Thousand Families

Why was the study necessary?
In 1939 the infant death rate in the UK was 62 per 1000 births. In modern terms this equates to the infant death rate currently seen in the most deprived parts of Africa. Sir James Spence, then Professor of Child Health in Newcastle (the first such appointment in England) was able to identify that the majority of the deaths in infancy were a result of infection. The high rate in Newcastle was also compounded by the large number of excessively poor households. The outbreak of war prevented any immediate research, but in 1947 Spence and his team began the Thousand Families Study. The original objective was to study, for 1 year, babies born in Newcastle and find out why they contracted so many, and such severe infections. The idea was to look at what circumstances in the family and household led to this level of ill-health. This was a novel idea and was revolutionary in the history of epidemiological studies of child health.

How did the study work?
The study team recruited all 1142 babies born to mothers resident within the city of Newcastle upon Tyne in May and June of 1947 into the study (less than 0.5% of families refused to participate). The study members had a red spot placed on their GP record to identify them as being in the study and subsequently were known as ‘Red Spot Babies’.

In the first year information was collected in a variety of formats:-

-	Antenatal charts (showing information relating to pregnancy and delivery)
-	Midwife report (charting progress and observations in the first 14 days)
-	Hospital records (if a visit had to be made to a hospital)
-	Health visitor book. Health visitors were recruited to collect information over and above any information that would have been collected in the normal course of events. The book was designed specifically for the study and allowed the health visitors to record everything they saw on their visits. This included information on feeding, sleeping, siblings, household income, state of the home, parenting etc. The areas of collection broadly covered health, social issues, parenting (mothers only!), income and family support.
-	Photos. An archive of photos was collected giving a wealth of picture evidence. These pictures cover children playing in the street, pictures depicting standards of housing, pictures of the research meetings (held every Saturday morning), pictures of the health visitors in the families’ houses.
-	Housing survey. A survey was commissioned by Newcastle City Council which surveyed every household of a red spot baby and reported on the quality and standard of it.

The information collected gives an astonishing depiction of the quality of people’s lives in Newcastle at the time. 14% of houses were deemed by the Council’s Survey to be unfit for habitation (by 1947 standards, and not our modern standards). 33% of houses were overcrowded. 1 in 4 houses did not have their own toilet and 40% of households had no bath.

At the end of the first year 1625 illnesses had been documented (averaging at 1.5 illnesses per child). Almost every child had contracted a respiratory tract infection (cough or cold) worthy of reporting. By this time there were 967 babies still in the study (some had died, others had moved away from Newcastle). Although the study was originally meant to last only a year, the significance of the data was realised, and it was decided to continue the study, following up on children in full until the children were 15 years old. Partial follow-ups were also done on some of the Red Spots at age 22. A limited study on a small sample was also done at 33. This is where the strength of the 1000 Family Study lies; the fact that such a broad sample of the population was sampled in so much depth and for so long. The information collected is of great relevance and importance today – far more so than could have been imagined at the time. The commitment of the families involved and of the Red Spots cannot be underestimated. In 2002 the prestigious International Journal of Epidemiology reported that, “Few epidemiological studies have explicitly taken a life course approach. An exception to this is the 1000 families study”.

At the end of the first year it was concluded that ‘maternal capacity’ was the most important factor in determining the health of the children – how well they were mothered. This was a very subjective judgement made by the health visitor. However, in recent times this conclusion has been questioned. The data have been looked at again using modern analytical techniques not available at the time. This has shown that although there does indeed appear to be a link between ‘poor mothering’ and health, the strongest effect is actually due to poverty. Some participants were brought up in households where the conditions were so adverse that no ‘satisfactory’ mothering would ever have been possible.

At age 15 it was shown that children from more affluent households were more than an inch taller, and had fewer infections, than their less affluent counterparts. It is now accepted that growth can be an indicator of adverse health, but at the time this was a revolutionary concept and this sort of work has helped to set the agenda for children’s health in the community ever since.