November 1955 345

Socio-economic Conditions of Tuberculous Patients in Northern Ireland

By A. BARR Statistician, Oxford Regional Hospital Board, formerly Northern Ireland Tuberculosis Authority

In a recent survey into the extent and need for a rehabilitation service for tuberculous patients in Northern Ireland (Barr, z953, I955) certain information was collected concomitantly on the patients' environ- mental and economic circumstances. As it is felt that these details possibly might be of some general interest, the main findings of this particular section of the enquiry are presented in this paper.

At the outset it should be noted that the survey was confined to patients whose disease had been classified either 'quiescent' or 'arrested,' since in any rehabilitation scheme the candidates would be drawn principally from this group. The sample of 4oo was chosen by random numbers from 7,o68 eligible patients who formed approxi- mately half of the total register of known tuberculous cases in the Province. Apart from the percentage employed, it seems reasonable to conclude from a number of relevant comparisons that the environmental data is representative of the total population of tuberculosis patients amounting to z4,838 persons at January I, z953.

The survey was carried out during the first quarter of I953 by the Health Visitors (37 in all) of the Northern Ireland Tuber- culosis Authority. Each Health Visitor was responsible for the sample members within her own particular area. Such an arrange- ment had the inherent advantage that the investigator generally knew the patients' circumstances intimately.

Inevitably, a number of persons could not be traced or refused to co-operate in the survey. In all, there were 72 (i8.o per cent) sample failures, but no material differences were discovered between these cases and the original sample for certain known

characteristics.* Therefore, although it can- not be definitely asserted that the sample failures do not bias the findings, there is no reason to believe that they constitute a different group from the remaining 328 subjects and they are ignored in the further analysis of the results.

Housing Conditions The majority (216 or 65- 3 per cent) of the patients lived in terrace houses while 63 (i 9 .2 per cent) lived in detached houses and 49 (x4"9 per cent) resided in semi-detached houses. No less than 312 (95"z per cent) of the patients lived in homes where the tenancy was the whole house while in a further 7 (2-i per cent) the tenancy was restricted to a part of the house. In the other cases, the patient either lived in a flat or rooms.

The state of repair of the house was termed 'good' if it was structurally fit, weatherproof and dry, while deviations from this were denoted by 'fair' and 'poor'. Of the 328 houses visited 67. 3 per cent came within the definition of 'good' while approxi- mately z 5 per cent were 'fair' and a further z 5 per cent wcrc damp. The remaining 2 per cent wcre neglected and in nccd of extensive repair.

When considering such questions as lighting and ventilation of prcmises it is difficult to apply any accurate standard of measurement as a great deal depends upon the subjectivc standards of the investigator. Generally speaking, lighting and vcntilation were regarded as unsatisfactory if:

(a) living rooms were so dark as to hinder domestic work without artificial light and it was difficult to sec whether the rooms were clean.

*The criterion adopted throughout was the 5 per cent level of probability.

346 T U B E R C L E November 1955

(b) Windows in the living rooms and bedrooms we/:e smaller than one-tenth of the floor area and were incapable of opening at least 5o per cent.

(c) Rooms and bedrooms without a flue and fireplace had not a special ventilating opening of at least 3o sq. in. unobstructed area.

The percentage of ill-lit and badly ventilated houses is relatively small as can be seen from Table I.

TABLE I.-ANALYSIS OF 328 HOUSES BY" LIGHTING AND "VENTILATION

Lighting Ventilation Per- Per-

Standard Number centage Number centage Good .. 299 9 I'2 3o2 92"o Bad .. 29 8.8 26 8.o

Total 328 xoo.o 328 Ioo.o

Unsatisfactory lighting was not invariably associated with poor ventilation. O f the 29 cases in which lighting was bad, 7 had adequate ventilation, while of the 26 instances of insufficient ventilation, 4 had satisfactory lighting. Defective lighting and ventilation were combined in 22 instances representing 6- 7 per cent of the total houses visited. Approximately one-quarter of the ill-lit premises and almost one-fifth of the badly ventilated houses were located within the city boundary of Belfast.

A water supply in the house was found in 258 (78"8 per cent) instances; I45 were in Belfast and the remaining 113 were located in the remainder of the Province. O f the Belfast houses, 7I had a hot and cold supply while 74 had a cold supply alone. Only one house in Belfast had no supply in the house, but there was a supply available in the yard. Outside Belfast, 65 had both hot and cold water, and 48 had an internal cold water tap. The remaining 69 houses were without a water supply in the house; in r1 cases the water had to be carried a distance greater than one furlong but in only one instance was the source farther than one mile.

It is interesting to compare these figures

with those obtained in an earlier survey of Old People in Northern Ireland (Adams and Cheeseman, I95I), i n which it was found that approximately half the houses visited in Belfast had hot and cold water while the rest with one exception had cold water internally or from a tap in the yard. The findings of the present survey corres- pond closely; 48.6 per cent of the Belfast houses had hot and cold water while the remaining 5 I-4 per cent had a cold supply either in the house or yard. There is not, however, the same assimilation in the rest of the Province. In the Old People's survey, about a quarter had hot and cold water available while 14 per cent had a cold supply in the house, whereas in this present survey 35"7 per cent of the provincial houses had hot and cold water laid on and 26"4 per cent had a cold supply only. Probably the experience found in both surveys in Belfast is generally applicable, while in the other part of the Province where a direct supply of water is not so common, the presence of a hot or cold supply or even a cold supply alone is determined largely by economic and social influences.

The availability of a direct water supply governs to some extent the type of sanita- tion. Thus it might be expected that there would be 258 houses with flush water closets. In fact, there were 262 (80.0 per cent) the difference being accounted for by cases in which the water closet was used jointly by a numbcr of houscs with a common sourcc of domestic water available within a few yards.

Living Conditions The numerical size of family varied fron~ a patient living alone to a family of 9 adults and 5 children. The maximum number of adults (i.e. persons of 15 years of age and over) in any one family was 9, while the maximum number of children was 7. Counting a child as a person the mean number of persons in the family was 4"7, which is greater than the census of Popula- tion (I95I) figure of 3"99 persons (Registrar- General for Northern Ireland, i955).

November 1955 T U B E R C L E 347

T h e living accommoda t ion of the pat ients is summar ized in Tab l e I I .

TABLE II . - LIVINO ACCOMMODATION OF SAMPLE I~.IEMBERS

,Number of Percentage `Number of rooms households of total

Bed/living room . . 3 0"9 I living- I bedroom I8 5"5

room-}- 3 bedrooms 59 i8.o 3 ,, 74 22.6 4 ,, 5 i "5

living- i bedroom I o. 3 rooms-}- 2 bedrooms 52 I5"9

3 ,, 73 22.3 4 ,, I8 5"5 5 ,, 6 1-8

3 ° r m ° r e I bedroom ~ - - living- 2 bedrooms I 0- 3 rooms+ 3 ,, I 0. 3

4 ,, Io 3.0

(o5r more) 7 2" I

Total 328 xoo'o

Needless to say, the patients residing in a house with three or more l lving-rooms were economical ly dependen t on o ther members o f the household. In 2 instances, the patients lived on farms o f over Ioo acres, while in 2 o ther cases the head of the house was self- employed in a prosperous business. In the remaining cases, there were at least 3 adul t members in full-time remunera t ive employ- ment .

In I33 (40"5 per cent) cases the pat ient did not share the bed room with anyone, while in a fur ther I38 (42"I per cent) the bed room was shared with an adult . In the remaining 57 (I7"4 per cent) instances the pat ient shared the bed room with I or more chi ldren or with 2 or more adults. T h e greatest n u m b e r shar ing a bed room was 6 adults and r child, while in 3 instances the bed room was shared wi th 4 children. A separate bed was used by I62 (49"4 per cent) patients; I49 (45"4 per cent) shared the bed with x adult ; in 5 ( I ' 5 per cent) cases the bed was shared with a child; in 2 (0. 7 per cent) it was shared with 2

chi ldren; in 7 (e.I per cent) it was shared wi th I adul t and x child; in 2 (0. 7 per cent) it was shared with I adul t and 2 chi ldren and in I (0. 3 per cent) it was shared with 2 adults.

I t is r a the r surprising to find that in no less than 60 per cent o f the sample the pat ient shared the bed room with one or more per- sons, while over 5 ° per cent o f the total cases h a d not got a separate bed. In over- c rowded* families it is p robab ly unavoidable tha t the pat ient should have to share a bed, bu t even after el iminating this group the bed room is shared in 57"7 per cent and the bed in 49 "5 per cent o f the non-overcrowded families. Such conditions are the more remarkab le when one considers tha t the Author i ty ' s Welfare Scheme provides for bed and bedding on a frcc loan basis dur ing the patient 's illness.

In i7 .4 per cent o f the sample there was more than one tuberculous pat ient in the household (see Ta b l e H I ) .

TABLE I I I. - NUMBER OF TUBERCULOUS PATIENTS IN HOUSEIIOLDS OF SAMPLE I-~[EMBERS (FIGURES 1N BRACKETS INDICATE NUMBER OVERCRO~.VDED)

`Number in fami~ `Number of Percentage tuberculous households of total

Patient alone 27t 82.6 Patient + i child I I ( I ) 3"4

,, -}- 2 children 3(3) 0"9 ,, + I adult 32(2) 9-8 ,, -a t- 2 aduhs 8(i) 2- 4 ,, + 3 adults I 0. 3 ,, + I adult and

2 ctfildren 2 0.6

Total 328(7) Ioo.o

O u t o f the 57 households in which there was more than one pat ient , only 7 occurred in families living in overcrowded conditions at the t ime o f the survey. T h e major i ty of the families with mult iple cases had at one t ime been living in overcrowded accommo- da t ion and h a d been rehoused because o f the presence o f tubcrculosis.

*The definition of overcrowding is that used in the Census of Population, namely, where there is an average of more than two persons per room, irrespective of age or sex of the individual members of the family.

348 T U B E R C L E November 1955

The Extent of poverty The numbers of persons in full-time employ- mcnt varied from the family with no one working to 7 full-time working members. O f the total, 28 (8- 5 per cent) had no one employed; I27 (38.7 per cent) had I person employed; 87 (26. 5 per cent) had 2 employ- ed, 5 ° (I5.2 per cent) had 3 employed, while 36 ( i i - i per cent) had 4 or more employed.

The survey was not originally designed to measurc the extent of poverty prevailing among patients , but it is felt that even a rough estimate of the degree of poverty in the sample may "be of some value and interest. Most enquiries into financial cir- cumstances suffer from the real hindrances of refusal to give the information sought and from the possibility of inaccurate details being tendered, and consequently, unless the information is meticuIously cross-checked the results at the best can only bc approxi- mate. No attempt has been made to check the present data; if the details appeared inconsistent, the interviewer was asked to verify the patient's statement. The section on financial circumstances was in fact optional with the result that 59 sample members withheld details. Thus the informa- tion relates to 269 patients only.

In order to determine the degree of poverty it was first of all necessary to decide upon a poverty line. The most appropriate seemed to be that suggested by Scebohm Rowntree and Lavers (I95I) in an investiga- tion into poverty in the City of York. After allowing for the cost of food, fuel and light, repairs to clothing and sundry expenses like a daily newspaper, wireless licence, travel- ling, holiday, books, toba'cco, drink, etc., but excluding any allowance for rent and rates, the authors concluded that the absolute minimum income required for differently constituted families was as follows:

Un- Employed employed £ s . d . £ s . d .

Man alone . . . . I I6 I I I7 II Woman alone . . . . x IX I I 13 2

Two women living to- gether . . . . 2 t 4 7 ~ 14 x

Man and woman .. 2 17 2 2 ~6 o Man, woman and one

child . . . . . . 3 I I I I 3 I O I I

~'Ian, woman and two ctfildren . . . . 4 6 4 4 5 4

h Ian, woman and three children . . . . 5 o 2 4 I9 2

For each additional dependent child, the sum of i4s. was allowed; for each additional dependent adult female the sum allowed was I5S. I Id., while for each dependent male adult an allowance of I9S. was made. On this standard, 2 (I. 5 per cent) of the employed sample members, i8 (I5. 9 per cent) of the unemployed sample members, and I (I.2 per cent) of the housewives were in poverty, giving an overall figure of 2I (6. 4 per cent). The high level of poverty in the unemployed group is noteworthy. O f the i8 families in this category, 9 patients were the head of households with young families from 2 to 6 children. In several instances, families were just above the basic standard. If, for any reason, the economic circumstances of the family should deteri- orate, for example through the illness or unemployment of another member, the surplus margin would quickly disappear and the family would be forced into substandard existence. While the actual extent of and the reasons for the existence of poverty among tuberculous patients cannot be ascertained from the present survey, there seems to be little doubt that it does exist especially in families where the patient is head of the house and is unemployed. This subject is well worth special consideration and in- vestigation.

Summary

( I ) The results of a survey of social and environmental circumstances of a group of tuberculous patients in Northern Ireland are reported. In all, 328 patients were investigated out of a total of 40o originally selected.

(2) The majority of the patients resided in separate tenanted houses.

No~'erab'er 1955 T U B E R C L E 349

(3) Approximately 17 per cent of the houses were in a bad state of repair.

(4) Unsatisfactory lighting and]or venti- lation occurred in just over 8 per cent of the cases.

(5) All the houses in Belfast had a water supply in the house or yard; the correspond- ing percentage for the rest of the Province was 62.I per cent.

(6) The average number of persons in the families visited was 4"7 persons.

(7) A separate bedroom for the patient was available in x33 (40"5 per cent) in- stances. A further I38 (42.I per cent) shared t h e bedroom with one adult. The remainder either shared the bedroom with one or more children and/or two or more adults.

(8) I62 (49"4 per cent) patients slept in a separate bed, x49 (45"4 per cent) shared the bed with one adult, and the remainder shared the bed with one or more children.

(9) In 57 (I7.4 per cent) cases, there was more than one patient in the household.

(Io) It is believed that a certain degree of poverty exists especially in households where the patient is head of the family and is out of work. The actual extent of the prevailing poverty cannot be measured by the present survey, but it is suggested that the subject should be investigated more closely.

Acknowledgment

I should like to thank the Northern Ireland Tuberculosis Authority, the Health Visitors of the Authori ty, especially Miss A. Brown, and Dr E. A. Cheeseman of the Depart- ment of Social and Preventive" Medicine of the Queen's University, Belfast, for their co-0peration and assistance.

- r - "

References Adams, G. F., and Cheeseman, E. A. (x95 I) Old Persons

in Northern Ireland. Belf~t: Northern Ireland Hospitals Authority.

Barr, A. (1953) A Social Account of Tuberculosis in Ireland. Unpublished thesis available at the Queen's University, Belfast.

Barr, A. (1955) British ffournal of Preventive and Social Medicine, Ix, xol.

Registrar-General for Northern Ireland (1955) Personal Communication.

Seebohm Rowntree, B., and Lavers, G. R. (,95 Q Poverty and the Welfare State. London- Longrnans, Green and Co.

(concluded from page 344)

References

[x] Irish Trade 07oun,al and Statistical Bulletin (z951) June, p. 76.

[2] Irish Trade 07ournal and Statistical Bulletin (x954) September, p. I53.

[3] Hess, Evelyn V., and Macdonald, Norman (z954) Lancet, il, x3~.

[4] Census of Population 195I (Ireland) Memorandum on changes in, and distribution of population by areas, p. 6.

[5] Census of Great Britain 195x. [6] Deeney, James, et al. (x954) National Tuberculosis

Survey. Report to M.R.C. of Ireland. [7] Census of Ireland 185i. Part V, Vol. I, 447- [8] Flynn, Michael P., and Joyce, J. Cyril (i954)

Tubercle, xxxv, 27o. [9] O'D°nnell, Brendan(x955) Personal communlcation.

[xo] Burke, P.J . (z951) B.M.ff., u, 887. ] I l l Flynn, Michael P. (x952) 07. It. Med. Ass., xxxb 312. [12] Cowell, J. St. P., and O'Meara, R. A. Q. (195I,

1952 and 1953) Reports of National B.C.G. Committee, Dublin.

[13] Census of Populatlon I946 (Ireland) Vol. m. [ 14] Blomqulst, Edward T. (1955) Department of Health,

Washington. Personal conimunleation. [i5] Chaves, Aaron D. (1955) Department of Health,

City of N.Y. Personal communication. [16] Plunkett, Robert E. (1955) Department of Health,

State of N.Y. Personal communication. [17] Palmer, Carroll, E. (x955) Department of Health,

Washington. Personal communication. [18] Plunkett, Robert E. (I95~) Trans. Nat. Tub. Ass.

N.Y., p. 493. [19] Dunlevy, Margaret (i955). Personal communication. [2o] Editorial, Lancet (i954) 11, 1267. [2 i] Myers, J. Arthur (x 952) Diseases of the Chest, xxI i, 6o 7.

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