Introduction

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Between 1961 and 1994, the proportion of households made up of a lone parent with dependent children increased from 2% to 7%, and the number of households increased from 16.2 million to 23.1 millionthus the actual number of households with lone parents and dependent children in Britain increased fivefold.¹ In 1991, 19.4% of children were living in a one parent family situation, mostly (18%) with their mother. There is an excess of lone parents in black African and Caribbean ethnic groups, in social class III non-manual (assessed in women), and in metropolitan areas such as Greater London, south Wales, and the western part of Scotland.¹

The Committee on One Parent Families identified finance and housing as major problems²: Bradshaw noted that two thirds of lone parents received supplementary benefit.³ Studies of the health of children in single parent households have generally found that it differs little from the health of children in two parent situations.^4-7 However, a common definition of single parent household was not always used. Behavioural problems,⁸ accidents,^9-11 and non-accidental injury¹² have been found more commonly in children of single parent households, and an Australian study reported reduced rates of polio immunisation.¹³ Roberts and Pless drew attention to the twofold difference in rates of injury between the children of lone mothers and those in two parent households and related this difference to elements of social deprivation.¹⁰

Kai studied 95 parents of preschool children, including 29 sole parents in a disadvantaged inner city community, and drew attention to parental anxiety about the gravity of feverish illnesses.¹⁴ The impression of general practitioners that young single mothers bring their babies more readily to the doctor with comparatively minor problems was part of the consensus assessment which led to the establishment of the Jarman index as a determinant of a deprived area.¹⁵ This paper examines some of the problems for health and health care delivery associated with childhood in a single parent household and assesses both the needs of such children and the implications for general practitioners.

	Methods

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Data collected in the fourth national study of morbidity in general practice were used.¹⁶ The participating general practitioners and practice nurses in 60 practices recorded their assessment of the problems at each face to face encounter between September 1991 and August 1992. The problems were entered onto the practice computer, using conventional medical terms, and stored as Read codes.¹⁷ A consultation or episode type was assigned to each entry, distinguishing "first ever" diagnoses, "new" episodes of illness, and "ongoing" consultations. The total study population of approximately half a million was representative of the national census population by age, sex, marital status, tenure of housing, economic position, occupation, and whether they lived in an urban or rural area. There were small differences in distribution by social class and by ethnic composition.¹⁶

Socioeconomic data were collected by trained field workers.¹⁸ For children under 16 years of age, data obtained included housing tenure, ethnic group, country of birth, whether they were living with one or more adults, economic position of parent one year ago, and current or most recent occupation and employment status of parent. These data were obtained in a single interview from each person registered during the course of the study year. In most cases the data for children were provided by the mother; for a minority they were provided by the father and occasionally by a grandparent. Unlike the census, the definition of social class was not restricted to people who had been employed at some stage during the past 10 years; thus, more people were assigned social classes in the survey than in the census. The occupation of the head of the household (usually the mother when the household had only one adult and the father in other households) was as described by the respondent. Answers applicable at the time of interview were applied to the data for the entire year.

For this study, comparisons were made between children (aged <1 year, 1-4 years, and 5-15 years) living in a household with two or more adults (other household) and children in households with only one adult. Children were counted on the first occasion they consulted for the specified reason, and rates were expressed per 10 000 person years at risk, calculated from the number of days each child was registered in the practice during the survey. Children were grouped by age at the midpoint of the study; hence those aged 17 months or less at the end of the study year were aged less than 12 months at the midpoint of the study and were included in the group <1 year.

Comparisons were made for children consulting with: any illness (international classification of diseases ninth edition, chapters 1-17 inclusive); infectious diseases (ICD chapter 1); acute respiratory infections (ICD numbers 460-466); asthma (ICD 493); accidents excluding medical misadventure (ICD E800-E869 and E880-E949); immunisation (ICD V03-V06); and home visits.

Separate analyses of differences in terms of odds ratios were made using logistic regression. ^{19 20} The reference population was children living in households with two (or more) adults and the analyses took into account age (month of birth in those aged <1 year), sex, and practice. Odds ratios and 95% confidence intervals were derived relative to the reference populations. In further regression analyses, we included urbanisation (derived from patients' post code), ethnic origin, social class, housing tenure, and distance to practice (distance between patient's and practice postcodes treated as a continuous variable). For reference purposes, the index population was white, living in an urban area, social class I or II, in owner occupied housing. Odds ratios (and confidence intervals) were derived for the effect of each factor independent of all others.

We also calculated the average annual number of consultations per child for each condition, and the 95% confidence interval, and compared these for children in households with one adult and those in other households. After normality of distribution was tested for, differences were evaluated by t test.

	Results

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The study population included 93 356 children aged 0-15 years for whom we had relevant socioeconomic information: 10 983 (11.8%) were living in households with one adult. Table 1 summarises the distribution by ethnic group, social class, and housing tenure. The proportions of children in households with one adult were greatest among people of black (African or Caribbean) origin, in social class IIIN, and living in council housing.

Table 2 shows rates for children consulting with illnesses, reporting accidents, receiving immunisation, and visited at home. Rates for any illness in children under 1 year exceed 10 000 per 10 000. This apparent anomaly relates to the use of a denominator based on person years at risk. New babies frequently attend the general practitioner soon after birth and on average would only be at risk for 6 months of the study year. Rates for any illness were slightly greater in children of all ages living in households with one adult, but rates differed for infections (ICD chapter 1), acute respiratory infections, and asthma. Rates for asthma in boys exceeded those for girls.

Rates for children consulting with accidents were considerably higher in households with one adult: for boys under 1 year they were 50% higher, and for girls they were 35% higher. In all age groups, accident rates for boys were higher than those for girls. Boys under 1 year and aged 1-4 years and girls aged 1-4 years were less likely to present for immunisation if living in households with one adult. Overall, one third more children in households with one adult were visited at home.

The primary regression analyses (with adjustments for age, sex, and practice only) showed that children in the three age groups in households with one adult were more likely to present with infections, more likely to present with accidents, less likely to present for immunisation (except age group 5-15 years), and more likely to have received a home visit (table 3). Odds ratios were generally similar to those derived using the fuller analysis model, with the exception of the result for immunisation in children <1 year, where the odds ratio in the fuller model was 0.96 (95% confidence interval 0.69 to 1.34). Residence in council housing was the single most important adverse factor for achieving immunisation (0.54; 0.41 to 0.71). Social class and ethnic origin by themselves were not associated with poor immunisation uptake.

To assess the impact on general practitioners' workload, we examined the mean numbers of consultations per child for each condition studied (table 4). We first checked to ensure that there were no important differences in the registration period of children in households with one adult and of those in other households. Differences in mean numbers of consultations were mainly found among children aged under 1 year and included increased mean numbers of consultations for any illness, acute respiratory infections, and home visits. Decreased mean numbers were found for immunisation; mean numbers for infections and for accidents were similar.

	Discussion

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Generalisability
This study has shown higher rates for children consulting and increased mean numbers of consultations per child consulting by children in households with one adult compared with children in other households, particularly in the first year of life. Increased rates of home visits were seen throughout childhood. A household with one adult ("sole adult household") is not quite the same as "single parent family," though the implications of the findings of this study are the same. The interviewers were members of practice staff seconded to the study and familiar with the household composition of many of the families involved. It is unlikely that bias could be introduced from variations in the responses of interviewees from the two household groups. Some children effectively were reared by a sole parent but because they were living in households with other adults (in a grandparental home, for example) they were included in the "other household" category.

Interpretation
The number of children presenting with accidents was greater in households with one adult regardless of age, as in other studies. ^{9-11 22} In contrast, the results for immunisation indicate that fewer boys were brought for immunisation; among those who came there was a reduced mean number of consultations, suggesting that fewer completed the immunisation course. However, these results should be seen in the context of other relevant factors such as residence in council housing. The interrelationships between poverty and health contain several components, among which housing is perhaps the most significant. ^{2 3} The links between low income and poor housing on the one hand and childhood accidents on the other have already been identified.¹⁰ It is not simply a matter of the type of housing; access to nursery places and child care may be equally important. Supportive care for socially disadvantaged people has been shown to improve pregnancy outcome as measured by birth weight.²³