Investigating Local Concerns About the Effects on Health of the Sonae Chipboard Factory Situated on Knowsley Industrial Park

Investigating Local Concerns about the Effects on Health of the Sonae Chipboard Factory Situated on Knowsley Industrial Park

Edited by Dr Diana Forrest Knowsley Director of Public Health

December 2002

Acknowledgements

With grateful thanks to:

Fran Bailey Administrator, Liverpool Public Health Observatory John Baxter Senior Principal Environmental Officer, Knowsley MBC Lis Bennett Head of Medicines Management, Knowsley PCT Gail Birss Information Manager, Central Operations, Liverpool Nigel Fleeman Researcher, Liverpool Public Health Observatory Barbara Hanratty Clinical Lecturer, Liverpool Public Health Observatory Stephen Horsley Locum Consultant in Public Health, Knowsley PCT Jeanette Jones Public Health Information Manager, St Helens and Knowsley PCTs Michelle Loughlin Public Health Associate, Knowsley PCT Chris McLoughlin Administrator, Liverpool Public Health Observatory Mike Sandys Public Health Information, Research & Intelligence Manager, St Helens and Knowsley PCTs Alex Scott-Samuel Director, Liverpool Public Health Observatory Jackie Spiby Consultant in Environmental Public Health, Chemical Incident Response Service, London Neil Turner Head of Environmental Health & Consumer Protection, Knowsley MBC Janet Ubido Researcher, Liverpool Public Health Observatory Basil Wiratunga Consultant in Communicable Disease Control, Merseyside and Cheshire Health Protection Unit

The survey respondents from Northwood and Stockbridge Village.

With particular thanks to the Liverpool Public Health Observatory for carrying out the Health Survey.

Thanks are also due to the following for their helpful advice:

Virginia Murray, Director, Chemical Incident Response Service, London Brian Staples, Consultant in Public Health Medicine, Communicable Disease Surveillance Centre, North West Martyn Regan, North West Regional Epidemiologist Helen Casstles, Senior Lecturer in Environmental Public Health, John Moores University Professor John Ashton, CBE, Regional Director of Public Health/Regional Medical Officer, Directorate of Health and Social Care (North), North West Public Health Group Professor Ruth Hussey, CBE, Director of Health Strategy/Medical Director, Cheshire and Merseyside Health Authority Kate Ardern, Director of Public Health, South Liverpool PCT

Contents

Page No.

1. Executive Summary 5

2. Introduction 7

3. The Approach Taken 9

4. The Chipboard-manufactoring Process 11

5. Chipboard Production and Health 13

6. Environmental Information 17

6.1 Particulate Air Quality in Knowsley 17 6.2 Particleboard Manufacture 18 6.3 Monitoring the Sonae Chipboard Factory 20

7. Health Related Information 23

7.1 Baseline Data on Population Heath and Deprivation 23 7.2 Hospital Admissions 29 7.3 Prescribing Data 34 7.4 Health Survey 36

8. Conclusions 66

9. Recommendations 66

Appendix 1: Health Survey Questionnaire and covering letter 67

List of Tables

Table No. Page No.

1. Particleboard manufacture – emissions (EPA, 1996) 13

2. Effects of inhaled formaldehyde (CIRS 2002) 14

3. Emissions limits from the W.E.S.P. main stack 20

4. Deaths from all causes: 1997 – 1999 23

5. Deaths from cancer: 1997 – 1999 23

6. Deaths from lung cancer: 1997 – 1999 24

7. Deaths from heart disease: 1997 – 1999 24

8. Deaths from diseases of the respiratory system: 1997 – 1999 24

9. Emergency admissions for diagnosis of respiratory diseases for people of all ages 29

10. Emergency admission rates per 1000 population for diagnosis of respiratory 30 diseases for people of all ages

11. Annual emergency admission rates per 1000 population for diagnosis of 30 respiratory diseases for people of all ages

12. Annual number of bronchodilators and corticosteroid inhalers prescribed (i.e., 34 number of prescription items), 1995 – 2001

13. Sex of respondents 41

14. Age of respondents 42

15. Employment status 42

16. Housing tenure 43

17. Number of people living in the home 44

18. Percentage of people with fair or poor reported health 45

19. Number of times respondents have seen, or been seen by, their doctor in the last 45 year

20. Respondents reporting a specific health problem in the last year 48-50

21. Respondents reporting breathing difficulties 51

22. Chest affected by atmosphere 51

23. Causes of stress sited 52

24. Percentage leading a „sedentary lifestyle‟ 54

Table No. Page No.

25. Number of cigarettes smoked a day amongst current smokers 54

26. Respondents reporting problems relating to issues highlighted in the 2001 Health 57 and Community Survey

27. Effects of local factories on individual health 58

28. Effects of local factories on others 59

29. Factories mentioned more than once (that were listed by Northwood respondents 59 who replied)

30. Factory-related health problems listed by Northwood respondents who replied 60

List of Figures

Figure No. Page No.

1. Location of Sonae Chipboard Factory and surrounding area 7

2. Knowsley annual averages smoke concentration (ug/m3) 1962 - 1999 17

3. Annual Mean Fine Particulate (PM10) in Knowsley, Sefton and St Helens 2000 to 18 2002

4. Standardised Mortality Ratios: Knowsley MBC 25 All cancers, Persons, all ages: 1997 – 1999

5. Standardised Mortality Ratios: Knowsley MBC 26 Lung cancer, Persons, all ages: 1997 – 1999

6. Standardised Mortality Ratios: Knowsley MBC 27 Heart disease, Persons, all ages: 1997 – 1999

7. Standardised Mortality Ratios: Knowsley MBC 28 Respiratory disease, Persons, all ages: 1997 – 1999

8. Emergency admission rates for respiratory disease: All ages, Northwood 30

9. Emergency admission rates for respiratory disease: All ages, Stockbridge Village 31

10. Emergency admission rates for respiratory disease: All ages, All Knowsley 31

11. Emergency admission rates for respiratory disease: 0-15 year olds, Northwood 32

12. Emergency admission rates for respiratory disease: 0-15 year olds, Stockbridge 32 Village

13. Emergency admission rates for respiratory disease: 0-15 year olds, All Knowsley 33

14. Annual number of bronchodilators and corticosteroid inhalers prescribed (i.e., 35 number of prescription items), 1999 - 2002

1. Executive Summary

Introduction

This investigation was carried out by St Helens and Knowsley Health Authority, followed by Knowsley Primary Care Trust (PCT), in consultation with Knowsley Metropolitan Borough Council (MBC), in response to concerns of some Kirkby residents about the effects on their health and quality of life of a local chipboard manufacturing factory (Sonae).

Aim

To assess the potential risks to health and quality of life associated with the operation of a chipboard factory situated on the Knowsley Industrial Park.

Methodology

This investigation was based on the following four areas of work: i) A literature review on potential health risks from chipboard factories was carried out by the Chemical Incident Response Service. ii) Assessment of environmental monitoring information was performed by Knowsley Metropolitan Borough Council. iii) Trend data on routine health statistics was assessed by St Helens and Knowsley Health Authority and Knowsley Primary Care Trust. iv) The results of a cross-sectional health survey carried out by the Liverpool Public Health Observatory on behalf of St Helens and Knowsley Health Authority, (and after April 2002, Knowsley Primary Care Trust).

Conclusions

 This study has looked into the concerns of local residents about the health effects resulting from the Sonae Chipboard Factory. The methodology used has been based on national guidelines.  It is possible to describe the potential irritant effects resulting from over-exposure to the emissions emanating from a chipboard factory. No studies have conclusively demonstrated that any particular chipboard manufacturing process has caused such effects in the surrounding community.  Process monitoring has shown that the emissions from the factory are fully compliant with authorized statutory control limits. The number of odour units is above the level originally estimated by Sonae.  In relation to respiratory disease, there is no evidence of increased admissions to hospital, or increased prescribing in general practice in Northwood, since the factory has been in operation. This suggests that the levels of serious respiratory disease have not increased in Northwood.

 Comparing Northwood residents with those of Stockbridge Village, there were more people in Northwood reporting a number of symptoms, which would affect their quality of life. From available data, it is not possible to determine the source of these symptoms.  Some Northwood residents are concerned about effects on their quality of life, resulting from living in the area.

Recommendation

Knowsley Primary Care Trust should continue close monitoring and surveillance of the health and quality of life of the residents of Northwood.

2. Introduction

This investigation was carried out by Knowsley Primary Care Trust (PCT) and Knowsley Metropolitan Borough Council (MBC) in response to concerns of Knowsley residents about emissions from a chipboard factory (Sonae) which had opened on Knowsley Industrial Park in 1999. The location of this factory is shown in Figure 1. It is on Knowsley Industrial Estate, along with a number of other factories. The closest wards are Northwood and Tower Hill in Knowsley, and Bickerstaffe (in West Lancashire)

Figure 1: Location of Sonae Chipboard Factory and surrounding area

source: www.multimap.co.uk

Early in 2001, a group of people from Kirkby and Simonswood began to share thoughts about how they felt their quality of life was being affected by the nearby Knowsley Industrial Park. They were particularly concerned about the possible health effects of the chipboard factory. These residents formed an action group which they called Knowsley Against Toxic Sonae (K.A.T.S).

An Environmental Liaison Group was set up to discuss the concerns of the community about Sonae. This group was chaired by George Howarth M.P., and brought together Sonae, Knowsley Metropolitan Borough Council, St Helens and Knowsley Health Authority (later Knowsley Primary Care Trust) and members of the community. St Helens and Knowsley Health Authority set up an inter-agency group to consider what investigations should be undertaken. This group included representatives from Public Health, Environmental Health, and the Chemical Incident Response Service, and was chaired by Dr Basil Wiratunga, Consultant in Communicable Disease Control.

This report contains a literature review undertaken by the Chemical Incident Response Service, and the results of investigations undertaken by the relevant agencies in Knowsley. This includes the environmental monitoring carried out by Knowsley MBC, routine health data provided by the Primary Care Trust, and the results of a cross- sectional health survey carried out by the Liverpool Public Health Observatory on behalf of Knowsley Primary Care Trust

3. The Approach Taken

The approach taken was based upon recommendations in the Department of Health document “Investigating the health impact of emissions to air from local industry” 1 and on a number of methods described in similar evaluations.

A paper by Marla Orenstein of Edinburgh University2 described procedures to evaluate and manage risks to public health associated with the normal operation of a (hypothetical) chipboard factory. This included a literature review, description of the chipboard making process, assessment of risk and risk management.

Another paper by Clwyd Health Authority, Glyndwr District Council and the Welsh Combined Centres for Public Health3 described a feasibility study to determine the need for an epidemiological appraisal of the impact of a chipboard factory in Wales. This paper described the industrial processes concerned, evaluated the literature on known health effects of exposure to potential factory emissions and investigated public complaints about the factory. It also assessed routine health data on death rates, hospital admissions and GP prescribing for bronchodilators and corticosteroids as well as reviewing the results of local environmental consultancy reports.

This report therefore set out the following aim and objectives:

Aim

To evaluate the potential risks to health and environment associated with the operation of a chipboard factory situated on the Knowsley Industrial Park.

Objectives

 To review the literature on the potential effects of chipboard factories on health.

 To utilise environmental monitoring information to assess whether the air emissions from the factory are meeting national standards

 To examine routine data on health and deprivation to describe the local health profile in general, and to obtain baseline data from which to monitor trends.

 To assess trends in data about the prescribing of bronchodilators and corticosteroid inhalers.

 To assess trends in hospital admission rates for respiratory disease in Kirkby over the period in which the factory has been operational.

 To carry out a cross-sectional health survey to investigate local concerns about effects on health and on quality of life.

REFERENCES: SECTION 3

1. Department of Health. Investigating the health impact of emissions to air of local industry. London, Department of Health, 2000. http://ww.doh.gov.uk/comeap/statementsreports/goodpracticeguide.pdf (last accessed 20/11/2002) 2. Orenstein M. Risk Assessment and risk management: Investigating community complaints of a (hypothetical) chipboard factory. University of Edinburgh, 2001. http://www.geocities.com/HotSprings/6796/board.html#Introduction (last accessed 15/11/2002) 3. Bowen H, Karani G, Layzell J. Feasibility study to determine the need for a specific epidemiological appraisal of the impact of the Kronospan factory on the health of the resident population of Chirk, Clwyd. Joint report of Clywd Health Authority, Glyndwr District Council and the Welsh Combined Centres for Public Health. Cardiff. University of Wales, 1996.

4. The Chipboard-manufacturing process

Wood chipboard manufactured in the UK is generally made up of three layers, though this can vary if required. The two outer layers are generally made of finer material than the coarser material in the centre or core of the board. Raw materials are transported to the site in the form of bought in fresh softwood chips, sawdust and recycled fibre. The wood material is then passed through the relevant equipment such as woodchippers, hammermills, flakers and refiners to reduce the size of the wood particle to that suitable to the production process. From this point the wood material is passed through a dryer, used to dry the wood product, before it is blended with resin. The fuel for dryers can be waste wood from natural gas or oil, or a combination of these. The resin is blended into the wood product, then layered out as described above on to a belt before passing through a forming machine to lay out a continuous mat. This material then enters the press, which applies heat and pressure to the mat of wood particles and resin which activates the resin and thus bonding the fibres into a solid woodchip panel. Following the pressing operation, the boards are cooled before sanding and trimming to the required size. Finishing operations can include the application of a veneer, but otherwise is packaged ready for dispatch. A wet electrostatic precipitator (WESP) is used to abate gaseous pollutants from the process, cyclones are placed at all relevant parts of the system to recover wood dust for re-use in the process, and bag filters are used to abate particulate matter from the process.

Description of Sonae (UK) Ltd Authorised Process

Sonae UK Limited, Knowsley Industrial Park North, Kirkby, operate a chipboard manufacturing process which is authorised under Part 1B of the Environmental Protection Act 1990 by Knowsley Borough Council. Emissions to air are controlled by the authorisation. The authorisation stipulates conditions that follow national guidance from the Secretary of State. Monitoring from the main exhaust stack for particulate matter, condensable volatile organic compounds (CVOCS), formaldehyde and total aldehydes occurs every 3 months, in accordance with the authorisation and the process guidance note to assess the levels against statutory emission limits. The plant must comply with the conditions within the authorisation or enforcement action can be taken.

Fresh softwood woodchips, sawdust and recycled woodchips enter the process. They are graded, cleaned and dried before blending with glue, formed and pressed on a continuous line. The boards of chipboard are then cooled, sanded and either melamine coated, cut to size or tongue and grooved before dispatching off site. A hot gas generator on site produces hot gas to dry woodchips, heat oil in a heat exchanger (to heat the press), as well as utilising excess heat by putting it back into the stack at high level. The emissions from the process are collected and ducted to abatement equipment, a wet electrostatic precipitator (WESP) before they are emitted to atmosphere. This is to ensure that concentrations of listed above meet the emission limits.

The process is a timber process as defined in Schedule 1 of The Environmental Protection (Prescribed Processes and Substances) Regulations 1991 as amended, for the manufacture of particleboard (excluding medium density fibreboard). The process requires an authorisation because it involves the manufacture of products consisting mainly of wood, as well as the sawing and sanding of the product, where the throughput of the works in any 12-month period exceeds 1,000 cubic metres.

REFERENCES: SECTION 4

1. Orenstein M. Risk Assessment and risk management: Investigating community complaints of a (hypothetical) chipboard factory. University of Edinburgh, 2001. http://www.geocities.com/HotSprings/6796/board.html#Introduction (last accessed 15/11/2002) 2. Bever MB. Encyclopedia of materials science and engineering. Oxford: Pergamon Press, 1986. 3. Mitchel D, Scott DW. Investigation of emissions from a chipboard production plant. Stevenage: Warren Spring Laboratory. Murley L. editor (1992). 1992 NCSA Pollution Handbook. Brighton: The National Society for Clean Air and Environmental Protection, 1998.

12 5. Chipboard Production and Health

This chapter summarises a literature review on the potential health effects of chipboard production, which was requested by Knowsley Primary Care Trust from the Chemical Incident Response Service.1

Particulate board or chipboard is a panel material manufactured under pressure and heat from particles of wood and/or other lignocellulosic material in particle form with the addition of an adhesive.

Any potential health implications would relate to the emissions arising through the processes, and can be described according to the various stage of the process at which they occur as summarized in Table 1.

Table 1: Particleboard manufacture - emissions 2

SOURCE EMISSIONS Resin and wax storage and make-up tanks Resins Paraffins Ammonia Formic acid Press emissions Volatile organic compounds Particulates Formaldehyde Drier emissions Particulates Carbon Monoxide Volatile organic compounds Oxides of nitrogen Aldehydes Trimming and Sanding Particulates Pneumatic conveying systems Intermediate water/fibre storage Finishing Ammonia Material handling and storage Solvents (paints) Adhesives (laminates) Formaldehyde Particulates Boiler/Heater emissions Particulates Volatile organic compounds Carbon monoxide Oxides of nitrogen

The emissions most significant to the manufacturing process itself are: formaldehyde, particulates (wood dust) and volatile organic compounds (VOCs).

Formaldehyde

Formaldehyde is naturally occurring in the environment and in the air all the time.

It is a widely used substance especially in the production of resins with urea, phenol and melamine, and to a small extent, their derivatives. Formaldehyde-based resins are used as adhesives and for impregnating resins in the manufacture of particleboard, plywood furniture and other wood products.

Formaldehyde occurs in occupational environments mainly as gas2, and varying levels of exposure may occur.

It is a colourless gas with a pungent, irritating odour. It can cause both primary irritation and sensitisation dermatitis. The odour is perceptible to previously unexposed persons at 1 part per million (ppm). However, even a short period of exposure will decrease the ability to smell it. Symptoms expected at various concentrations are:

Table 2: Effects of Inhaled Formaldehyde2,3 (from CIRS 20023)

Concentration Clinical effects 0.1-0.3 ppm Irritation to mucous membranes 0.5-1.0 ppm Odour threshold 1-3 ppm Irritation of eyes, nose and throat 2-5 ppm Irritation to mucous membranes, eyes, nose, pharynx and respiratory tract, and lacrimation

Chronic effects as a result of continued/repeated exposure to formaldehyde are less well documented. The International Agency for Research on Cancer (IARC) has concluded that, while there is sufficient evidence to suggest that formaldehyde can cause cancer in animals, it has not been proven to cause cancer in humans.4

Particulates

Particulate emissions from the particleboard manufacturing process comprise wood dust particles of varying sizes.

Wood is classified for industrial use into two distinct types, softwoods and hardwoods.5

Occupational exposure to wood dust is encountered at all stages of wood processing. In the furniture industry, dust levels vary widely but only a small proportion (less than 25%) of dust is of respirable size (less than 5 diameter). Thus, most material is effectively trapped in the nasal passages6. The physical characteristics of wood dust vary with the process employed and the physical properties of the wood. There has been no literature published on environmental exposure to wood dust or exposure within a domestic setting. All literature focuses on occupational exposure to wood dust.

The irritant effects of wood on the skin and respiratory system are well documented 7,8 Wood dust can be irritant to the body through contact with the skin and through inhalation. 14

Condensable Volatile Organic Compounds (CVOCs)

Condensable Volatile Organic Compounds (commonly referred to as CVOCs) are also significant emissions from the particle board manufacturing process.

CVOCs make up a large and diverse group of organic substances that share the property of volatilising into the atmosphere at normal room temperatures.9 The World Health Organisation defined CVOCs as the group of organic compounds occurring in air within a boiling point range of 50-1000C to 240-2600C.10 CVOCs are involved in the formation of ground level ozone along with sunlight and pollutants from road transport.

Emissions from the production of particle board arise from several steps in the manufacturing process. The largest emission source is the drying of the particles, which may account for about 75% of the total CVOC emissions from the manufacture of particleboard11. Several studies12,13,14 have investigated the effect of process variance on levels of CVOCs emitted from the manufacture of particle board, with varying results.

Effects of irritation due to CVOCs may include conjunctivitis, sneezing, coughing, hoarseness, a feeling of dryness of mucous membranes, skin erythma or oedema and changes in breathing patterns9.

Reviews of Health Impact of Chipboard Manufacturing

Despite concerns expressed from a variety of different sources about health impacts of chipboard production there have been few systematic investigations. In Chirk, Clwyd Wales where the District Council received some 600 complaints over a period of 12 years it was concluded that there was ”no clear cut evidence, at present, of any long- term medical problem in Chirk. There are however limitations to the data used.” The complaints related to “relatively minor, short term symptoms, which would not be expected to appear in the health data available.” It was considered that the symptoms were consistent with known effects of short-term exposure to formaldehyde and wood dust,” but were also “symptoms commonly found in all populations”. It was also confirmed that “it was not possible to prove that these symptoms are linked with emissions from Kroonospan (the plant) in the absence of real time data on atmospheric level formaldehyde and wood dust in the community” and such monitoring would need to be able to relate peaks of symptoms to peaks of emissions.

A study, by Elias and Kraut16 in Manitoba investigated formaldehyde levels in air near a particleboard plant. The study was undertaken following concerns raised by the local community in relation to odours and a variety of respiratory and irritative symptoms which were reported to occur when the winds blew over the plant towards the local community. The survey was supported by the company and community representatives as part of a joint cooperative programme to identify and control the source of the concerns. The plant produced five tons of formaldehyde resin particle board each hour. Air concentrations of formaldehyde were measured in the residential area 600 meters north west of the plant. At the same time wind direction was measured at the roof to the plant in order to relate any formaldehyde levels found at the monitoring site to the plant through the wind directions. The average formaldehyde level for the plant winds was 0.015 and for the city winds was 0.009. These results are not significantly different at

15 the 95% confidence level. The peak formaldehyde level was 0.16 this finding occurred three times in the 3186 samples. Ten percent of the time formaldehyde levels exceeded 0.05 ppm when from the city and twenty percent of the time when from the plant. They conclude: “The hourly and peak levels, although at a level which could elicit symptoms in some sensitive individuals, were not felt to be high enough to explain all the symptoms voiced by community representatives.”

Conclusion

It is possible to describe the potential irritant effects resulting from over-exposure to the emissions emanating from a chipboard factory. There are no studies that have conclusively demonstrated that any particular chipboard manufacturing process has caused such effects in the surrounding community.

REFERENCES: SECTION 5

1. Spiby J (2002). Chipboard production and health. CIRS 2. EPA (1996). Batneec Guidance Note for Board Manufacture. Environmental Protection Agency Ardcavan, Wexford, Ireland. EPA No LC 11(2/96). 3. CIRS (2002) Chemical Incident Response Service, London. 4. IARC (1995). IARC Monographs on the evaluation of carcinogenic risks to humans. Volume 62. Wood dust and formaldehyde. International Agency for Research on Cancer. Lyon, France. 5. Fengel D and Wegener G (1983). Wood - Chemistry, Ultra structure, reactions. 2nd Ed, Berlin, Walter de Gruyter. 6. Hounam RF and Williams J (1974). Levels of airborne dust in furniture-making factories in the High Wycombe area. Br J Ind Med 1974 ; 31 : 1-9. 7. Woods B and Calnan CD (1976). Toxic Woods. Br J Dermatol 1976 ; 94(suppl 13) : 1-97. 8. Hausen B (1981). Wood injurious to human health. De Gruyter, Berlin, 1981. 9. BRE (1996). Indoor Air Quality in Homes : Part I. The Building Research Establishment Indoor Environment Study - BR299. ISBN 1 86081 059 4. 10. WHO (1989). Formaldehyde (Environmental Health Criteria 89), Geneva, International Programme on Chemical Safety. 11. Boswell JT and Hunt ML (1991). A survey of air emission from reconstituted wood plants. In Proceedings of the 25th Inter Particleboard/Composite material symposium. TM Maloney, ed. Washington State University. Pulman, Washington, pp 125-146. 12. Wang W and Gardner DJ (1999). Investigation of volatile organic compound press emissions during particleboard manufacture. Part 1- UF-bonded southern pine. Forest Products Journal 1999 ; 49(3) : 65-72. 13. Sundin EB, Risholm-Sundman M and Edenholm K (1991). Emission of formaldehyde and other volatile organic compounds from sawdust and lumber, different wood-based panels, and other building materials : a comparative study. In : Proceedings of the 26th International Particleboard/Composite Materials Symposium, Washington State Univ., Pullman, Wash. pp.151- 171. Forest Prod Soc, Madison, Wis. 14. Baumann MGD, Batterman SA and Zhang, GZ (1999). Terpene emissions from particleboard and medium-density fibreboard products. Forest Products Journal 1999 ; 49(1) : 49-56. 15. Bowen H, Karani G, Layzell J. (1996) Feasibility study to determine the need for a specific epidemiological appraisal of the impact of the Kroonospan factory on the health of the resident population of Chirk, 16. Elias JD and Kraut A (1996). Formaldehyde Levels in Community Air Near a Particleboard Plant. Proc 89th Air and Waste Management Association Annual Meeting and Exhibition, Nashville, Tennessee June 23-28, 1996.

16 6. Environmental Information

6.1 Particulate Air Quality in Knowsley

Historically, the authority has monitored for smoke and particulate pollution for over 40 years. Figure 1 shows the annual average smoke concentration in the borough from 1962 to 1999. As can be seen from the graph there has been a dramatic fall in the levels of smoke and particulate recorded in the borough from 185ug/m3 in 1962 to 7ug/m3 in 1999. From an air quality perspective concentrations are much reduced on those encountered 40 years ago.

Figure 2: Knowsley Annual Averages Smoke Concentration (ug/m3) 1962 - 1999

200 180 160 140 120 100 80 60

40 Smoke Concentration (ug/m3) Concentration Smoke 20

1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Knowsley Annual Averages Smoke (ug/m3)

In addition the National Air Quality Strategy requires local authorities to monitor and record air quality. The Strategy was adopted in April 1997 and has introduced a range of national air quality standards and objectives to enable air quality to be measured and assessed. The standards are based on the available information concerning the health effects resulting from different ambient concentrations of selected pollutants and are the consensus view of medical experts on the Expert Panel on Air Quality Standards (EPAQS). Much research has been carried out in order to set the standards at a level, which provide maximum protection to human health. The standard for annual mean concentration of fine particles (PM10) currently stands at 40 ug/m3 with an associated timescale for achievement by the end of 2004. Figure 2 Presents the fine particle concentrations currently recorded in the Knowsley, Sefton and St Helens areas. From this monitoring it is evident that the standard is currently achieved in all the authorities and therefore the levels on fine particles encountered within these authorities are not considered to be placing the health of the individual at risk.

Figure 3: Annual Mean Fine Particulate (PM10) in Knowsley, Sefton and St Helens 2000 to 2002

Fine Particulate in ug/m3 5

0 Knowsley Sefton St Helens Local Authority

2000 2001 2002

6.2 Particleboard Manufacture

Under the Environmental Protection Act 1990, Part IB and according to the Secretary of States Process Guidance Note (PG6/4(95)) and the consultation draft of the „IPPC A(2) Guidance for the Particleboard, Oriented Strand Board and Dry Process Fibreboard Sector‟, releases to atmosphere from the manufacturing of wood chipboard could include the following and therefore all such plants are abated to deal with such emissions:

POTENTIAL EMISSIONS IF SOURCE SOURCE HOW CONTROLLED HOW REGULATED IS NOT ABATED Particulate Dryer and Press There are no direct Local Authority Air Matter emissions to atmosphere Pollution Control (LAPC) from these two sources, they under the Environmental are both ducted via cyclones Protection Act 1990 and a wet scrubbing system (EPA90 – Part IB) and the before the WESP for Pollution Prevention and abatement Control Regulations 2000. Emission limit value 20mg/m3 Formaldehyde Released from There are no direct Local Authority Air and other the resin during emissions to atmosphere Pollution Control (LAPC) aldehydes pressing and from these two sources, they under the Environmental curing of the are both ducted via cyclones Protection Act 1990 boards and a wet scrubbing system (EPA90 – Part IB) and the before the WESP for Pollution Prevention and abatement Control Regulations 2000. Formaldehyde Emission Limit Value 20mg/m3 . Total Aldehydes Emission Limit Value 20mg/m3 Condensable Contained in the There are no direct Local Authority Air Volatile wood chips and emissions to atmosphere Pollution Control (LAPC) Organic the resin from these two sources, they under the Environmental Compounds released during are both ducted via cyclones Protection Act 1990 (CVOCs) wood chip drying and a wet scrubbing system (EPA90 – Part IB) and the and board before the WESP for Pollution Prevention and pressing abatement Control Regulations 2000. operation. CVOC Emission Limit Value 130mg/m3

All stack (WESP) emissions monitoring that have been undertaken at Sonae UK Limited since the date of authorisation have met the process guidance limit values set out in the Secretary of States Process Guidance note (PG 6/4(95)), (noted above).

Other releases could potentially include:

 Water vapour from the WESP and wet scrubbers; Particulates from debarking, size reduction operations and cyclones;

Emissions from the trimming, sanding and finishing areas are controlled using enclosed bag filters and ducting. As such no emission limits are set by the Secretary of State in the Process Guidance Note as the emissions from these areas are controlled by the efficiency of the filters used. At the Sonae UK Limited site, all emissions from such areas are locally extracted and ducted to enclosed storage silos for use in the process. The resin and wax storage and make-up tanks are also not required to be authorised.

19 6.3 Monitoring of the Sonae Chipboard Factory

Routine Monitoring

Sonae UK Limited, Knowsley Industrial Park North, Kirkby, operate a chipboard manufacturing process which is authorised under Part 1B of the Environmental Protection Act 1990 by Knowsley Borough Council, regarding emissions to air only. Their authorisation stipulates conditions that follow guidance from the Secretary of State. Emissions from the WESP stack are monitored for particulate matter, condensable volatile organic compounds (CVOCs), formaldehyde and total aldehydes every 3 months in accordance with their authorisation to comply with emission limit values set out by the Secretary of State and stipulated within the authorisation.‟

The process emissions are treated using a wet electrostatic precipitator (WESP) following wet scrubbing, cyclones and bag filters.

Table 3: Emissions Limits from the W.E.S.P. main stack

Column 1 Column 2

Substance Concentration (mg/m3) Concentration of particulate matter from the WESP 20 Particulate matter from all contained sources other 50 than the WESP. Condensable volatile organic compounds (CVOCs) (excluding particulate matter, and calculated as 130 carbon) Formaldehyde 20 (as formaldehyde) Total aldehydes (calculated as carbon) 20

All monitoring results to date have shown compliance with all of the emission limits set by the authorisation, and an officer from the local authority attends the monitoring exercises.

All results of the routine stack monitoring are available to view on the public register held at the Environmental Health offices.

Additional Verification Monitoring

Operators of prescribed processes are required to monitor emissions and Sonae has carried out the regular monitoring described elsewhere in this report. A decision was made by the Council to carry out its own independent monitoring using specialists who also recommended an investigation of odour. Odour has been a source of complaint since the plant opened. The approach to the Council‟s investigation is outlined below.

The law concerning odour is not prescriptive and there are no statutory limits for emission of or exposure to odour. Secretary of State‟s guidance on which the 20 authorisation conditions imposed by Knowsley Council are based says that the aim shall be that all emissions are free from offensive odour outside the process boundary, as perceived by the local authority. Because the odour emitted is not regarded as a classically offensive odour (such as sewage works or manure) the Council sought information to support the contention that any odour can become offensive if it is strong enough.

To obtain an objective assessment of odour and quantify the impacts on residents near the factory the Council asked Sonae to establish the odour concentration and the sampling for this was combined with the monitoring carried out by the Council‟s consultant. A series of key steps were taken which involved; a) establishing the actual concentration of odour emitted from the main chimney, b) independently sampling pollutants emitted, c) assessing the adequacy of dispersion from the existing chimney, d) assessing improvements to dispersion that might be achieved by raising the chimney height (a height that could be achieved using the existing structure was considered) and, e) establishing an “acceptance criteria” for odour strength at receptor. 5,6,7

Conclusions from this work were that dispersion of the prescribed substances is sufficient and that health based criteria are not breached however the work predicted that the acceptance criteria established for odour is exceeded at many of the receptor locations close to the factory.

Odour Monitoring

Odour monitoring was undertaken over and above the statutory requirements for monitoring of the stack. Odour monitoring was carried out by specialist consultants (acting for Sonae) who took extractive samples from the stack which were subsequently analysed by an independent panel to determine the odour concentration odour units at source. Following recommendations from Knowsley Borough Council‟s consultants, odour modelling was carried out from the 35 metre high chimney to determine the level of odour at receptors and to establish an „acceptance criteria‟ for odour strength. It was predicted that a proportion of receptors within six km of the WESP stack would experience a recognisable odour above the acceptance criteria.

Formaldehyde Monitoring

Formaldehyde is monitored for routinely from the stack, but additional monitoring over and above the statutory requirements was undertaken off-site, at locations north, south east and west of the site for formaldehyde, during periods when the plant was operational and when the plant was not operational for background concentrations. All values determined were all considerably less than the World Health Organisation‟s figure of 0.1mg/m3 measured as a 30-minute average concentration. (COMEAP/2000/19).

The Health and Safety Executive deal with occupational exposure limits on the site itself for the workforce.

Conclusions

1. Process monitoring has shown that the emissions from the factory are fully compliant with authorised statutory control limits. 2. The number of odour units is above the level originally estimated by Sonae.

REFERENCES: SECTION 6

1. Knowsley Metropolitan Borough Council. (2000) Sonae UK Limited. Authorisation Reference Number EPA IB/0100/6.7/6\4. KMBC. 2. 2.Department of the Environment. The Environmental Protection Act 1990. Chapter 43. London: HMSO, 1990. 3. Department of the Environment. (1995.) Secretary of State‟s Guidance – Processes for the Manufacture of Particleboard and Fibreboard. PG6/4(95) 4. Environment Agency. Consultation Draft: Integrated Pollution Prevention and Control (IPPC) Guidance for the Particleboard, Oriented Strand Board and Dry Process Fibreboard Sector. Bristol: Environment Agency, 2000. 5. Enviros Aspinwall. November 2000. Modelling Review, Sonae UK Ltd. Knowsley. KN0040001A. Prepared on behalf of Knowsley Metropolitan Borough Council. 6. Enviros Aspinwall. March 2002. Monitoring of Emissions, Sonae UK Ltd. Knowsley. KN0040002A. Prepared on behalf of Knowsley Metropolitan Borough Council. 7. Casella Stanger. October 2002. Dispersion Modelling of WESP Stack Emissions. Sonae (UK) Ltd. CS/AQ/1911/final. Prepared for Knowsley Metropolitan Borough Council. 8. The United Kingdom National Air Quality Strategy, The Stationary Office – March 1997. 9. Air Quality Review and Assessment of Knowsley Stage 2 and 3 Report – Knowsley Metropolitan Borough Council – February 2001.

22 7. Health Related Information

7.1 Baseline Data on Population Heath and Deprivation

Levels of deprivation in Knowsley borough are relatively high. The Overall Index of Multiple Deprivation 2000a (Department of Transport, Local Government and the Regions, Indices of Deprivation 2000) ranks Northwood as the 20th most deprived ward in England (score 77.26) from a total of 8,414 wards. Tower Hill is ranked 59th (score 71.56) and Bickerstaffe is ranked 3,220th (score 21.80).

The general health experience of the populations of Knowsley and Northwood is relatively poor. During 1997-1999, Knowsley Borough experienced higher death rates from all causes, cancers, heart disease and respiratory disease than the North West of England as a whole. Within Knowsley, the rates for lung cancer and heart disease were particularly high in Northwood, while rates for respiratory disease were very high in Tower Hill (Tables 4-8 and Figures 4-7).

This information provides baseline data from which to measure future trends.

Table 4: Deaths from all causes, 1997-1999b

Actual Deaths SMR Northwood 197 148 Stockbridge Village 172 147 Kirkby 1231 132 Tower Hill 133 141 Bickerstaffe 39 89 Knowsley Borough 4838 127 North West Region 225299 110

Table 5: Deaths from cancer, 1997-1999

Actual Deaths SMR Northwood 64 174 Stockbridge Village 56 176 Kirkby 380 150 Tower Hill 46 176 Bickerstaffe 13 121 Knowsley Borough 1329 132 North West Region 54510 109

a The source for all data in this section is the National Statistics website (http://www.neighbourhood.statistics.gov.uk/home.asp) except where stated.

b SMR=Standardised Mortality Ratio. 100 is taken as the England and Wales level. 23

Table 6: Deaths from lung cancer, 1997-1999

Actual Deaths SMR Northwood 25 291 Stockbridge Village 18 253 Kirkby 126 217 Tower Hill 17 307 Bickerstaffe 3 126 Knowsley Borough 405 178 North West Region 13560 122

Table 7: Deaths from Heart Disease, 1997-1999

Actual Deaths SMR Northwood 51 174 Stockbridge Village 39 156 Kirkby 269 134 Tower Hill 16 88 Bickerstaffe 9 94 Knowsley Borough 1048 127 North West Region 50587 115

Table 8: Deaths from diseases of the respiratory system, 1997-1999

Actual Deaths SMR Northwood 32 160 Stockbridge Village 29 167 Kirkby 232 166 Tower Hill 27 226 Bickerstaffe 3 40 Knowsley Borough 924 157 North West Region 38940 115

24 Figure 4: Standardised Mortality Ratios: Knowsley MBC All Cancers, Persons, All Ages: 1997 - 1999

25 Figure 5: Standardised Mortality Ratios: Knowsley MBC Lung Cancer, Persons, All Ages 1997-1999

26 Figure 6: Standardised Mortality Ratios: Knowsley MBC Heart Disease, Persons, All Ages: 1997 - 1999

27 Figure 7: Standardised Mortality Ratios: Knowsley MBC Respiratory Disease, Persons, All Ages: 1997 - 1999

7.2 Hospital Admissions

Rates of hospital admission can provide information about particular health problems in a population. An unexpected increase in hospital admissions for a particular diagnosis, can indicate that there is a new problem which needs to be investigated.

The Sonae factory became operational in January 2000. Data on emergency admissions for respiratory disease in Northwood, Stockbridge Village and Knowsley Borough during the years 1999 to 2002 were studied, for all ages, and for children aged under 16 years. This showed that there were higher rates of admission in Northwood compared with Stockbridge Village and Knowsley as a whole (Table 9). However, while rates have fluctuated since January 2000, there has been no overall trend towards an increase in admission rates in any of these areas over the period in which the chipboard factory in Knowsley was operational (Tables 10 & 11 and Figures 8-13). These trends will continue to be monitored.

Table 9: Emergency admissions for diagnosis of respiratory diseases for people of all agesc

Northwood Stockbridge Village Knowsley 1999/2000 2000/01 2001/02 1999/2000 2000/01 2001/02 1999/2000 2000/01 2001/02 Apr 8 11 7 7 3 9 179 215 216 May 12 11 15 10 4 6 178 200 217 Jun 7 6 5 8 6 9 191 160 181 Jul 12 6 7 9 6 10 173 159 193 Aug 6 5 4 9 2 3 163 145 127 Sept 2 6 8 5 8 8 174 151 149 Oct 7 4 8 5 8 10 192 175 205 Nov 9 6 6 11 7 9 233 192 191 Dec 11 10 10 9 12 13 271 288 243 Jan 14 4 13 12 9 11 364 277 292 Feb 14 10 9 4 4 9 203 247 256 Mar 5 6 9 4 12 8 167 229 212

c Diagnostic codes used: ICD10 J00-J99 (Diseases of the respiratory system) 29

Table 10: Emergency admission rates per 1000 population for diagnosis of respiratory diseases for people of all ages

Northwood Stockbridge Village Knowsley 1999/2000 2000/01 2001/02 1999/2000 2000/01 2001/02 1999/2000 2000/01 2001/02 Apr 1.5 2.0 1.3 1.1 0.5 1.4 1.1 1.4 1.4 May 2.2 2.0 1.1 1.5 0.6 0.8 1.1 1.3 1.4 Jun 1.3 1.1 0.9 1.2 0.9 1.4 1.2 1.0 1.2 Jul 2.2 1.1 1.3 1.4 0.9 1.5 1.1 1.0 1.2 Aug 1.1 0.9 0.7 1.4 0.3 0.5 1.0 0.9 0.8 Sept 0.4 1.1 1.5 0.8 1.2 1.2 1.1 1.0 1.0 Oct 1.3 0.7 1.5 0.8 1.2 1.5 1.2 1.1 1.3 Nov 1.7 1.1 1.1 1.7 1.1 1.4 1.5 1.2 1.2 Dec 2.0 1.9 1.9 1.4 1.8 2.0 1.7 1.8 1.6 Jan 2.6 0.7 2.4 1.8 1.4 1.7 2.3 1.8 1.9 Feb 2.6 1.9 1.7 0.6 0.6 1.4 1.3 1.6 1.6 Mar 0.9 1.1 1.7 0.6 1.8 1.2 1.1 1.5 1.4

Table 11: Annual emergency admission rates per 1000 population for diagnosis of respiratory diseases for people of all ages

Northwood Stockbridge Village Knowsley 1999/2000 19.8 14.2 15.9 2000/2001 15.8 12.4 15.5 2001/2002 18.7 15.9 15.8

Figure 8: Emergency Admission Rates for Respiratory Disease All Ages: Northwood

3 1999/2000 2000/2001 2.5 2001/2002

1.5

1 Rates ofadmission per 1000 population

0.5

April May June July August March October January February September November December Month

Figure 9: Emergency Admission Rates for Respiratory Disease All Ages: Stockbridge Village

2.5 1999/2000 2000/2001

2 2001/2002

1.5

ratesadmissionof per 1000 population 0.5

April May June July August March October January February September November December Month

Figure 10: Emergency Admission Rates for Respiratory Disease All Ages: All Knowsley

2.5 1999/2000 2000/2001 2 2001/2002

1.5

ratesadmissionof per 1000 population 0.5

April May June July August March October January February September November December Month

Figure 11: Emergency Admission Rates for Respiratory Disease 0-15 Year Olds: Northwood

9 1999/2000

8 2000/2001

7 2001/2002

3 rates of admission per1000 population

0 Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar Month

Figure 12: Emergency Admission Rates for Respiratory Disease 0-15 Year Olds: Stockbridge Village

9 1999/2000

8 2000/2001 2001/2002 7

3 rates of admission per1000 population

0 Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar Month

Figure 13: Emergency Admission Rates for Respiratory Disease 0-15 Year Olds: All Knowsley

1999/2000 7 2000/2001 2001/2002

3 rates of admission per1000 population 2

0 Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar Month

Conclusion

There is no evidence of an increase in admissions to hospital for respiratory disease amongst the residents of Northwood, since the chipboard manufacturing factory in Knowsley has been in operation.

Recommendation

Trends in hospital admission rates for respiratory disease in Northwood should continue to be monitored.

33 7.3 Prescribing Data for Respiratory Disease

Changes in the general practice (GP) prescribing patterns can indicate changes in experience in a population of relatively minor episodes of illness that do not involve admission to hospital. An increase in prescribing may indicate that a particular health problem has increased in severity. Prescribing trends may also be influenced by GP practice policies, availability of other healthcare facilities and they may also reflect the population‟s consultation behaviour. Respiratory tract problems might be expected in a population exposed to formaldehyde or wood dust2.

Prescribing patterns for respiratory disease were looked at, to try to identify any changes. Corticosteroid inhalers and bronchodilators are commonly prescribed in general practice to treat asthma and some other forms of respiratory illness.

Table 12: Annual number of Bronchodilators and Corticosteroid inhalers prescribed (i.e. number of prescription items), 1995-2001.

Year Northwood Stockbridge Village 1995 19,932 7,862 1996 20,805 8,325 1997 21,710 9,250 1998 21,728 9,413 1999 21,306 9,784 2000 20,199 10,426 2001 20,059 10,954

During the period 1995 – 2001, the period before and during which the chipboard factory in Knowsley has been operational, there was no significant change in prescribing by GPs of bronchodilators or corticosteroid inhalers for respiratory disease in Northwood (Table 12). For comparative purposes, prescribing data for Stockbridge Village are also shown. There is an increase in prescribing for respiratory disease in Stockbridge Village. This may be due to an increase of respiratory disease in Stockbridge Village, or it could be because the GPs have changed the way they manage respiratory disease in that area.

Figure 14 compares prescribing trends in Northwood and Stockbridge Village, with Knowsley Borough as a whole, during 1999 – 2002.

Figure 14: Annual number of Bronchodilators and Corticosteroid inhalers prescribed (i.e., number of prescription items), 1999-2002

200000 180000 160000 140000 120000 100000 80000 60000 40000

20000 Number of Prescription Items Prescription of Number 0 Northwood Stockbridge Village Knowsley Borough

1999/2000 2000/2001 2001/2002

Conclusions

From the above data, it can be concluded that there is no trend towards an increase in prescribing for respiratory disease in Northwood.

Recommendations

Prescribing data for respiratory disease in Northwood should continue to be monitored.

35 7.4 Health Survey

ABSTRACT

Introduction

A survey was commissioned in 2002 by Knowsley Primary Care Trust in response to concerns of Knowsley residents that living near to the proximity of their homes to Knowsley Industrial Park was adversely affecting their health.

The survey set out to compare the perceived health status and influencing factors in the population of Northwood (situated close to Knowsley Industrial Park) with that of a control population of similar socio-demographic composition (situated about 5km away) in Stockbridge Village.

Aim

To investigate local concerns about the effects on health and quality of life associated with living near to the Knowsley Industrial Park.

Method

A cross-sectional survey was conducted in Northwood, and Stockbridge Village which is similar to Northwood in terms of economic and health status, but situated about 5km away. A postal questionnaire was sent to a total of 2000 households (1000 to each ward).

Results

 There were 921 valid responses (46.1% response rate). Response rates were similar in both areas.  Respondents in each area were similar in terms of age, levels of physical activity and smoking.  Significantly more Northwood residents were in employment and owned their own homes.  There were more large households in Northwood.  People in both areas reported positive feelings about their neighbours and communities, and a strong „sense of community‟ was found in Stockbridge Village.  Both areas expressed worries about money, safety and health.  Stockbridge Village respondents reported significantly higher levels of long- term disability, illness or infirmity.  A significantly higher proportion of Stockbridge Village respondents had been exposed to occupational dust, fumes or chemicals during their working lives.  Arthritis was the most commonly reported disability in both areas.  There was no overall difference in frequency of visits to the doctor between Northwood and Stockbridge Village.  The prevalence of reported mental health disorders was low in both areas.  Stress levels did not vary significantly between the two areas.  Money, safety and health were sources of stress in both areas.

36  Significantly more Northwood residents reported safety, air pollution, noise from nearby, always being in a hurry, work problems and unpleasant noise outside the home as sources of stress.  Vandalism, crime, litter, youths riding motorcycles and lack of facilities were causes for concern in both Northwood and Stockbridge Village.  Levels of smoking and of physical activity were similar in the two areas.  Amongst Northwood residents there were significantly more people reporting respiratory symptoms, allergies, skin rashes, eye irritations, headaches, stomach and bladder trouble, back trouble, headaches, tiredness and difficulty sleeping.  Local industry was perceived as affecting quality of life for a proportion of the Northwood residents, and some people reported that they experienced symptoms that they perceived as being associated with industrial pollution

Introduction

This survey was commissioned in 2002 by St Helens & Knowsley Health Authority (and was taken forward, from April 2002, by Knowsley Primary Care Trust) in response to concerns of Knowsley residents about their health. Residents living near to the Knowsley Industrial Park were worried that the proximity of their homes to local industry was having adverse effects on their health. There were particular concerns about the potential effects of a chipboard factory (Sonae) that was situated on the park.

In 2001 the community action group Knowsley Against Toxic Sonae (K.A.T.S) carried out a health survey of some of the residents in Northwood who lived in close proximity to the park. This survey indicated some health concerns, but both the Health Authority and the authors of the K.A.T.S study agreed that there were shortcomings in the methodology used in that study. It did, however, highlight further the local worries about health. Respondents to the K.A.T.S survey were concerned about dust, residues on cars and houses, and unpleasant odours from Knowsley Industrial Park. There was also a perception that health was deteriorating in the area with regard to respiratory diseases, chest, nose, and throat irritation, asthma, and skin disorders. Knowsley Primary Care Trust felt that these findings justified further investigation.

This report contains the results of a survey carried out on behalf of Knowsley Primary Care Trust by the Public Health Observatory at Liverpool University. The survey set out to compare the perceived health status and influencing factors in the population of Northwood (situated close to Knowsley Industrial Park) with that of a control population of similar socio-demographic composition (situated about 5km away from the Knowsley Industrial Park) in Stockbridge Village.

Background

Populations of Northwood and Stockbridge Village:

Northwood is a ward in Kirkby, an area of Knowsley borough, close to the Knowsley Industrial Park (See Map, Figure 1). It encompasses a large housing estate. There are approximately 5,379 people living there (1999 mid year population estimates 50.7% males; 49.3% females) and 3,901 (72.5%) are aged 19 and over1.

Similarly, Stockbridge Village is a ward in Knowsley situated approximately 5km away from the Knowsley Industrial Park (See Map, Figure 4). It also encompasses a large housing estate. There are approximately 5,231 people living there (1999 mid year population estimates 50.1% males; 49.9% females) and 3,831 (73.2%) are aged 19 and over1.

General health status

Interpreting statistics relating to small populations is complex. Routine health- related data do suggest, however, that Stockbridge Village is similar to Northwood in terms of its general health experience.

During 1997-1999, Knowsley borough experienced higher death rates from all causes, cancers and ischaemic heart disease than the North West of England as a whole. Both Northwood and Stockbridge Village, however, experienced amongst the highest rates of deaths from all causes, cancers and ischaemic heart disease in Knowsley (Section 7.1).

Death rates from diseases of the respiratory system in Northwood and Stockbridge Village were similar to those in Knowsley as a whole, but all were higher than those in the North West Region (Section 7.1).

During 1999-2002, emergency admissions to hospital for people diagnosed with respiratory disease were higher in Northwood than they were in Stockbridge village and Knowsley (Section 7.4). There was, however, no significant change in admission rates in either area over that period.

Economic and material statusd

The Overall Index of Multiple Deprivation 2000 (Department of Transport, Local Government and the Regions, Indices of Deprivation 20002) ranks Northwood as the 20th most deprived ward in England (score 77.26) and Stockbridge Village as the 38th (score 74.33) from a total of 8,414 wards. Another commonly used measure of deprivation is the Townsend Index. Based on the 1991 census, Stockbridge Village‟s Townsend score (10.9253) was very similar to that of Northwood (10.3681)

Aim

To investigate local concerns about the effects on health and quality of life associated with living near to the Knowsley Industrial Park.

Objectives

To describe the socio-economic circumstances, health related behaviours, perceived health problems and local factors influencing health for the residents of Northwood ward.

To compare the perceived health problems and influencing factors for the study population with a control population of similar socio-demographic composition, and general health experience, situated within Stockbridge Village. d The source for all data in this section is the National Statistics website (http://www.neighbourhood.statistics.gov.uk/home.asp) except where stated. 39

Methods

Ethical approval for this study was obtained from the St. Helens and Knowsley Local Research Ethics Committee.

Design

A cross-sectional survey was performed, using a postal questionnaire. (Appendix I).

The sample

The study population was defined within an arbitrary radius of 2.5km from the Knowsley Industrial Park. This encompassed the residential area of Northwood. The control population was selected from Stockbridge Village, a ward within Knowsley borough which is socio-demographically similar to Northwood, but situated approximately 4.75km away from the industrial park.

A sample size of 2000 (1000 in each of the study and control areas) was estimated to be sufficient to detect a response difference of 10% between the two groups (80% power). This meant that approximately one in four of the residents (of those aged 19 and over) in each area were sampled.

The postcodes of Northwood and Stockbridge Village residents were identified. Subjects whose postcodes identified them as Northwood and Stockbridge Village residents were then selected randomly by Liverpool Central Operations Group from centrally held lists of patients registered with local general practitioners. Only one individual per household was surveyed and questionnaires were only sent to residents aged 19 and over.

The questionnaire

A postal questionnaire (Appendix 1) was constructed. Most questions used within the survey were well-validated. Some were questions which had been used in the Health Community Study undertaken within Knowsley in 2001, and others were well-tested questions to unearth respiratory symptoms and other health care problems.

It contained 56 questions on:

i) Demographics ii) Health status iii) Lifestyle iv) Occupational exposures v) Community and environment

The questionnaire also invited respondents to comment upon the questions asked, or anything else that they thought might be relevant.

40 Care was taken to ensure that the questionnaire and accompanying letters were as simple and easy to read as possible. The covering letter explained that the survey was being undertaken in response to local concerns about living close to Knowsley Industrial Park (Appendix 2). No reference was made to specific companies.

The survey was relatively long. To avoid this discouraging respondents, an A5 format was used. Other accepted methods of enhancing response rates were used, with regard to the accompanying letter,3 the use of reminders,4 and the use of incentives3.

Two reminders were sent; a postcard at two weeks, and a second questionnaire at four weeks. Pre-paid envelopes were provided to return the questionnaire and completed questionnaires were entered into a free draw to win a £25 postal order.

Results of the survey were anonymised.

Results

Response rate

There were 921 valid responses (a 46.1% response rate) with 438 (43.8%) from Northwood and 483 (48.3%) from Stockbridge Village. The difference in response rate between the two areas was not statistically significant.

Forty three questionnaires were returned due to invalid addresses (32 in Northwood and 11 in Stockbridge Village).

Demographic characteristics of respondents

Sex and age

47.8 % (497) of respondents were male and 52.2% (435) were female (Table 13). A higher proportion of the Northwood respondents were female (54.7%).

The majority of respondents from both areas were of similar ages (Table 14). The age breakdown by sex was also similar in both areas.

Table 13: Sex of respondents

Stockbridge Northwood Total Village 197 240 437 Male 45.3% 50.1% 47.8% 238 239 477 Female 54.7% 49.9% 52.2% 435 479 914 Total 100.0% 100.0% 100.0%

41 Table 14: Age of respondents

Stockbridge Northwood Total Village 83 67 150 18-39 19.4% 14.3% 16.8% 201 225 426 40-64 47.1% 48.2% 47.7% 143 175 318 65+ 33.5% 37.5% 35.6% 427 467 894 Total 100.0% 100.0% 100.0%

Educational and employment/material status

Northwood respondents were significantly more likely to own a car than those from Stockbridge Village; 55.7% (240) in Northwood and 44.5% (209) in Stockbridge Village; chi square =11.314, DF=1, p=0.01.

Northwood respondents were also significantly more likely to have left school by the age of 17; 10.0% (43) in Northwood and 4.6% (22) in Stockbridge Village; chi square=10.05, DF=1, p=0.02.

The overall reported unemployment rate was 7.5% (69). The unemployment was significantly higher amongst Stockbridge Village respondents (8.8%) compared with Northwood (6.2%) There were also more people unable to work for health reasons, and more retired people in Stockbridge Village. Overall, the differences in employment status between the two areas were significant (chi square=18.017, DF=7, p=0.012).

Table 15: Employment status

Northwood Stockbridge Village 104 85 Employed – full time 23.9% 17.7% 41 23 Employed – part time 9.4% 4.8% 11 11 Self-employed 2.5% 2.3% 27 42 Unemployed 6.2% 8.8% 156 192 Retired 35.8% 40.1% 22 38 Housewife 5.0% 7.9% 65 80 Unable to work for health reasons 14.9% 16.7%

42 10 8 Other 2.3% 1.7%

Over half of both Stockbridge Village respondents, (58%) and Northwood respondents (53.8%) had been unemployed for more than a year at some time in their lives.

Home Life

Length of residence

A total of 59.6% of respondents had lived at their current address for 15 years or more. Only 17.1% had lived at this address for less than 5 years. There were no significant differences in length of residence between the Northwood and Stockbridge Village residents.

Housing tenure

Respondents from Northwood were almost twice as likely as those from Stockbridge Village to be owner-occupiers, in housing bought either privately or from the council. (62.0% house owners in Northwood; 35.1% house owners in Stockbridge Village) (Table 16). More than half (56.4%) of Stockbridge Village respondents lived in housing rented from a housing association, whereas a relatively small proportion of Northwood respondents (7.1%) rented such accommodation, most being rented from the council at that timee. Differences in housing tenure between the two areas were statistically significant (chi square=304.582, DF=5, p<0.001).

Table 16: Housing tenure

Stockbridge Northwood Village 139 40 Owned-bought privately 31.8% 8.4% 132 127 Owned-bought from council 30.2% 26.7% 127 30 Rented from councilc 29.1% 6.3% Rented from housing 31 268 association 7.1% 56.4% 7 5 Rented privately 1.6% 1.1% 1 5 Other 0.2% 1.1%

e From 15 July, 2002, the council-owned property in Northwood was transferred to a housing association. 43

Household size

Approximately one in three Stockbridge Village respondents (32.4%) lived on their own, compared to one in four Northwood respondents (24.8%) (Table 17). There were significantly more people in Northwood living in larger households (Chi square=22.846, DF=5, p<0.001).

Table 17: Nu Number of people living in the home

Northwood Stockbridge Village 106 152 1 24.8% 32.4% 145 189 2 34.0% 40.3% 82 62 3 19.2% 13.2% 59 51 4 13.8% 10.9% 23 11 5 5.4% 2.3% 11 4 6 or more 2.5% 0.8%

Summary: Demographic Characteristics

 There were similar response rates in Northwood and Stockbridge Village  There was a higher proportion of female respondents in Northwood  Age structures of the respondents from the two areas were similar  There were significantly higher rates of unemployment in Stockbridge Village  60% of respondents had been resident at their current address for 15 years  Northwood residents were significantly more likely to be owner-occupiers than Stockbridge Village residents  More people in Northwood lived in larger households.

Reported health status

Health in general and long-standing illness

Respondents‟ self-reported health in general was similar in both Northwood and Stockbridge Village, though this varied by age with more respondents in the older age groups reporting their health to be „fair‟ or „poor‟ (Table 18). Generally, more males viewed their health as „fair‟ or „poor‟ than females.

44 In both Northwood and Stockbridge Village, approximately one in three respondents had seen (or been seen by) their doctor more than five times within the last year (Table 19). There were no significant differences in numbers of visits to the doctor in the two areas.

Table 18: Percentage of people with fair or poor reported health

Males Females 18-39 40-64 65+ All 18-39 40-64 65+ All Northwood 25.0 47.9 62.5 50.5 16.9 41.3 64.7 42.0 Stockbridge 35.7 53.3 63.5 54.5 5.8 46.5 63.6 42.4 Village

Table 19: Number of times respondents have seen, or been seen by, their doctor in the last year

Northwood Stockbridge Village Not at all 55 57 12.8% 12.2% Only once 53 52 12.4% 11.1% 2-3 times 112 135 26.1% 28.9% 4-5 times 82 92 19.1% 19.7% More than 5 127 131 times 29.6% 28.1%

Long standing illnesses, disabilities or infirmities

Generally high levels of long-standing disability, illness or infirmity were reported, but these were significantly greater in Stockbridge Village (64.5% [305]) than in Northwood (59.0% [252]) (chi-square=2.842, DF=1, p=0.09). A majority of these reported that they had seen their doctor in the last year (99.2% [236] in Northwood; 98.3% [281] in Stockbridge Village).

The most commonly reported disability, illness or infirmity was arthritis. Arthritis was reported by 32.1% (81) of Northwood respondents and 29.7% (91) of Stockbridge Village respondents.

One in five respondents reported that they had heart disease (19.8% [50] in Northwood; 20.0% [61] in Stockbridge Village) and around one in ten complained of other circulatory diseases (9.9% [25] in Northwood; 13.4% [41] in Stockbridge Village).

One in ten reported that they suffered from asthma (11.5% [29] in Northwood; 9.8% [30] in Stockbridge Village).

Other long standing illnesses mentioned included diabetes (8.3% [21] in Northwood; 11.1% [34] in Stockbridge Village), eye problems (3.2% [8] in Northwood; 2.3% [7] in Stockbridge Village), stomach problems (other than cancer) (2.8% [7] in Northwood; 2.3% [7] in Stockbridge Village), a gastrointestinal disorder or disease (other than cancer) (2.8% [7] in Northwood; 3.6% [11] in Stockbridge Village), osteoporosis (2.4% [6] in Northwood; 3.9% [12] in Stockbridge Village), stroke (1.6% [4] in Northwood; 4.6% [14] in Stockbridge Village) and cancer (1.2% [3] in Northwood; 3.3% [10] in Stockbridge Village).

Mental disorders

The reported prevalence of mental health disorders was relatively low and there were no significant differences between the two areas (Depression:4.4% [11] in Northwood and 5.2% [16] in Stockbridge Village; anxiety: 2.8% [7] in Northwood; 2.3% [7] in Stockbridge Village; other mental health problems: 2.0% [5] in Northwood and1.0% [3] in Stockbridge Village).

Specific health problems encountered in the last year

General: Respondents were asked whether they had encountered a number of specific health problems in the last year and whether they had seen a doctor about these. A wide range of potential problems were investigated including coughs, colds, allergies, respiratory complaints, circulatory problems, cancers, depression and anxiety.

Significant differences were found between Northwood and Stockbridge Village for 19 of the 44 different symptoms/conditions investigated (Table 8):

Chronic bronchitis: About one in ten of Northwood respondents (9.5%) reported chronic bronchitis, compared to one in twenty (5.4%) of Stockbridge Village respondents; nearly all saw their doctor

Sinus Trouble / Catarrh: More than one in three Northwood respondents (37.8%) and nearly one in four Stockbridge Village respondents (23.3%) complained of sinus trouble or catarrh. In both areas, few people consulted a doctor about this.

Sore throat: Over half of Northwood respondents (52.2%) reported having had sore throats in the preceding year compared to one in three of Stockbridge Village respondents (33.3%). In both areas, most sufferers did not see their doctor about this.

Throat congestion: In Northwood, 30.7% complained of throat congestion compared with 19.5% in Stockbridge Village. Few Stockbridge Village residents had consulted their doctor about this.

46 Dry cough: Nearly half of Northwood respondents (44.6%) experienced a dry cough compared to just over one in four of Stockbridge Village respondents (27.2%). Again, most sufferers didn‟t see their doctor about this.

Persistent cough: One in four respondents from Northwood (25.0%) and almost one in five from Stockbridge Village (17.6%) reported having had a persistent cough, half of these had consulted a doctor.

Wheeze or wheezy chest: Over one in three Northwood respondents (39.3%) reported to suffer from this compared to just over one in four of Stockbridge Village respondents (27.9%). Most sufferers saw their doctor about this.

Shortness of breath: This was reported by more than one in three respondents from Northwood (37.1%) and over one in four from Stockbridge Village (26.7%).

Chest trouble (other than chest pain): Around one in seven Northwood respondents (13.5%) and under one in ten from Stockbridge Village (7.6%) had experienced chest trouble.

Allergies: Around one in seven Northwood respondents (13.5%) reported to suffer from these compared to just over one in twenty of Stockbridge Village respondents (7.0%). Proportionally twice as many saw their doctor about this in Northwood.

Skin rashes: In Northwood 25.3% of respondents reported to suffer from skin rashes compared with 22.5% of Stockbridge Village respondents. More respondents saw their doctor about this in Northwood.

Stomach trouble : In Northwood 30.8% of respondents reported to suffer from stomach problems compared with 26.1% of Stockbridge Village respondents.

Kidney / bladder trouble: Around one in seven Northwood respondents (14.3%) and under one in ten of Stockbridge Village respondents (8.6%) reported kidney or bladder troubles. In both areas, the majority consulted a doctor.

Eye irritation: Over one in three respondents from Northwood (37.9%) and under one in four from Stockbridge Village (23.5%) reported this symptom. 2.5 times as many in Stockbridge Village saw their doctor about this.

Back trouble: More Northwood respondents reported back trouble (41.5%), though compared to Stockbridge Village respondents (34.7%) fewer consulted a doctor.

Headaches: 40% Northwood respondents reported headaches compared to 26.9% in Stockbridge Village.

Always feeling tired: 41.6% Northwood respondents reported feeling tired all the time, compared to 31.6% in Stockbridge Village. More Northwood residents had seen their doctor about this. 47

Difficulty sleeping: In Northwood 36.9% experiences sleeping difficulties compared with 28.5% in Stockbridge Village.

Palpitations / breathlessness: Over one in four Northwood respondents (27.3%) and one in five from Stockbridge Village (20.7%) had experienced palpitations or breathlessness. Most went to see their doctor.

Table 20: Respondents reporting a specific health problem in the last year

Has health problem Has health problem Does not have health AND seen a doctor but not seen doctor problem

Stockbridge Stockbridge Stockbridge Northwood Northwood Northwood Village Village Village

Colds and flu 96 85 148 164 185 226 ( 2=3.247, DF=2, p=0.197) 22.4% 17.9% 34.5% 34.5% 43.1% 47.6%

Pneumonia 10 14 2 2 416 457 ( 2=0.346, DF=2, p=0.841) 2.3% 3.0% 0.5% 0.4% 97.2% 96.6%

Asthma 48 49 11 4 390 450 ( 2=4.514, DF=2, p=0.105) 10.7% 9.7% 2.4% 0.8% 86.9% 89.5%

Chronic bronchitis 34 23 5 1 370 422 ( 2=6.615, DF=1, p=0.037)* 8.3% 5.2% 1.2% 0.2% 90.5% 94.6%

Lung disease 19 17 3 5 390 450 ( 2=0.828, DF=2, p=0.661) 4.6% 3.6% 0.7% 1.1% 94.7% 95.3%

Sinus trouble or Catarrh 75 50 86 60 265 363 ( 2=22.528, DF=2, p<0.001)* 17.6% 10.6% 20.2% 12.7% 62.2% 76.7%

Sore throat 94 59 130 98 205 314 ( 2=33.503, DF=2, p<0.001)* 21.9% 12.5% 30.3% 20.8% 47.8% 66.7%

Throat congestion 52 30 79 62 296 379 ( 2=16.041, DF=2, p<0.001)* 12.2% 6.4% 18.5% 13.2% 69.3% 80.5%

Dry cough 68 41 122 87 236 343 ( 2=30.141, DF=2, p<0.001* 16.0% 8.7% 28.6% 18.5% 55.4% 72.8%

Persistent cough 54 39 52 44 318 388 ( 2=7.579, DF=2, p=0.023)* 12.7% 8.3% 12.3% 9.3% 75.0% 82.4%

Wheeze or wheezy chest 97 85 71 47 259 341 ( 2==14.566, DF=2,p=0.001)* 22.7% 18.0% 16.6% 9.9% 60.7% 72.1%

Shortness of breath 97 86 62 41 269 348 ( 2=12.646, DF=2, p=0.002)* 22.7% 18.1% 14.5% 8.6% 62.9% 73.3% Chest pain 69 68 26 20 332 385 ( 2=2.363, DF=2, p=0.307) 16.2% 14.4% 6.1% 4.2% 77.8% 81.4% Other chest trouble 45 28 12 8 365 436 ( 2=8.282, DF=2, p=0.016)* 10.7% 5.9% 2.8% 1.7% 86.5% 92.4%

Allergies 36 19 21 14 366 441 ( 2=10.760, DF=2, p=0.005)* 8.5% 4.0% 5.0% 3.0% 86.5% 93.0% Skin rash/skin trouble (e.g. 67 85 41 22 319 368 Eczema) 15.7% 17.9% 9.6% 4.6% 74.7% 77.5% ( 2=8.827, DF=2, p=0.012)* 48

* Statistically significant difference (p<0.05)

Table 20 (continued): Respondents reporting a specific health problem in the last year Has health problem Has health problem Does not have health AND seen a doctor but not seen doctor problem

Stockbridge Stockbridge Stockbridge Northwood Northwood Northwood Village Village Village

Stomach trouble 81 87 51 37 296 352 ( 2=7.476, DF=2, p=0.093)* 18.9% 18.3% 11.9% 7.8% 69.2% 73.9%

Liver trouble 7 15 3 4 418 457 ( 2=2.266, DF=2, p=0.322) 1.6% 3.2% 0.7% 0.8% 97.7% 96.0%

Arthritis / Rheumatism 111 150 34 27 284 297 ( 2=4.691, DF=2, p=0.096) 25.9% 31.6% 7.9% 5.7% 66.2% 62.7%

Kidney / bladder trouble 47 35 14 6 365 434 ( 2=8.274, DF=2, p=0.016)* 11.0% 7.4% 3.3% 1.3% 85.7% 91.4%

Piles / haemorrhoids 22 36 33 25 374 414 ( 2=4.183, DF=2, p=0.123) 5.1% 7.6% 7.7% 5.3% 87.2% 87.2%

Pleurisy 15 6 0 2 414 468 ( 2=3.004, DF=1, p=0.064) 3.5% 1.3% 0.0% 0.4% 96.5% 98.3%

Tuberculosis 6 0 1 3 420 472 ( 2=2.083, DF=1, p=0.149) 1.4% 0.0% 0.2% 0.6% 98.4% 99.4%

Hay fever 35 26 39 39 354 407 ( 2=2.875, DF=2, p=0.238) 8.2% 5.5% 9.1% 8.3% 82.7% 86.2%

Eye irritations 75 71 87 40 266 361 ( 2=29.817, DF=2, p<0.001)* 17.5% 15.0% 20.3% 8.5% 62.1% 76.5%

Painful joints 107 124 87 73 236 278 ( 2=3.680, DF=2, p=0.159) 24.9% 26.1% 20.2% 15.4% 54.9% 58.5%

Back trouble 105 111 73 54 251 310 ( 2=6.891, DF=2, p=0.032)* 24.5% 23.4% 17.0% 11.4% 58.5% 65.3%

High blood pressure 103 127 7 6 319 342 ( 2=1.044, DF=2, p=0.593) 24.0% 26.7% 1.6% 1.3% 74.4% 72.0%

Angina 42 58 5 4 381 414 ( 2=1.496, DF=2, p=0.473 9.8% 12.2% 1.2% 0.8% 89.0% 87.0%

Heart attack 19 17 1 0 409 459 ( 2=0.684, DF=1, p=0.408) 4.4% 3.6% 0.2% 0.0% 95.3% 96.4%

Stroke 7 11 1 0 422 466 ( 2=0.219, DF=1, p=0.640) 1.6% 2.3% 0.2% 0.0% 98.1% 97.7%

Lung cancer 2 5 1 0 426 472 ( 2=0.314, DF=1, p=0.575) 0.5% 1.0% 0.2% 0.0% 99.3% 99.0%

Other cancer 8 18 4 1 417 457 ( 2=0.973, DF=1, p=0.324) 1.9% 3.8% 0.9% 0.2% 97.2% 96.0%

49 Faints / dizziness 56 53 37 28 332 395 ( 2=3.914, DF=2, p=0.141) 13.2% 11.1% 8.7% 5.9% 78.1% 83.0%

Headaches 56 42 115 86 257 348 ( 2=17.372, DF=2, p<0.001)* 13.1% 8.8% 26.9% 18.1% 60.0% 73.1% * Statistically significant difference (p<0.05)

Table 20 (continued): Respondents reporting a specific health problem in the last year

Has health problem Has health problem Does not have health AND seen a doctor but not seen doctor problem

Stockbridge Stockbridge Stockbridge Northwood Northwood Northwood Village Village Village

Migraine 24 18 39 34 363 423 ( 2=3.124, DF=2, p=0.210) 5.6% 3.8% 9.2% 7.2% 85.2% 89.1%

Diabetes 30 46 9 10 389 419 ( 2=2.094, DF=2, p=0.351) 7.0% 9.7% 2.1% 2.1% 90.9% 88.2%

Always feeling tired 88 69 90 82 250 327 ( 2=10.219, DF=2,p=0.006)* 20.6% 14.4% 21.0% 17.2% 58.4% 68.4%

Difficulty sleeping 77 65 81 71 270 341 ( 2=7.291, DF=2, p=0.026)* 18.0% 13.6% 18.9% 14.9% 63.1% 71.5%

Nerves & Anxiety 54 43 45 37 330 396 ( 2=5.602, DF=2, p=0.061) 12.6% 9.0% 10.5% 7.8% 76.9% 83.2%

Depressive illness 42 42 15 16 372 419 ( 2=0.283, DF=2,p=0.868) 9.8% 8.8% 3.5% 3.4% 86.7% 87.8%

Difficulty concentrating 26 24 48 46 353 406 ( 2=1.168, DF=2, p=0.558) 6.1% 5.0% 11.2% 9.7% 82.7% 85.3%

Palpitations / breathlessness 69 63 48 35 311 376 ( 2=6.129, DF=2, p=0.047)* 16.1% 13.3% 11.2% 7.4% 72.7% 79.3% Worrying over every little thing 43 43 63 67 324 367 ( 2=0.364, DF=2, p=0.833) 10.0% 9.0% 14.7% 14.0% 75.3% 76.9%

* Statistically significant difference (p<0.05)

Chest problems

A significantly higher proportion of Northwood respondents had experienced attacks of wheezing, whistling in their chest or shortness of breath, either ever (37.6% compared with 30.8% in Stockbridge Village)or in the last 12 months (48.8% compared with 35.5% in Stockbridge Village) (Table 21). There was also a significantly higher proportion of Northwood residents (24.6% compared with 17.1% in Stockbridge Village) who said that shortness of breath had wakened them in the past 12 months and that their chest illnesses had sometimes prevented them from doing their usual activities in the past 12 months (30.2% compared with 23.2% in Stockbridge Village).

50 Table 21: Respondents reporting breathing difficulties

Stockbridge Northwood Village Respondents who had to stop for breath when walking at their 132 116 own pace on level ground ( 2=3.347, DF=2, p=0.067) 32.3% 26.5% Respondents who got short of breath when walking with people 149 131 their own age on level ground ( 2=3.703, DF=1, p=0.054) 36.4% 30.2% Respondents who got short of breath when hurrying on level 243 236 ground or walking up a slight hill ( 2=2.134, DF=1, p=0.144) 58.8% 53.6% Respondents who had attacks of wheezing or whistling in their 198 156 chest in the last 12 months ( 2=15.174, DF=1, p<0.001)* 48.8% 35.5% Respondents who had ever had attacks of shortness of breathing 152 134 with wheezing ( 2=4.335, DF=1, p<0.037)* 37.6% 30.8% Respondents whose breathing was normal between attacks 103 71 ( 2=6.532, DF=2, p=0.038)* 67.7% 53.0% Respondents woken at night by shortness of breath in the last 12 98 74 months ( 2=7.157, DF=2, p=0.007)* 24.6% 17.1% Chest illnesses which have kept respondents from doing their 120 100 usual activities for a week or more within the last 12 months 2 30.2% 23.2% ( =5.227, DF=1, p=0.022)* * Statistically significant difference (p<0.05)

Chest problems exacerbated by the atmosphere

Respondents were also asked about whether they had any chest problems made worse by the weather. Humid and damp weather were considered by residents in both areas to exacerbate their problems. A significantly higher proportion of Northwood respondents, however, thought their chest problems were affected by foggy weather, still weather or a smoky atmosphere (Table 22).

Table 22: Chest affected by atmosphere

Stockbridge Northwood Village Foggy weather 92 58 ( 2=13.635, DF=1, p<0.001)* 21.0% 12.0% Damp weather 95 94 ( 2=0.699, DF=1, p=0.403) 21.7% 19.5% Cold weather 81 82 ( 2=0.362, DF=1, p=0.0547) 18.5% 17.0% Hot weather 73 62 ( 2=2.694, DF=1, p=0.101) 16.7% 12.8% Still weather 31 17 ( 2=5.886, DF=1, p=0.015)* 7.1% 3.5% Humid weather 105 93 ( 2=3.030, DF=1, p=0.082) 24.0% 19.3% Smoky atmosphere 171 136 ( 2=12.244, DF=1, p<0.001)* 39.0% 28.2% * Statistically significant difference (p<0.05) 51

Stress over the past year

There were no significant differences in the overall levels of stress reported in Northwood and Stockbridge Village over the previous year (Northwood 30.8% [135]; Stockbridge Village 27.3% [132]). There were, however, some significant differences in the source of stress in each reported in each area (Table 23). Generally, respondents in both areas indicated that money, safety and health were great sources of stress. In Northwood, a significantly higher proportion of respondents said that their stress was caused by not feeling safe, air pollution, noise from nearby, always being in a hurry, work problems and unpleasant noise outside the home compared with Stockbridge Village respondents.

The largest difference between the two areas in terms of sources of stress concerned air pollution and unpleasant smells outside the home.

Table 23: Causes of stress cited

Stockbridge Northwood Village Unemployment 42 51 ( 2=0.238, DF=1, p=0.626) 9.6% 10.6% Housing problems 50 43 ( 2=1.598, DF=1, p=0.206) 11.4% 8.9% Money problems 115 133 ( 2=0.191, DF=1, p=0.662) 26.3% 27.5% Neighbours 40 35 ( 2=1.092, DF=1, p=0.296) 9.1% 7.2% Not feeling safe in the area 110 64 ( 2=21.098, DF=1, p<0.001)* 25.1% 13.3% Dirt 43 15 ( 2=17.535, DF=1, p<0.001)* 9.8% 3.1% Family problems 94 125 ( 2=0.2475, DF=1, p=0.116) 21.5% 25.9% Air pollution 144 15 ( 2=142.534, DF=1, p<0.001)* 32.9% 3.1% Noise from nearby 71 36 ( 2=17.153, DF=1, p<0.001)* 16.2% 7.5% Always being a hurry 53 37 ( 2=5.136, DF=1, p=0.023)* 12.1% 7.7% Problems to do with work 50 28 ( 2=9.354, DF=1, p=0.002)* 11.4% 5.8% Other people’s health problems 101 95 ( 2=1.576, DF=1, p=0.209) 23.1% 19.7% Own health problems 157 153 ( 2=1.787, DF=1, p=0.181) 35.8% 31.7% Unpleasant smells outside the home 176 25 ( 2=164.989, DF=1, p<0.001)* 40.2% 5.2% * Statistically significant difference (p<0.05) 52

Summary - Reported Health Status

 Stockbridge Village respondents reported significantly higher levels of long- term disability, illness or infirmity.  Arthritis was the most commonly reported disability in both areas.  The prevalence of reported mental health disorders was low in both areas.  There was no overall difference in frequency of visits to the doctor between the two areas.  Amongst Northwood residents there were significantly more people reporting respiratory symptoms, allergies, skin rashes, eye irritations, headaches, stomach and bladder trouble, back trouble, headaches, tiredness and difficulty sleeping.  Stress levels did not vary significantly between the two areas.  Money, safety and health were sources of stress in both areas.  Significantly more Northwood residents reported safety, air pollution, noise from nearby, always being in a hurry, work problems and unpleasant noise outside the home as sources of stress.  Air pollution and unpleasant smells outside the home accounted for the greatest difference in terms of stress causes in Northwood, compared with Stockbridge Village.

Lifestyle

Physical activity

There were no significant differences in respondents‟ physical activity in the two areas. Over half of the respondents (50.6% [211] in Northwood; 55.7% [250] in Stockbridge Village) undertook no „vigorous‟ exercisef at all.

Nearly 2 in 3 respondents, however, reported that they did undertake some form of moderate activityg every day (64.1% [266] in Northwood; 66.1% [286] in Stockbridge Village)

Over 60% of respondents in both Northwood and Stockbridge Village thought they led a „sedentary lifestyleh‟ (60.8% [247] in Northwood; 63.5% [280] in Stockbridge Village) (Table 24). The proportion leading a sedentary lifestyle rose with increasing age.

f Aerobic exercise lasting more than 20 minutes g Moderate activity e.g. walking or light housework h ‘Sedentary lifestyle‟ was defined as no vigorous activity on an average weekday and vigorous activity less than once a month. 53 Table 24: Percentage leading a ‘sedentary lifestyle’

Male Female 18-39 40-64 65+ All 18-39 40-64 65+ All Northwood 39.1 60.9 71.0 62.0 29.6 56.3 90.5 59.6 Stockbridge 40.7 63.6 70.9 63.4 37.8 66.3 73.6 63.8 Village

Smoking

Over 60% of respondents had smoked at some time in their lives (63.9% [280] in Northwood; 65.6% [317] Stockbridge Village).

Over 30% of respondents said they still smoked at the time of the survey (34.9% [153] in Northwood; 34.4% [166] in Stockbridge Village).

Of the „current smokers‟, there was no significant difference in the proportion in Northwood and Stockbridge Village who reported that they smoked 15 or more cigarettes a day (55.4% in Northwood compared to 49.1% in Stockbridge Village) (Table 25).

Table 25: Number of cigarettes smoked a day amongst current smokers

Northwood Stockbridge Village 15 16 1-4 10.0% 9.7% 52 68 5-14 34.7% 41.2% 61 62 15-24 40.7% 37.6% 22 19 25+ 14.7% 11.5%

Of the 278 respondents who were ex-smokers, 252 provided information on their previous smoking habits. Around half (49.6%, 125) had smoked for 25 years or more. A significantly higher proportion of Stockbridge Village respondents had previously smoked for 25 years or more (59% [82] in Stockbridge Village, compared with 38% [43] in Northwood; chi square=13.736, DF=4, p<0.01).

Of the ex-smokers, a significantly higher proportion of Northwood respondents had given up smoking more recently (30.9% [35] in the last 14 years, compared with 18% [25] in Stockbridge Village, chi square=13.736, DF=4, p<0.01).

Overall, however, there was no significant difference in the smoking habits of ex- smokers from the two areas.

Occupational exposure

Significantly more respondents from Stockbridge Village reported exposure to either dust or to fumes and chemicals during some or most of their working lives: 54

Exposure to dust (chi-square=25.334, DF=3, p<0.001): Nearly half had been exposed to dust during some or most of their working lives in Stockbridge Village (48.7% [217]) compared with one in three in Northwood (32.4% [133]).

Exposure to fumes and chemicals (chi-square=7.581, DF=3, p<0.049). In Northwood, 20.7% [83], and in Stockbridge Village, 27.9% [112], reported such exposure during some or most of their working lives.

One in three of all respondents reported exposure to extremes of temperature during some or most of their working lives (33.8%, [285]). There were no significant differences in exposure between the two areas.

Summary - Lifestyle and Occupational Exposure

There were no significant differences in rates of Physical Activity in Northwood and Stockbridge Village.

 Over 60% of respondents in both areas lived a „sedentary lifestyle‟.  There was no overall difference in smoking habits between the two areas.  60% of respondents had smoked at some point in their lives  Over 30% still smoked at the time of survey.  A significantly higher proportion of Stockbridge Village respondents had been exposed to occupational dust, fumes or chemicals during their working lives.

Community and Environment

Community Spirit

58.9% of Stockbridge Village respondents considered their area to have a „sense of community‟ compared to 53.1% of Northwood respondents (chi-square = 11.205, DF = 1, p<0.01).

Neighbourhood Problems

Respondents were asked about the seriousness of 16 specific problems which had been raised in the Health and Community Survey of 2001. Northwood residents had significantly more serious concerns in general, than those from Stockbridge Village (Table 14). Areas causing significant concern were as follows:

Vandalism: Three out of four Stockbridge Village respondents reported that this was a problem compared to two in three Northwood respondents. Northwood respondents were more likely to view vandalism as a „serious problem‟.

Litter or Rubbish: In both areas two in three respondents saw this as a problem. Northwood respondents were more likely to see the problem as „serious‟.

Smells and Fumes: Two out of three Northwood respondents described smells or fumes as a problem, compared to one in five in Stockbridge Village. Northwood respondents were 15 times more likely to state smells and fumes to be a „serious problem‟.

Assaults and Muggings: Northwood residents were twice as likely to suggest that assaults and muggings were a „serious‟ problem.

Smoke or Steam from nearby Factories: Four out of five Northwood respondents stated that smoke or steam from nearby factories was a problem compared with only one in 20 from Stockbridge Village. Northwood residents were 90 times more likely to describe smoke or steam to be a „serious problem‟.

Burglaries: More than half of the respondents from both areas viewed burglaries as a problem. Northwood respondents were more likely to consider that burglaries were a „serious problem‟.

Speeding Traffic: Three-quarters of Northwood respondents and two-thirds of those from Stockbridge Village noted this as a problem.

Uneven/Dangerous Pavements: Respondents from both areas perceived this to be a problem. Northwood respondents were twice as likely to find pavements a „serious‟ problem.

Area‟s Reputation: Respondents in both areas viewed this as a problem but a greater proportion of Northwood respondents viewed it as a „serious‟ problem.

Lack of Places for kids to Play: Two in three Northwood respondents reported that this was a problem compared to one in two in Stockbridge Village.

Lack of Leisure Facilities: Two in three respondents from Northwood and one in two from Stockbridge Village noted this as a problem. Northwood residents were twice as likely to see this as a „serious‟ problem.

Walking after Dark: This was a concern for two-thirds of the respondents from Northwood and half from Stockbridge Village.

Noise in the Area: One in two Northwood respondents and two in five from Stockbridge Village saw this as a problem.

56 Table 26: Respondents reporting problems relating to issues highlighted in the 2001 Health and Community Survey

Serious problem Some problem Not a problem No response

Stockbridge Stockbridge Stockbridge Stockbridge Northwood Northwood Northwood Northwood Village Village Village Village Vandalism 169 115 170 238 65 80 34 50 ( 2= 24.059, DF=3 38.6% 23.8% 38.8% 49.3% 14.8% 16.6% 7.8% 10.4% p<0.001)* Litter or rubbish 134 97 167 224 94 110 43 52 ( 2=14.179, DF=3, 30.6% 20.1% 38.1% 46.4% 21.5% 22.8% 9.8% 10.3% p=0.003)* Smells or fumes 197 15 103 71 96 311 42 86 ( 2=289.322, DF=3, 45.0% 3.1% 23.5% 14.7% 21.9% 64.4% 9.6% 17.8% p<0.001)* Assaults & muggings 38 19 150 129 171 240 79 95 ( 2=18.815, DF=3, 8.7% 3.9% 34.2% 26.7% 39.0% 49.7% 18.0% 19.7% p<0.001)* Smoke or steam 272 3 90 19 51 369 25 92 ( 2=587.722, DF=3, 62.1% 0.6% 20.5% 3.9% 11.6% 76.4% 5.7% 19% p<0.001)* Burglaries 82 36 210 213 97 159 49 75 ( 2=36.309, DF=3, 18.7% 7.5% 47.9% 44.1% 22.1% 32.9% 11.2% 15.5% p<0.001)* Youngsters causing trouble 119 110 164 197 1.4 115 51 61 ( 2=2.623, DF=3, 27.2% 22.8% 37.4% 40.8% 23.7% 23.8% 11.6% 12.6% p<0.453) Speeding traffic 185 145 140 162 71 128 42 48 ( 2=21.029, DF=3, 42.2% 30% 32% 33.5% 16.2% 26.5% 9.6% 9.9% p<0.001)* Needles/syringes 19 14 87 86 257 288 75 95 ( 2=2.687, DF=3, 4.3% 2.9% 19.9% 17.8% 58.7% 59.6% 17.1% 19.7% p<0.442) Uneven/dangerous pavements 74 40 168 152 149 207 47 84 ( 2=28.710, DF=3, 16.9% 8.3% 38.4% 31.5% 34.0% 42.9% 10.7% 17.4% p<0.001)* Nuisance from dogs 55 48 133 133 191 226 59 76 ( 2=3.363, DF=3, 12.6% 9.9% 30.4% 27.5% 43.6% 46.8% 13.5% 15.7% p=0.339) Area‟s reputation 96 68 114 127 166 213 62 75 ( 2=10.370, DF=3, 21.9% 14.1% 26.0% 26.3% 37.9% 44.1% 14.2% 15.5% p<0.016)* Lack of places for kids to play 203 152 109 138 74 136 52 57 ( 2=27.132, DF=3, 46.3% 31.5% 24.9% 28.6% 16.9% 28.2% 11.9% 11.8% p<0.001)* Lack of leisure facilities 192 102 106 125 84 185 56 71 ( 2=66.768, DF=3, 43.8% 21.1% 24.2% 25.9% 19.2% 38.3% 12.8% 14.7% p<0.001)* Walking after dark 156 75 132 172 108 171 42 65 ( 2=50.758, DF=3, 35.6% 15.5% 30.1% 35.6% 24.7% 35.4% 9.6% 13.5% p<0.001)* Noise 72 54 150 149 168 208 48 72 ( 2=9.454, DF=3, 16.4% 11.2% 34.2% 30.8% 38.4% 43.1% 11.0% 14.9% p<0.024)* * Statistically significant difference (p<0.05)

Neighbourhood connections

Respondents were presented with a series of 13 statements about their neighbours and the community. There were similar response rates to these questions in the two areas.

The majority of people in both areas reported positive feelings about their neighbours and their community.

A significantly higher proportion of Northwood residents, however, „strongly disagreed‟ with the statement Overall I think this is a good place to bring up children’ (chi square=30.316, DF=5, p<0.001) (18.9% [83] in Northwood compared to 8.3% [40] in Stockbridge Village).

Local industry and health

The survey specifically asked respondents about local industry and its perceived health effects. There were 751 responses, 406 coming from Northwood and 345 from Stockbridge Village.

Perceived impact of local factories on health generally

In Northwood, a significantly higher proportion of respondents (62.5%) felt that the local factories had made their health either slightly or much worse (Table 27) compared with just 5.0% in Stockbridge Village (chi square=269.094, DF=2, p<0.001).

Table 27: Effect of local factories on individual health

Stockbridge Northwood Village 152 328 No noticeable effect 37.4% 95.1% 150 13 Made health slightly worse 36.9% 3.8% 104 4 Made health much worse 25.6% 1.2%

Respondents were also asked to state what they thought the impacts had been on others (friends, family, neighbours) who lived in their area. Approximately three out of four Northwood respondents felt local factories had made other people‟s health worse compared to one in ten from Stockbridge Village (Table 28). Differences were statistically significant between the two areas (chi- square=321.802, DF=2, p<0.001).

Table 28: Effect of local factories on others

Stockbridge Northwood Village 77 287 No noticeable effect 21.5% 90.0% 145 26 Made health slightly worse 40.5% 8.2% 136 6 Made health much worse 38.0% 1.9%

Factories thought to be responsible for ill health

Respondents who thought that local factories were affecting their health were asked to identify the factories they thought were responsible. Two hundred and three (74.9%) of the 271 respondents who had expressed health concerns over local factories answered this question. A further 22 respondents named factories, without having identified any effects on health previously.

Table 29 lists the factories mentioned more than once by people from Northwood who responded to this question. A high proportion of respondents (97.3%) thought that the chipboard factory, Sonae, was associated with adverse effects on their health. Kodak, Kerrs and Rentokil were also mentioned.

Table 29: Factories mentioned more than once (that were listed by Northwood respondents who replied)

Number % Sonae 216 97.3 Kodak 14 6.3 Kerrs 5 2.3 Rentokil 3 1.4 Total* 222

*Because respondents could list more than one factory, this will not equal the sum of all the responses above

Views on specific health impacts

Respondents were asked to suggest up to three health problems that they thought could be related to nearby factories. Of the 271 respondents who had expressed health concerns relating to nearby factories, 89.3% (242) answered this question (235 in Northwood, 7 in Stockbridge Village).

In addition, 28 people who had expressed no health concerns of their own in the previous questions suggested theoretical health problems here (25 in Northwood, 3 in Stockbridge Village). 59

The most common health complaints that respondents associated with local factories were throat, eye, chest, nasal, coughs and breathing problems (Table 30). Smells were also mentioned again by 24.5% of respondents.

Table 30: Factory-related Health Problems listed by Northwood respondents who replied

Number % Throat 76 29.2 Eyes 75 28.9 Chest * 71 27.0 Nasal (incl. colds) 67 25.8 Smells 61 24.5 Cough 60 23.1 Breathing* 60 23.1 Smoke/fumes 43 16.5 Dust 42 16.2 Headaches 34 13.1 Nausea/ stomach 19 7.3 Noise 10 3.9 Tiredness 10 3.9 Doors/ windows closed 9 3.5 Anxiety/stress 7 2.7 Other 46 17.7 Total** 260 * ‘Chest’ and ‘Breathing’ have been listed separately, because both were sometimes mentioned by the same person. ** Because respondents could list more than one health problem, this will not equal the sum of all the responses above.

Summary - Community and Environment

A significantly higher proportion of respondents from Stockbridge Village considered their area to have a „sense of community‟ than those in Northwood.

Northwood residents had significantly more serious concerns about their neighbourhood than Stockbridge Village. These include concerns about vandalism, litter, smells and fumes, assaults and muggings, smoke and steam from factories, burglary, speeding traffic, uneven pavements, lack of leisure facilities for children, safety after dark, and noise.

The majority of people in both areas, however, reported positive feelings about their neighbours and community.

A significantly higher proportion of Northwood residents strongly disagreed that their area was a good place to raise children.

A significant higher proportion of Northwood respondents thought that local factories made their health, or the health of their friends and neighbours, worse compared with Stockbridge Village.

A high proportion of respondents who indicated that local factories affected their health thought that this was due to the Sonae chipboard factory.

The potential health impacts of local factories on health were identified by respondents as throat, eye, chest, nasal, coughs and breathing problems. Smells were also thought to be a problem.

Additional Comments

At the end of the questionnaire, many respondents provided additional information that they thought would be relevant The main themes highlighted in these comments were:

 Concerns about factories in general  Concerns about the Sonae factory specifically  Fears about dust, smells, smoke, fumes, noise, from the Sonae factory specifically  Dissatisfaction with the appearance of the Sonae factory  Perceptions that fumes from Sonae were falling to the ground on occasions  Worries about the impact of local industry on health and environment  Fear that emissions were not monitored adequately  Perceptions that local people were not informed about the monitoring of emissions  Perceived lack of job opportunities available to local people on the Knowsley Industrial Park  Perception that local concerns and opinions were ignored

There were also comments about:

 Crime and vandalism  Youths riding motorcycles (in Stockbridge Village)  Perceived lack of Police  Perceived lack of facilities and employment opportunities

Discussion

The Findings

This study described the health perceptions and socio-economic circumstances of people living in two areas of Knowsley, which differed in their proximity to the Knowsley Industrial Park. A number of significant differences between Northwood (situated close to Knowsley Industrial Park) and Stockbridge Village (situated about 5km from Knowsley Industrial Park) were highlighted.

61 Response rates to the survey (47% overall) were similar in both areas and respondents in each area were similar in terms of their age, levels of physical activity and smoking habits - all of which can affect health. A significantly higher proportion of Northwood residents were in employment and owned their own homes, and more people in Northwood lived in larger households. The majority of people in both areas reported positive feelings about their neighbours and communities, though a significantly stronger „sense of community‟ was found in Stockbridge Village. Residents of both areas expressed worries about money, safety and health.

Stockbridge Village residents reported significantly higher levels of disability, illness or infirmity. A significantly higher proportion of Stockbridge Village residents had also been exposed to occupational dust, fumes or chemicals. The survey, however, found a number of specific conditions and symptoms to be significantly higher in Northwood compared with Stockbridge Village. These included a number of respiratory symptoms and conditions, allergies, skin rashes, eye irritations, headaches, tiredness and difficulty sleeping. Northwood respondents also had strong concerns that local factories were having an adverse effect on their health. Smells, smoke, fumes, dust, noise as well as unsightliness were commonly thought to be a problem. The Sonae factory was specifically mentioned in the survey by a number of respondents, who were worried that it was having a negative impact on the health of local people. In addition, there was fear about the nature of local industrial processes, and perceived „secrecy‟ surrounding the monitoring of emissions.

Other issues such as vandalism, crime, litter, youths riding motorcycles and lack of facilities were also listed as causes for concern in Northwood and Stockbridge Village.

Interpreting the Findings

Several important issues must be considered when interpreting the findings of this study:

Visibility of Local Industry

The study set out to evaluate health perspectives in two populations that were comparable in terms of socio-demographic characteristics and general health status (standardised mortality rates for major chronic diseases), but differed in their exposure to local industry.

The „control‟ area, Stockbridge Village, is largely a residential area of Knowsley which has no sight of local factories or chimneys.

It is possible that the high visibility of the Knowsley Industrial Park to Northwood residents may have, in itself, increased some of the fears about its potential health effects.

62 Influencing Community Opinions

A fire at the Sonae chipboard factory attracted much attention from the media. This unfortunately coincided with the posting of the first questionnaire. It is therefore possible that the resulting media attention may have made some Northwood residents more critical of local industry than they otherwise would have been. The letter that accompanied the survey also mentioned that there had been concerns over local industry. In addition to this, Northwood residents had previously been encouraged to complete a survey carried out by the action group, Knowsley Against Toxic Sonae (K.A.T.S). They may also have been approached by other groups on similar issues. The Northwood residents would have heightened awareness of the symptoms to be concerned about. This could have influenced the views of some of the Northwood respondents and may have, in some cases, led to some residents being reluctant to complete more forms. Alternatively, motivation to return the questionnaire could well have been greater where there was heightened awareness of local concerns. The survey achieved an overall response rate of 47%, which was comparable to previous surveys in the same area. The response rates in Northwood and Stockbridge Village were similar, suggesting that it was meaningful to compare the data obtained from the two areas. Nothing is known, however, about the views of those residents who did not respond.

Regardless of media and other factors influencing public opinion, listening to local voices is an important way of finding new knowledge about factors affecting health and quality of life5. The experiences and perceptions of members of the community have their own validity, which can only serve to add to current scientific understanding or expectations.

Attribution of Symptoms and Self-reporting

This study relied upon people‟s perceptions of health and self-reporting. Self- reported symptoms, illnesses and health behaviours can be variable. Checklists and long questionnaires such as this one provide prompts, and can even increase the number of symptoms and disorders reported6. Questions asking about the previous year are also prone to recall bias, as memories can fade over such long periods. The potential influences on health may also change dramatically within the space of a year.

Most of the questions in the survey had, however, been successfully used previously7 and the results highlighted both similarities and differences between Northwood and Stockbridge Village.

The survey was conducted in two relatively deprived areas of the North West. Smoking rates were high, and the incidence of heart disease and lung cancers were well above the national average. These, and other conditions, could have influenced many of the respiratory symptoms that were reported. The mortality data (section 7.1) indicates that rates of respiratory disease were similar in both areas. There were no significant differences in smoking rates, levels of deprivation or levels of physical activity between Northwood and Stockbridge Village. These factors, therefore, cannot explain the differences in symptoms reported between the two areas. 63

The survey found significantly more reported respiratory symptoms, allergies, skin rashes, eye irritations, headaches, tiredness and difficulty sleeping in Northwood compared with Stockbridge Village. The reason for this is not clear. Some respondents of Northwood suggested that local industry was having a negative effect on their health. In particular, they thought that dust, smoke, fumes and odours from the Sonae chipboard factory were responsible. The symptoms are consistent with symptoms that are associated with formaldehyde, wood-dust and CVOCs, but they are also common symptoms. There is no good baseline data available on throat, eye or skin conditions to show whether the trends have increased in Northwood. Despite the reported high prevalence of respiratory and other symptoms in Northwood, an examination of hospital admission rates for respiratory diseases in Knowsley between 1999 and 2002 (the period before and during which the Sonae factory had been operational) showed high levels of hospital admission for respiratory disease in Northwood, but no increase in admission rates in the past 2 years. (section 7.2). There was also no increase in the levels of prescribing for respiratory disease by general practitioners in the area during this time, although the prescribing levels were consistently high in Northwood (section 7.3). This could mean that the increased prevalence of respiratory symptoms also existed in Northwood prior to the opening of the Sonae factory. This study did not ask about frequency, severity or duration of symptoms. Nor did it ask whether the symptoms had worsened in the past 2 years.

Local Industry and Monitoring

Industry may have both positive and negative impacts on local communities. Pollution and increased traffic are typical disadvantages, but factories are also a source of employment, and they may bring revenue into areas in other ways, as workers use local shops and services, for example. It follows that feelings towards industry can sometimes be ambivalent.

This did not appear to be the case in this survey. Respondents highlighted dust, smoke, fumes and odours from the Sonae chipboard factory in particular, as a local concern in Northwood. Knowsley Metropolitan Borough Council have carried out a number of investigations regarding concentrations and dispersion of pollutants, including odour, emitted from the factory.

It has been found that the emission levels from the factory are fully compliant with authorized statutory control limits. The number of odour units is above the level originally estimated by Sonae.

64 Survey Conclusions

 There was no overall difference in frequency of visits to the doctor between Northwood and Stockbridge Village.  The prevalence of reported mental health disorders was low in both areas.  Stress levels did not vary significantly between the two areas.  Money, safety and health were sources of stress in both areas.  Significantly more Northwood residents reported safety, air pollution, noise from nearby, always being in a hurry, work problems and unpleasant noise outside the home as sources of stress.  Vandalism, crime, litter, youths riding motorcycles and lack of facilities were causes for concern in both Northwood and Stockbridge Village.  Levels of smoking and of physical activity were similar in the two areas.  Amongst Northwood residents there were significantly more people reporting respiratory symptoms, allergies, skin rashes, eye irritations, headaches, stomach and bladder trouble, back trouble, headaches, tiredness and difficulty sleeping.  Local industry was perceived as affecting quality of life for a proportion of the Northwood residents, and some people reported that they experienced symptoms that they perceived as being associated with industrial pollution.

REFERENCES: SECTION 7

1. North West NHS Executive, Small Area Database, 1999. 2. Department of the Environment, Transport and the Regions. Indices of Multiple Deprivation 2000. London: Department of the Environment, Transport and the Regions 2000. 3. McCol E, Jacoby A, Thomas L, Soutter J, Bamford C, Steen N, et al. 2001. Design and use of questionnaires: a review of best practice applicable to surveys of health service staff and patients. Health Tech Assessment 5(31):116-117 4. Peterson RA, Albaum G, Kerin RA. 1989. A note on the alternative contact strategies in mail surveys. J Market Research Soc 31: 409-418 5. Moffatt S, Phillimore P, Bhopal S, Foy C. 1995. “If this is what it‟s doing to our washing, what is it doing to our lungs?” Industrial Pollution and Public Understanding in North East England, Soc Sc Med 41(6):883-891, pp 884 & 887. 6. Abramson JH, Abramson ZH. 1989. Survey methos in community medicine. Fifth edition. London: Churchill Livingstone. 7. Barrow S. Key Indicators from a Health & Community Survey in St Helens & Knowsley 2001 – Salford: Institute of Public Health Research and Policy, University of Salford. 8. Ubido J (2002). In their own words. Liverpool Public Health Observatory.

8. Conclusions

 This study has looked into the concerns of local residents about the health effects resulting from the Sonae Chipboard Factory. The methodology used has been based on national guidelines.

 It is possible to describe the potential irritant effects resulting from over-exposure to the emissions emanating from a chipboard factory. No studies have conclusively demonstrated that any particular chipboard manufacturing process has caused such effects in the surrounding community.

 Process monitoring has shown that the emissions from the factory are fully compliant with authorized statutory control limits. The number of odour units is above the level originally estimated by Sonae.

 In relation to respiratory disease, there is no evidence of increased admissions to hospital, or increased prescribing in general practice in Northwood, since the factory has been in operation. This suggests that during the past 2 years the levels of serious respiratory disease have not increased in Northwood.

 Some Northwood residents are concerned about effects on their quality of life, resulting from living in the area.

9. Recommendation

Knowsley Primary Care Trust should continue close monitoring and surveillance of the health and quality of life of the residents of Northwood.

Appendices

Appendix 1: Health Survey Questionnaire and Covering Letter

Liverpool Public Health Observatory Department of Public Health Whelan Building Quadrangle Liverpool L69 3GB

Dear Resident

Knowsley health and community survey

You may know that some local people are concerned about the possible effects on their health of living near the Knowsley Industrial Estate. Because of these concerns, Knowsley Primary Care Trust has asked the Liverpool Public Health Observatory to carry out a survey. This survey will be similar to the Health and Community Survey in 2001, and will identify any changes since then.

We would like to ask for your help in completing a survey form. The questions are easy to answer; we ask you to tick the boxes on the form, and write your own comments at the end, if you wish. The questions ask about you and your health, especially your lungs and chest, as well as exercise, smoking, your home and your working life.

Your name has been selected at random from a list of people living in the area. Your replies will be CONFIDENTIAL, and we will not identify you from your answers. Knowsley Primary Care Trust is funding this study to learn more about the health of people in Knowsley, but you will not personally be at any disadvantage if you decide not to take part. Please return the questionnaire in the envelope provided. No stamp is needed. Thank you very much for your help.

Yours faithfully,

Mr Nigel Fleeman Dr Barbara Hanratty Dr Alex Scott-Samuel Researcher Clinical Lecturer Director Liverpool Public Health Department of Public Health Liverpool Public Health Observatory Observatory

Knowsley health and community survey

Instructions for answering the questions

There are several types of question in this booklet. Most of them can be answered easily by ticking a box. For example:

Q. Do you wear glasses? Yes  No 

Some of the questions have several boxes and you may be asked to tick ONE only. For example:

Q. How often do you wear glasses? Some of the time  Most of the time  All of the time 

A few questions ask you to write your answer on a line. For example:

Q. How long have you worn glasses?______

Some of the questions ask you to tick more than one box. For example:

Q. Which other people in your household wear glasses? (Please tick ANY that apply to you) Spouse/Partner  Children  Parents 

Some of the questions ask you to tick ONE BOX IN EACH ROW. For example: Yes No Contact lenses – daily disposables   Contact lenses – monthly disposables   Contact lenses – other  

Please remember, it is your PERSONAL VIEWS we are interested in. For most of the questions there are no right or wrong answers.

THANK YOU – PLEASE START AT QUESTION 1 ON THE NEXT PAGE

ABOUT YOU 68

1. What sex are you? Male  Female 

2. How old are you? ____ years old

3. Do you or any members of your household normally have the use of a car or van? Yes  No 

4. We would like to know a little about your education. What age did you leave school? 16 years or under  17 years or over  Still at school 

ABOUT YOUR HEALTH IN GENERAL

5. Would you say that for someone your age, your health in general is: Excellent  Very Good  Good  Fair  Poor 

6a) Do you have a long-standing illness, disability or infirmity? (By long-standing we mean anything that has troubled you over a period of time, or that is likely to trouble you over a period of time) Yes  No 

6b) If you have a long-standing illness, disability or infirmity, please give brief details ______

6c) Does this illness or disability limit your activities in any way? Yes, severely  Yes, moderately  No 

6d) Have you seen your doctor about this? (Please answer for your main problem if you mentioned more than one problem) Yes  No 

7. In the last year have you suffered from any of the following problems and if you have, have you seen a doctor about it? 69 (Please tick only ONE box in each row) Yes but I Yes and I have NOT NO have seen a seen a doctor doctor Colds and flu    Pneumonia    Asthma    Chronic bronchitis    Lung disease    Sinus Trouble or Catarrh    Sore throat    Throat congestion    Dry cough    Persistent cough    Wheeze or wheezy chest    Shortness of breath    Chest pain    Other Chest Trouble    Allergies    Skin rash / skin trouble, e.g. Eczema    Stomach trouble    Liver trouble    Arthritis or Rheumatism    Kidney or bladder trouble    Piles or haemorrhoids    Pleurisy    Tuberculosis    Hay Fever    Eye irritations    Painful joints    Back trouble    High Blood Pressure    Angina    Heart Attack    Stroke    Lung Cancer    Other Cancer    Faints or dizziness    Headaches    Migraine    Diabetes    Always feeling tired    Difficulty sleeping    Nerves and anxiety   

7. Continued . . . In the last year have you suffered from any of the following problems and if you have, have you seen a doctor about it? (Please tick only ONE box in each row)

Yes but I Yes and I have NOT NO have seen a seen a doctor doctor Depressive illness    Difficulty concentrating    Palpitations or breathlessness    Worrying over every little thing   

If you are physically unable to walk please go to question 15

8. Do you have to stop for breath when walking at your own pace on level ground? Yes  No 

9. Do you get short of breath walking with other people of your own age on level ground? Yes  No 

10. Do you get short of breath when hurrying on level ground or walking up a slight hill? Yes  No 

11. Have you had attacks of wheezing or whistling in your chest at any time in the last 12 months? Yes  No 

12a) Have you ever had attacks of shortness of breath with wheezing? Yes  No 

12b) If YES: Is/was your breathing absolutely normal between attacks? Yes  No 

13. Have you any time in the last year been woken at night by an attack of shortness of breath? Yes  No 

14. During the past year have you had any chest illness which has kept you from your usual activities for as much as a week? Yes 

No 

15. Do any of these weather or atmospheric conditions affect your chest? (Please tick ANY that apply to you but only if they definitely and regularly affect your chest) Foggy weather  Damp weather  Cold weather  Hot weather  Still weather  71 Humid/sticky weather  Smoky atmosphere 

16. In the last year, how often have you visited your doctor’s surgery/health centre or been visited at home by your doctor? (Please count all visits about YOUR health, whatever the reason. Don’t include visits for children or someone else) Not at all  Only once  Two or three times  Four or five times  Six or more times 

17. How much stress would you say you have been under in the last year? More than most people  About the same as most people  Less than most people 

18. Have any of these things been a cause of stress or anxiety for you in the last year? (Please tick ANY that apply to you) Unemployment  Housing problems  Money problems  Problems with neighbours  Not feeling safe in your neighbourhood  Dirt  Family problems  Air pollution  Noise (from nearby)  Always being in a hurry  Problems to do with work  Other people‟s health problems  Your own health problems  Unpleasant smells from outside the home 

ABOUT EXERCISE

19. How often do you take moderate exercise – things like going for a walk, walking the dog, bowling? Never  Less than once a month  More than once a month but less than  once a week One to three times a week  Four to six times a week  Every day of the week 

20. How often do you take vigorous exercise – things which last for more than 20 minutes and make you breathless (like jogging, football, aerobics, digging the garden) Never  Less than once a month  More than once a month but less than  once a week One to three times a week  Four to six times a week  Every day of the week 

21. During the day, on an average weekday, how do you spend MOST of your time? I am bedridden  Sitting down (e.g. driving or at a desk)  Doing moderate activity (e.g. walking, light housework)  Doing vigorous activity (e.g. which makes you breathless when you are fit, such as  digging, labouring, heavy housework)

ABOUT SMOKING

22. Do you smoke (cigarettes, cigars, or pipes) or have you ever been a smoker? Yes  No 

23. How many other people in your household smoke (cigarettes, cigars or pipes)? ____

If you have never been a smoker please go to question 31

24. Do you currently smoke at least once a day? Yes  No 

73 If you used to smoke please go to question 27

25. How many cigarettes on average do you smoke each day? (Please tick only ONE box) 1-4 cigarettes  5-14 cigarettes  15-24 cigarettes  25-34 cigarettes  35-44 cigarettes  more than 45  I only smoke a pipe  or cigars

26. If you are a pipe or cigar smoker, please state how much on average you smoke each day: ____ cigars ____ ounces of tobacco

Please go to question 31

27. For how many years did you smoke regularly? ____ years

28. How long ago did you stop? ____ years ago

29. How many cigarettes on average did you smoke each day? (Please tick only ONE box) 1-4 cigarettes  5-14 cigarettes  15-24 cigarettes  25-34 cigarettes  35-44 cigarettes  more than 45  I only smoked a pipe or cigars 

30. If you were a pipe or cigar smoker, please state how much on average you used to smoke each day: ____ cigars ____ ounces of tobacco

ABOUT YOUR HOME AND ENVIRONMENT

31. How long have you lived at your present address? ____ years

32. Is your present home : Owned (including on mortgage) – bought privately  Owned (including on mortgage) – bought from council  Rented from council  Rented from Housing Association  Rented from private landlord  Other 

33. Where have you lived most of your life (Please tick only ONE answer) 74 Same address or within one mile of present address  Elsewhere in Knowsley  Elsewhere in Merseyside  Outside Merseyside 

34. In addition to you how many other people live in your household? ____ people

35. Please write down the ages of the other people in your household ____ years old ____ years old ____ years old ____ years old ____ years old ____ years old

36. Does your present home have dampness or condensation on the walls, floor or the ceiling?

Yes, a little  Yes, a lot  No 

37. Does the roof of your present home leak? Yes, a little  Yes, a lot  No 

38. Does your present home have draughts through badly fitted doors and windows? Yes, a little  Yes, a lot  No 

39. People often talk about areas having a sense of community? Would you say there is a community feeling in your area? Yes  No 

40. In your area, how much of a problem are the following: (Please tick ONE in EACH row) Serious Some Not a problem problem problem Vandalism?    Litter and rubbish?    Smells and fumes?    Assaults and muggings?    Smoke or steam from nearby factories and industry?    Burglaries?    Trouble by children or youngsters?    Speeding traffic?    Needles or syringes?    Uneven or dangerous pavements?    Nuisance from dogs?    Reputation of neighbourhood?    Lack of safe places for children to play?    Lack of leisure facilities (parks, pools, etc)    Walking around after dark    Noise   

41. How much do you agree with the following statements about your neighbourhood? Neither Strongly Strongly (Please tick ONE in EACH row) Agree agree nor Disagree agree disagree disagree Overall I like living in this area      I feel like I belong to this neighbourhood      I visit my neighbours in their homes      The friendships I have with other people in      my neighbourhood mean a lot to me I believe my neighbours would help me in      an emergency I borrow things and swap favours with my      neighbours I would be willing to work together with      others on something to improve my neighbourhood I plan to stay in this neighbourhood for a      number of years I like to think of myself as similar to the      people who live in my neighbourhood I rarely have neighbours over to my house      to visit I regularly stop and talk with people in my      neighbourhood Living in this neighbourhood gives me a      sense of community Overall I think this is a good place to bring      up children

42. Do you feel that any of these things have put your health at risk in the last year? (Please tick ANY that apply to you) Poor housing  Money Worries  76 Noise from nearby  Dust in and around your home  Air pollution from local traffic  Air pollution from local industry  Working conditions or hazards at work  Your drinking habits  Your smoking habits  The food you eat 

43. Which of the statements below best describes your views? (Please tick only ONE answer) The location of local factories close to where I live: Has had no noticeable effect on my health  Has made my health slightly worse  Has made my health much worse 

44. If you said that local factories has affected your health, please briefly describe up to three problems you have experienced:

1) ______

2) ______

3) ______

45. If you said that local factories have affected your health, please identify which one(s) you think are responsible:

1) ______

2) ______

3) ______

46. Which of the statements below best describes your views of people you know well and who live in your area? (Please tick only ONE answer) The location of local factories close to where people I know well live:

Has had no noticeable effect on the health of any of them  Has made the health of some of them slightly worse  Has made the health of some of them much worse 

ABOUT YOUR WORKING LIFE

47. Which of the following best describes you (Please tick only ONE answer) Employed – full time  Employed – part time  Self-employed  Unemployed  Retired  77 Housewife  Unable to work for health reasons  Student (full-time)  Other 

47. Please describe your present (or last) job: that is your occupation and industry or line of work______

49. Please describe your main job in your working life if it was different from the one above: that is your occupation and industry or line of work______

50. Have you ever been unemployed for more than one year at a time Yes  No 

Thinking about your working life as a whole:

51. Have you worked in a lot of dirt and dust? Most of my working life  Some of my working life  Occasionally in my working life  Never during my working life 

52. Have you worked in extreme hot or cold temperatures, say below freezing or hot enough to sweat without exertion? Most of my working life  Some of my working life  Occasionally in my working life  Never during my working life 

53. Have you been exposed to fumes or chemicals at work? Most of my working life  Some of my working life  Occasionally in my working life  Never during my working life 

54. If applicable, which of the following best describes your spouse or partner (Please tick only ONE answer) Employed – full time  Employed – part time  Self-employed  Unemployed  Retired  Housewife  Unable to work for health reasons  Student (full-time)  78 Other 

55. Please describe his/her present (or last) job: that is his/her occupation and industry or line of work ______

56. Please describe his/her main job in his/her working life if it was different from the one above: that is their occupation and industry or line of work______

Please write below any other comments you would like to make about ANY of the questions above, or anything else that you think is relevant

THANK YOU VERY MUCH FOR COMPLETING THIS QUESTIONNAIRE