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Homeless Agency in December 2008, which indicated that there was a minimum of 942 households in Dublin in emergency accommodation for longer than 6 months. The challenge involved in achieving the objectives of Towards 2016and the Homeless Strategy is, therefore, higher than had been envisaged. Accordingly, the 2010 target will need to be. 2 Section 401(2) of the McKinney-Vento Homeless Assistance Act, 42 U.S.C. 11360 3 Individuals with disabilities who experience homelessness sleeping in shelters or in unsheltered locations for at least a year, or those who.

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Homeless

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Poverty and homelessness are phenomenons that have been around for thousands of years, affecting both humans and former pets (Strays), from the Ancient Egyptians to modern times, many people have lived in abject poverty but had a roof over their heads, others had to make due with living on the streets, forced to endure crime, filth, diseases, disrespect, and rough sleeping. Natural disasters, wars and civil wars cause millions of people to fall into poverty and end up homeless.Thankfully, there are many caring people and organizations that are helping the poor and homeless of the world; unfortunately, much more needs to be done.

Homeless PDF Free Download

© The Society of Public Health, 1991
Public Health (1991), 105, 287-296
Homeless Families in Hackney L. Parsons
Department of Public Health Medicine, City and Hackney Health Authority, St Leonard's Hospital Hackney, London N1
A retrospective study of medical records in Hackney and Tower Hamlets showed that the health of infants and school-children in temporary accommodation was impaired. Perhaps the most striking result was the high proportion of low birthweight in all four groups (10-25%). Of particular concern is the finding that 25% of babies living in Bed and Breakfast (B&B) hotels were born with a weight < 2,500 g. Amongst other findings was that a third of the infants 'born and bred' in B&B accommodation and their Tower Hamlets controls had been below the 10th centile at some time in their lives. The immunisation rates, however, were good. In the study of school-children, the school medical officer found that 30% of the children in B&B hotels were considered not to be in normal health compared with 20% of Finsbury Park residents. Ten percent of the children in B&B were considered not to have normal development and 47% of these had been referred for further investigation compared with 25% of the local residents. In contrast with the infants, the immunisation rates were poor. While it is not possible to infer any casual relationship from this study, it must be questioned whether these high risk children should be living in temporary accommodation for prolonged periods of time.
Introduction The hotels in the Finsbury Park area of Hackney have been used increasingly to provide temporary accommodation for homeless families from Tower Hamlets, Hackney and Camden. It is estimated that the numbers of families have approximately doubled in successive years until now there are over 450 families in 33 different hotels. Analysis of the ethnic background of these families shows that the majority (approximately 60%) are Asian (mostly from Bangladesh) and the rest are English, West Indian and Irish. Individually, reasons for their homelessness range from overcrowding and recent immigration to rent arrears, family disharmony, previous substandard accommodation, pregnancy and eviction for other reasons. However, collectively they can be seen as the victims o f the national housing crisis. Housing has suffered the greatest financial losses and contributed disproportionately to the cuts in public expenditureJ F r o m 1979/80 to 1982/83 there was a reduction from £7,000 million to approximately £3,800 million in the cash available for housing? Provision to local authorities in England has declined by 45% in real terms between 1979/80 and 1984/85. 3 Between 1978/79 and 1986/87 the share of public expenditure devoted to housing fell from 7.6% to 4.1%. 4 The number of new properties completed in the public sector in England and Wales has fallen from a peak of 157,000 in 1976 to 23,000 in 1986. 5 Private house completions reached a peak of 226,000 in 1968, fell to almost half by 198l before increasing to 169,000 in 1986. This represented 82% o f the total new construction in England and Wales in 1986 compared with 53% in 1968. In addition to this reduction of new building in the public sector, there has been the loss to local authorities of some of the Correspondence and reprint requests to: 9 Luralda Gardens, Saunders Ness Road, London El4 9BY.
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L. Parsons
best properties following the 1980 Housing Act. Total sales between 1980 and the end of 1986 reached nearly one million. 5 One indication that current housing policy is not entirely satisfactory for all families is the increase in homelessness. Local authorities in G r e a t Britain accepted responsibility for 120,000 homeless households in 1986 compared to 53,000 in 1978. Ninety-one percent of those in 1986 were found to be 'in priority need' for reasons such as dependent children. The total number of enquiries in 1986 were 244,000. At the end of 1986 a b o u t 22,000 accepted households were in t e m p o r a r y accommodation, of which 9,000 were in B&B. The n u m b e r of households in temporary a c c o m m o d a t i o n in G r e a t Britain at the end of 1986 was double that at the end o f 1983, whilst the n u m b e r in B&B a c c o m m o d a t i o n at the end of 1986 was treble that at the end of 1983. 6 M o r e recent data show that the numbers of homeless have continued to rise. In the first quarter o f 1988 alone, 31,070 households were accepted as homeless by local authorities in England and W a l e s - - a 12.5% increase over the figure for the first quarter o f the previous year. In M a r c h 1988, 26,950 households were in t e m p o r a r y a c c o m m o d a t i o n of one sort or another, a rise of 22% in 12 months. O f these households, 11,060 were in B&B establishments. In London alone, a total of 8,070 households are in B & B - - u p 79% in a year. 7 Nationally, this increase in the numbe T of families living in t e m p o r a r y a c c o m m o d a t i o n has caused concern a b o u t the effect o f hOmelessness on health 8 and the use o f services. 9 A recent study 1° in Bayswater concluded that there were no statistically significant differences in the outcome of pregnancy in homeless women, but the control group were local residents who also have p o o r sociodemographic characteristics. A recent review o f the medical literature ~ concludes that homelessness is a m a j o r public health issue o f the late 20th century that can only be addressed by enough decent healthy homes for people to live in. Locally the exponential increase in the number of families in t e m p o r a r y a c c o m m o d a t i o n in Finsbury Park puts pressure on the health services in H a c k n e y in a n u m b e r of ways. Firstly, these families are at high risk of ill-health for a variety of social and environmental reasons such as u n e m p l o y m e n t or low income, large overcrowded families, non-existent or very limited cooking facilities and limited or no space for children's activities. Secondly, their health status m a y be i m p a i r e d - - f o r instance, m a n y have p o o r immunisation status. A r a n d o m sample of children (under five years of age) in B&B a c c o m m o d a t i o n in H a c k n e y was surveyed in 1984.12 O f the 413 records reviewed, over half the children (208) had not been immunised at all. The p o o r coverage of pertussis and B C G is o f particular concern because o f the number of small babies in the hotels. Any infectious disease spreads rapidly in the overcrowded conditions. Finally, there seems to be a disproportionately high n u m b e r of children below the 10th centile weight for age, particularly amongst the Bangladeshi families. This is k n o w n to be associated with increased morbidity and mortality rates. 13 It was felt that a population based survey was indicated to measure the health status of the children of homeless families, including birthweight, growth indicators such as weight for age, immunisation status, and development. The results would help the health authority plan appropriate health services for homeless families. The concern of the D e p a r t m e n t o f C o m m u n i t y Medicine in City and H a c k n e y was shared by the Maternity Alliance, the L o n d o n Housing Aid Centre (SHAC), Shelter and the L o n d o n Food Commission who undertook jointly to investigate the health of children in homeless families. This paper reports the findings o f the epidemiological survey. A m o r e comprehensive report o f the health o f homeless families, including interviews and case histories, has been published separately. 14
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Methods
A retrospective study o f community health records was carried out to test the hypothesis that certain key indicators of the health status of children in B&B accommodation are impaired. The study was in two parts: firstly, an analysis of child health records (MCW 46) of children under the age of two years, registered at the John Scott Health Centre, which serves the hotels in the Finsbury Park area of Hackney; secondly, an analysis of school medical records of children aged five and over. Infan ts The infant study population was a group o f children born since 1 January 1985 to residents of B&B hotels, who were still resident there at the time o f data collection (February 1987). They had been brought up in B&B accommodation since birth and therefore were most likely to have been affected by any adverse health consequences o f such an upbringing. The study group is known as 'born and bred', and was identified from the Birth Book kept by the health visitors which contains information about all children registered at the Health Centre. This was cross-checked against records o f those who had transferred out of the area. A clerical assistant is employed by the health centre specifically to maintain the records of children in temporary accommodation in Finsbury Park because of the rapid turnover o f families. Two specialist health visitors and the clerical assistant keep the records up-to-date and comprehensive. Other staff, including the Clinical Medical Officer, were satisfied that the Birth Book offered a comprehensive method of identifying the population at risk. Three control groups were selected for this population. Firstly, other children under two years of age currently living in B&B accommodation. These children had moved into hotels since birth and therefore the length of time that they lived in B&B accommodation varied. It was thought that they might show intermediate signs of deprivation. They were identified in the Birth Book as having transferred into the area after birth, but were still resident in B&B. This is known as the 'moved in' group. Secondly, a group o f local geographical controls whose families were not homeless, were identified from records o f Finsbury Park residents registered at the John Scott Health Centre. A third control group was selected from a health centre in Tower Hamlets. This population was chosen because a high proportion o f long-stay residents in B&B are Bengalis from Tower Hamlets. Again, the Health Visitor's records were considered an accurate and comprehensive way of identifying the control groups. In all cases, controls were matched to the study group for sex and to within two months o f date o f birth. Data was collected from the M C W 46. This is the consultation record for children aged 0 5 years and is completed by the Health Visitor and Clinical Medical Officer. It contains detailed information about birthweight, family background and history, General Practitioner, use o f services, uptake o f immunisations, serial weight measurement and details of developmental checks. Ethnic origin was identified by surname, as the mother's country o f birth and the baby's ethnic origin are not recorded directly. In all cases the information required was complete unless indicated in the results. The health status indicators chosen for study were birthweight, immunisation, weight, developmental assessment and physical examination. The data was collected by the author and one other observer. Definitions had previously been agreed, several forms completed together and results were subsequently exchanged to check consistency.
L. Parsons
290
SchooLchildren The second part o f the study consisted of an analysis o f school medical records of children aged five and over. Most of the children in the Finsbury Park hotels attended one school, where it was estimated that approximately half o f the children lived in B&B accommodation. The records of all children entering this primary school between September 1985 and September 1986 were analysed. This group was divided by address into two groups: the study group resident in B&B a c c o m m o d a t i o n and a control group o f children resident in the Finsbury Park area. A second control group was selected from new entries to a school in Tower Hamlets matched by date of birth, sex and ethnic origin to the study population. The school records included data on family background and illnesses, General Practitioners, immunisations, physical examination, developmental assessment, and whether they were referred for further investigation or treatment. D a t a was collected by the school doctor at P a r k w o o d and the author in Tower Hamlets, with the consistency checks described above. Permission to consult the notes was given by the District Medical Officer in City and Hackney and Tower Hamlets and clearance was obtained from ethical committees in both Districts. The results were stored and tabulated on the N o r d C o m p u t e r at St Bartholomew's Hospital and analysed using a Statpac. Results
Infants There were 41 infants who had been born and bred in B&B a c c o m m o d a t i o n , and 49 who had m o v e d in. Differences in the age-sex structure o f the study groups are largely unremarkable. Fifty four percent of the born and bred infants were male c o m p a r e d to 47% o f those who m o v e d into B&B. Approximately two thirds of the infants were (~18 months o f age, with a slight shift of the infants who had moved in towards the older age group (18-23 months) (Table I). It is notable that a large proportion (80%) o f the infants born and bred in the H a c k n e y hotels had Asian surnames, although all of the infants in the sample were born in the U K . The moved-in group were ethnically more heterogeneous, with a third born outside the U K and only a third identified by surname as being of Asian ethnic origin. O f the Finsbury P a r k residents, only 12% had Asian surnames and 97.5% were born in the U K , while 88% o f the Tower Hamlets residents had Asian surnames, and 95% were born in the U K . Table I
Age characteristics of infants % aged:
Born and bred Moved in Finsbury Park residents Tower Hamlets residents
0-5 months
6 ll months
12-17 months
18-23 months
Total no. of infants (n)
29 16 29 29
34 35 34 34
32 31 32 32
5 16 5 5
41 49 41 41
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The mother's age at birth o f the child was not recorded in approximately half of the cases in each sample. The median and range (minimum and m a x i m u m ) in years varied from 21 (17-33) in the moved-in group to 29 (18-39) for the born and bred group, c o m p a r e d with 28.5 (21~40) for the Finsbury Park residents and 27 (20M2) years for the Tower Hamlets control group. In contrast, parity was well recorded. There was a much higher proportion of grand multips (4 + ) in the infants born and bred in B&B (46%), while the moved-in group were largely primips (57%). The median and range varied considerably. The mothers of infants born and bred in B&B a c c o m m o d a t i o n had a median parity of 4 (range 0-7), while the moved-in group had a median parity o f 1 (range 0-10) but this was not recorded in 9 (18%) cases. The parity of the Tower Hamlets sample was similar to the born and bred population (median 3, range 0-6), while the Finsbury Park residents had smaller families (median 2, range 0-5). The proportion of low birthweight infants (2,500 g or less) varied from 25% in the b o r n and bred groups to 10% in the Finsbury P a r k residents and those who had m o v e d into B&B. Fifteen percent of Tower Hamlets resident infants had low birthweight. Weighing under 2,200 g is sometimes ~5considered as an indicator o f low birthweight for Asian babies because they are on average 300 g lighter. When the proportion o f babies o f less than 2,200 g in each group was analysed, a marked variation is again seen. Although the numbers are small, 7% of the B&B group had birthweights below 2,200 g c o m p a r e d to 4 % of infants who had m o v e d into t e m p o r a r y a c c o m m o d a t i o n and 2% in each of the Finsbury Park and Tower Hamlets residents. The uptake o f immunisations is shown in Table II. The uptake of B C G at six weeks is high in all groups, but particularly for infants born and bred in B&B a c c o m m o d a t i o n and Tower Hamlets residents. The moved-in group had the lowest uptake for all immunisations. Measles was not recorded because relatively few infants in the study had reached 14 months. A third of the infants born and bred in B&B a c c o m m o d a t i o n , and their T o w e r Hamlets controls had been below the 10th centile at some time in their lives, while 20% were below the 10th centile weight for age at the time o f the study. This was twice the proportion o f the other two groups. A n u m b e r (15%) o f the moved-in group did not have their weight recorded. The M C W 46 forms are designed so that the examining D o c t o r only has to tick the relevant findings in the physical examination at various ages. Table I I I shows the proportion of children in each g r o u p for which no observations were recorded. Again, there is wide variation, with the examination being increasingly unlikely to be recorded as the child grows older. Table II
Immunisation status of infants % immunised against:
Born and bred Moved in Finsbury Park residents Tower Hamlets residents
BCG
DT/DPT
Polio
Total number (n)
81 74 78 85
68 60 71 85
68 60 71 88
41 49 41 41
292
L. Parsons Table II1 Physical examination of infants
% with no recorded physical examination at:
Born and bred Moved in Finsbury Park residents Tower Hamlets residents
6 weeks
6 months
10-12 months
Total number (n)
12 51 12 10
68 78 48 80*
74 75 65 4
41 49 41 41
* In Tower Hamlets the physical examination is not carried out at 6 months School-children
The survey of school records also revealed some interesting results. Records f r o m 41 children examined at school entry were analysed in this study. Over half the children ( n = 2 1 ) at the 5 + school medical examination were f r o m B&B accommodation. Ninety percent had Asian surnames, c o m p a r e d to 30% o f the Finsbury Park residents. Only 10% of school entrants resident in B&B had been born in the U K c o m p a r e d to 80% o f the Finsbury Park residents. One hundred percent of the Tower Hamlets controls (n = 20) had Asian surnames, and 60% o f these school-children had been born in the U K . The children in B&B a c c o m m o d a t i o n come f r o m larger families than either the Finsbury Park residents or the Tower Hamlets controls. The average n u m b e r of children in the families of school-children in B&B a c c o m m o d a t i o n was 5.2 c o m p a r e d with 2.9 in the Finsbury Park residents and 4.0 for the Tower Hamlets residents. Unlike the infants, the immunisation status of the school-children was p o o r (Table IV). Forty five percent had received no diphtheria, tetanus or polio immunisation and only 10% had had measles vaccine. Sixty-six percent were recorded as not having BCG, even though B C G is given at birth in m a n y parts of the world. However, City and H a c k n e y did not start offering neonatal B C G until 1984. The other finding o f interest was the conclusions o f the School Medical Officer. The school entry examination form concludes with three b o x e s - - n o r m a l health, normal development and whether a referral was made. The results are shown in Table V. Thirty percent of the children in B&B were not considered to be in normal health c o m p a r e d with 20% o f Finsbury Park residents. The Tower Hamlets residents were examined by a different doctor, so the opinions m a y not be comparable. Ten percent o f the children in B&B a c c o m m o d a t i o n were considered not to have normal development, and 47% o f these were referred for a second opinion or further investigation. All children in the study were registered with a General Practitioner. Discussion
A retrospective study was chosen because it is quick and less invasive than a prospective study. It was possible to identify the study group because o f the comprehensive way records are kept in the John Scott Health Centre. The study was designed so that the infants within the ' b o r n and bred' group had been in t e m p o r a r y a c c o m m o d a t i o n for differing periods of time, given by their age. It is o f extreme concern that over a third of the group had lived in a B&B hotel for nearly two years, and two-thirds had lived there tbr over one year (Table [).
Homeless Families in Hackney Table IV
293
Imm.unisation status of school children % completely immunised against:
DT and polio
Measles
BCG
Total number
35 85 85
10 65 85
20 10' 85
21 20 21
Bed and breakfast Finsbury Park residents Tower Hamlets residents
* City and Hackney started offering BCG to neonates in 1984. Table V
Health of school children
% considered abnormal in:
B&B Finsbury Park residents Tower Hamlets residents
Health
Development
% referred to hospital
Total number
30 20 10
10 15 5
47 25 20
21 20 21
It must be noted that collecting data f r o m medical records has several disadvantages. Primarily, the information a b o u t health and health status is invariably limited, and a proxy for health such as immunisation status or weight for age has to be used. The other m a j o r disadvantage o f a retrospective study is incomplete data. This is recorded where relevant, but was particularly significant for some variables such as maternal age and socio-economic class. D a t a a b o u t mother's marital status and father's occupation was so poorly recorded that it was not analysed. There are a n u m b e r o f reasons why socio-economic status is not well recorded for homeless families. Firstly, the homeless are almost always by definition unemployed, particularly when placed in hotels in other boroughs. Secondly, the Bengali c o m m u n i t y in the East End o f L o n d o n from which the born and bred group are largely drawn, are mainly employed in the 'rag' trade or restaurant business. The pattern of e m p l o y m e n t m a y be very different and hard for the families to explain, especially in a second language. Thirdly, the Registrar General's classification of socio-economic class has not been validated as a predictor o f morbidity and mortality in defined sub-groups o f the population such as the Bengalis o f T o w e r Hamlets. Other aspects o f lifestyle m a y be better predictors. Surname is frequently used as a proxy for Asian ethnic origin. A study in N o t t i n g h a m ~6 showed that using surnames and forenames as a test o f ethnicity was very reliable, and so has been used here. The data on m o t h e r ' s age is difficult to interpret because o f p o o r recording. It is possible that language difficulties, or different cultural perceptions of birth dates m a y influence the recording o f m o t h e r ' s age, but the p r o p o r t i o n o f missing data is the same in each group despite the different ethnic mix. It is likely, however, that health staff record younger and older mothers m o r e accurately, and this should be considered a source o f bias. Within these limitations it appears that the moved-in group had younger mothers (median 21 years,
294
L. Parsons
range 17 33), with a higher proportion (14%) of mothers under 20 years of age. The born and bred group, by contrast, was older (median age 29 years, range 18-39) with a higher proportion (15%) o f mothers aged 35 years or over. This pattern may reflect the ethnic origin of the study group as it is similar in the Tower Hamlets control group. However, it is interesting to note that the Finsbury Park residents also have a similar pattern. The data on mother's parity is o f great interest. The markedly different pattern seen in the moved-in sample compared with the born and bred reflects a difference between those groups. The former are small, mobile, younger families, while the latter are large, older, predominantly Asian families who spend a prolonged period of time (up to two years in this study) in B&B accommodation. While large families are probably more difficult to re-house, they are also the least suited to temporary accommodation with mothers and children at risk of ill-health. Perhaps the most striking result is the high proportion of tow birthweight babies in all four groups, which compares unfavourably with the 7.2% o f all babies born in England and Wales and 9.1% of those in City and Hackney who had birthweights under 2,500 gl7 in 1986. O f particular concern is the finding that 25% of babies born and bred in B&B accommodation are low birthweight. As 15% of the Tower Hamlets residents studied were also low birthweight, this indicates that there may be a number of confounding factors such as ethnic origin, maternal age and parity. It is not possible from this study to infer that B&B accommodation causes low birthweight. However, birthweight is one o f the most powerful predictors of increased morbidity and mortality and therefore it should be questioned whether these high risk children should be living in temporary accommodation for prolonged periods o f time. Those with a weight of 2,200 g or less are at considerably greater risk o f ill-health. The relatively high immunisation rates were a welcome finding, especially after the 1984 study.12 In the intervening period of time, a number o f special services had been introduced, including the clerical assistant, two specialist health visitors, a Bengali speaking health worker, and the Hackney 'healthmobile'. These have been described and evaluated elsewhere,19 and it is considered that they contribute significantly to the quality of care and improved uptake o f immunisation. The higher uptake o f BCG in the predominantly Bangladeshi groups may reflect cultural values and District policy. The lower uptake o f D T / D P T and polio in the born and bred group compared with the ethnically similar Tower Hamlets residents and the Finsbury Park residents who are receiving the same service is therefore disappointing. It may reflect reduced access to services which should be investigated. The moved-in group had the lowest uptake for all immunisations which may reflect mobility. The weight for age results are difficult to interpret. There has been considerable debate internationally about the appropriateness of using growth standards based on western children to monitor growth in children o f different ethnic origin. It could be argued that the high proportion of infants below the 10th centile in B&B accommodation is due to their genetic background not the environment, especially as the ethnically similar Tower Hamlets controls also have a high proportion of children below the 10th centile. It must be noted, however, that although the Tower Hamlets controls had permanent accommodation, it was of very poor quality, and these families were some o f the most deprived in the community. They should not, therefore, be considered 'normal' controls. There are also other confounding factors, such as birth order, that cannot be taken into account because of the size of the groups. This small study cannot answer these questions, but as it is clear from the literature 13that the morbidity and mortality of children below the 10th centile begins to rise, these children should be considered at high risk of ill-health.
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Infants are examined routinely at various ages depending on District policy. The six-week examination is important for early detection of physical problems. It is therefore o f particular concern that 50% o f the moved-in group had not been examined at this age. Again, the mobility of these families may reduce access to services. The study o f school records gives no idea o f how long the children had been in B&B accommodation, or how long they had been in Britain. Their poor health status may therefore have been due to many other reasons such as mobility and lack o f access to services elsewhere. However, some of the results are striking. The disruption that temporary accommodation causes is apparent in the finding that 50% of the school entry were in B&B accommodation. The mobility of this population must affect their own education, and that o f the local residents. In addition, the families are dislocated from their communities and put into classes of different background and ethnic mix. It is perhaps not surprising that the children in B&B accommodation come from larger families. Clearly this is to a certain extent a reflection o f housing policy and the property available. Unfortunately again it means that the largest families often stay in the worst accommodation for the longest period. The low immunisation rates for school-children in B&B accommodation may reflect mobility and a disrupted lifestyle. Poor recording may contribute to this. However, this finding suggests that a catch-up programme on school entry may be justified in mobile populations that are at risk o f ill-health. It is also of interest that nearly half (47%) o f the school-children in B&B accommodation were referred for a second opinion or further investigation, while the same doctor only referred 25% o f the Finsbury Park residents. This difference may indicate that the schoolchildren in B&B accommodation were unhealthier than the controls or merely reflect concern about poor social conditions. A secondary referral also ensures some continuity o f follow-up when the child moves, especially in the East End o f London. However, this disproportionately high number of referrals adds to the problems o f these families, and increases the workload of already over-stretched inner city services. This is an example of the hidden costs of B&B accommodation. This study was an attempt to document more comprehensively some of the differences in health status between children living in B&B accommodation compared with their neighbours in permanent accommodation. The theoretical possibilities about the aetiological links between ill-health and bad housing have not yet been adequately addressed, but include speculation about diet, damp, stress, lack of sunlight, susceptibility to infections, depression and even genetic selection. This study was not designed to look at aetiology, but it is hoped that the findings described will draw further attention to the plight o f homeless families and the need for definitive action. In conclusion, the p o o r health o f these children cannot be attributed to B&B accommodation, but as they are at high risk o f ill-health, the last place they should be is in over-crowded, unsatisfactory, temporary accommodation. In almost every case, this study found that those at greatest risk were least likely to have what they need. It appears that the 'Inverse Care Law '2° also applies to housing. Clearly, what these families need is decent, healthy housing--the concentration of an increasing number of high risk people in overcrowded temporary accommodation in one area is unsatisfactory. Health workers and community groups should continue to campaign for a better housing policy. However, given the national housing crisis it seems unrealistic to expect imminent closure o f these B&B hotels for use by homeless families, and so appropriate additional services must be planned. ~9
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L. Parsons
Acknowledgements The following people are thanked for their help with this study: Lyn Durwood of the Maternity Alliance and Matthew Gothill, School doctor at Parkwood, who helped with the data collection; the Health Visitors in Hackney and Tower Hamlets, particularly Ann Nixon, Sylvia Scott and Meg Ctapham; Alison Macfarlane, Ken Grant, Sian Griffiths, Jean Richards and Graham Bickler for their encouragement and comments; David Lloyd and especially Panna Patel for help with analysing results; and Anne-Marie Prior who provided secretarial support.
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