness during their primary school years. Alternatively, some other characteristics of the polluted areas may explain the findings.

Respiratory illness in British schoolchildren and atmospheric smoke and sulphur dioxide 1973-7. II: longitudinal findings.

A study was set up to investigate the effects of annual changes in the levels of atmospheric smoke and SO2 on changes in health from 1973 to 1977 in primary schoolchildren from 28 randomly selected areas of England and Scotland. Changes in health were measured by taking the change in number of respiratory conditions reported from one annual examination to the next. The number of areas with data on pollution in each period was 5,9,17, and 14 respectively and within these areas the response rate varied from 65% to 74%. Altogether 857, 1436, 2702, and 2036 children respectively who were of white ethnic origin, aged 6 to 11, and had complete data on sex, social class, and changes in health were studied in each period. In 1973-4 the levels of pollution were highest and showed the greatest decline. The greatest annual mean change in smoke was a decrease from 71.9 to 50.5 microgram/m3 and in SO2 a decrease from 94.2 to 47.6 microgram/m3. However, no relation was found between improvement in health and decreasing levels of pollution. In subsequent years, when the levels of pollution were lower and showed smaller changes, change in health was also unrelated to changes in pollution. Thus no evidence was found to suggest that the levels measured during the study were harmful to health.

The relation between respiratory illness in primary schoolchildren and the use of gas for cooking--II. Factors affecting nitrogen dioxide levels in the home.

The study was designed to determine whether there was an association between indoor levels of nitrogen dioxide (NO2) and respiratory illness and lung function in schoolchildren. NO2 was measured for one week in the winter outside and inside the homes of children aged 6-7 years living and attending primary schools in a defined 4 square km area in Middlesbrough, Cleveland, UK. Outdoor levels of NO2 measured at 75 points within the area ranged from 14-24 ppb weekly average. Measurements were also made in 428 kitchens with gas cookers, range 5-317 ppb, mean 112.2 ppb, and in 87 kitchens with electric cookers, range 6-188 ppb, mean 18.0 ppb. In a random subsample of homes the range of NO2 levels in 107 children's bedrooms in homes where gas was used for cooking was 4-169 ppb, mean 30.5 ppb, in 18 bedrooms in electric cooking homes the range was 3-37 ppb, mean 13.9 ppb. NO2 levels in the gas cooking kitchens were positively related to the presence of pilot lights, use of gas fires for main heating, number of regular smokers, and the number of people in the home. Information from 29 homes with the highest kitchen NO2 levels paired with 29 low NO2 gas cooking homes showed that the daily number of meals eaten and the frequency with which the cooker was used for heating and drying clothes were significantly greater in the high NO2 homes.

The relation between respiratory illness in primary schoolchildren and the use of gas for cooking--III. Nitrogen dioxide, respiratory illness and lung infection.

We examined the relation between lung function and respiratory illness in a population of 808 primary school children aged 6-7 years and the levels of nitrogen dioxide (NO2) in the kitchens and bedrooms in their homes. Complete data were collected on about 66% of the population. The children lived in a defined 4 square km area in Middlesbrough, Cleveland, UK. One week average outdoor levels of NO2 varied little over the area (14-24 ppb); The prevalence of respiratory illness was higher in children from gas than electric cooking homes (p approximately or equal to 0.1). Although prevalence was not related to kitchen NO2 levels (range 5-317 ppb) it increased with increasing levels of NO2 in the children's bedrooms in gas cooking homes (range 4-169 ppb, p approximately or equal to 0.1). Symptoms in siblings and parents were not related to kitchen NO2 levels. Lung function was not related to NO2 levels in the kitchen or bedroom. Because of the very low levels of NO2 at which an association with illness was observed and the inconsistency between our results in the UK and those from several studies in the US, it is possible that the NO2 levels were a proxy for some other factor more directly related to respiratory disease such as temperature or humidity.

Association between gas cooking and respiratory disease in children.

A four-year longitudinal study of the prevalence of respiratory symptoms and disease in schoolchildren and related environmental and socio-economic factors is in progress. We report results for the first year of this study (1973). A total of 5758 children aged 6 to 11 years from 28 randomly selected areas of England and Scotland were examined. In an analysis of the effects on health of possible indoor pollutants, boys and girls from homes in which gas was used for cooking were found to have more cough, "colds going to the chest", and bronchitis than children from homes where electricity was used. The girls also had more wheeze if their families used gas for cooking. This "cooking effect" appeared to be independent of the effects of age, social class, latitude, population density, family size, overcrowding, outdoor levels of smoke and sulphur dioxide and types of fuel used for heating. It was concluded that elevated levels of oxides of nitrogen arising from the combustion of gas might be the cause of the increased respiratory illness.