Family Practice 2012; 29:168–173 Ó The Author 2011. Published by Oxford University Press. All rights reserved.

doi:10.1093/fampra/cmr079 For permissions, please e-mail: journals.permissions@oup.com.

Advance Access published on 5 October 2011

Public knowledge of the symptoms of myocardial

infarction: a street survey in Birmingham, England
Sean Whitakera, Thomas Baldwina, Mohammed Tahira,
Omar Choudhrya, Andrew Seniora and Sheila Greenfieldb,*
a
College of Medical and Dental Sciences and bPrimary Care Clinical Sciences, School of Health and Population Sciences, College
of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
*Correspondence to Sheila Greenfield, Primary Care Clinical Sciences, School of Health and Population Sciences, College of
Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK; E-mail: s.m.greenfield@bham.ac.uk
Received 20 April 2011; Revised 12 August 2011; Accepted 25 August 2011.

Background. Myocardial infarction (MI) is a leading cause of death in the UK. A good clinical out-
come depends on rapid treatment following the onset of symptoms. A person’s knowledge of

Downloaded from http://fampra.oxfordjournals.org/ by guest on October 11, 2013

typical symptoms determines how quickly they present to the medical services.
Objectives. To investigate knowledge of MI symptoms among the general population and the
relationship between age, gender and socio-economic status with knowledge.
Methods. Street survey of 302 participants in Birmingham, UK, using an interviewer-assisted
questionnaire.
Results. Of seven symptoms accepted in the medical literature as typical of an MI, central chest
pain was the most frequently identified (75% of the sample), followed by arm pain or numbness
(40%), shortness of breath (35%), fainting or dizziness (21%) and sweating (21%). Feeling or be-
ing sick and neck or jaw pain were mentioned by 8.1% and 5.9%, respectively, while an atypical
or inapplicable symptom, collapse (9.9%) was mentioned more often than these. Over half the
sample knew only two or fewer MI symptoms. The mean number of typical symptoms identified
was 2.2 (SD = 1.28). Respondents from professional occupations and those with previous
experience of MI, whether direct or indirect, showed better awareness.
Conclusions. The study demonstrated a paucity of knowledge of MI symptoms among the
general public. Such findings provide a baseline to guide public health campaigns targeting
awareness of MI.
Keywords. General public, myocardial infarction, symptom knowledge.

Background symptoms.5 In all cases, however, the patient’s descrip-

Coronary artery disease is the commonest cause of
heart disease in the UK and approximately one in
eight women and one in five men die from the dis-
ease.1 It is the cause of acute coronary syndrome
(ACS), for which 114 000 patients in the UK are ad-
mitted to hospital each year.2 ACS includes unstable
angina and myocardial infarction (MI), which share
an underlying pathology of atherosclerotic changes
within a coronary artery wall limiting its patency and
reducing perfusion of the myocardium.
An MI typically manifests as chest pain or feeling of
tightness, which may radiate to the arms, neck, jaw and
back, with nausea, vomiting, dyspnoea and sweating.3
Uncommonly, for example, in some diabetic or elderly
patients, an MI presents silently. It may also present with
diverse atypical symptoms, for example, with abdominal
pain.4 Importantly, there can be gender differences in
tion of any symptoms is considered alongside electro-
cardiogram findings and cardiac-specific enzyme assays
when deciding on the correct course of treatment.
An MI is a time critical illness, which has a better
prognosis when medical assistance is sought immedi-
ately on experiencing symptoms. Early presentation
of the patient to hospital permits the delivery of treat-
ments that would otherwise be futile or contraindi-
cated. For example, thrombolysis has the potential to
limit myocardial damage and rescue stunned myocar-
dium if administered within 24 hours, although it
should be administered within 60 minutes of the onset
of pain to confer maximal benefit.6 Percutaneous coro-
nary angioplasty has rapidly gained popularity as
a treatment for MI;7 here again, the prognosis is better
with early intervention.
The delay between the onset of symptoms and treat-
ment is referred to as ‘pre-hospital delay’, which itself

168
 Public knowledge of the symptoms of MI
comprises ‘patient delay’ in calling for medical assis-
tance and ‘transport delay’ in travelling to the hospi-
tal.8 Once assistance is sought, however, treatment is
generally prompt. For example, during the period
2006–07, 64% of eligible MI patients received throm-
bolysis within 1 hour of calling for help, which com-
pares favourably with the national target of 68%.9
Lack of knowledge of MI symptoms is a major cause
of patient delay. Other delays may be due to denial,
fear and an unwarranted trust in self-management.
Some patients may fear embarrassment if they report
to hospital needlessly. Pre-hospital delay can be signifi-
cant: only 8.4% of patients in one UK study received
thrombolysis within 1 hour and 32.8% within 2 hours
of the onset of pain.10 Patient delay was largely
responsible in these cases.
In Western surveys, a large proportion of the popula-
tion recognized chest pain as the main symptom of an
MI.8,11,12 Other typical MI symptoms, such as arm and
jaw pain, and shortness of breath, were less commonly
recognized.7,11 As 33% of MIs present without chest
pain,13 an MI presenting in this way may lead to signif-
icant patient delay.14 Surveys of the UK population
are poorly represented in the literature. A small study
(N = 88) of patients admitted to hospital for a first MI
showed that 76% had expected chest pain as a symp-
tom, but only 34% had expected pain radiating to the
arm/shoulder.15 In a larger study based in London,11
87% correctly identified chest pain as a symptom of
MI, 62% identified chest pain radiating to left arm or
shoulder and 56% identified shortness of breath. While
these studies are useful in gaining an understanding of
patients’ knowledge, they are not broad or robust
enough to generate focused hypotheses about symptom
knowledge within the UK population. Findings from
Pakistan16 and Nepal17 generally indicated poorer
symptom knowledge than Western studies.
One of the key studies addressing knowledge of
groups of MI symptoms is the Rapid Early Action for
Coronary Treatment (REACT) trial.8 This multi-
centre community trial in America reported a defi-
ciency in the knowledge of typical MI symptoms, with
participants able to identify a mean of only three
symptoms. The lack of insight into MI symptoms was
confirmed by several other studies, with Zhang et al.14
finding only 20% of participants able to correctly
identify four symptoms.
Knowledge of symptoms varies by demographic
group. For example, the REACT trial8 reported a high-
er level of knowledge by the middle-aged and persons
of higher socio-economic class. These findings are sup-
ported by Zhang et al.’s research14 on the Beijing popu-
lation, where knowledge was superior for better
educated, wealthier and middle to late age groups. In
one study, African-American males and people from
low-income households were less knowledgeable than
white Americans and those from high-income
169
households, respectively.18 Associations between symp-
tom knowledge and gender are inconsistent. Several
studies report better symptom knowledge among
women,19,20 whereas others fail to show a difference.21
In summary, coronary artery disease is an impor-
tant cause of morbidity and mortality in the UK,
with profound health and socio-economic conse-
quences. An inability of lay people to identify and
associate several symptoms when diagnosing an MI
(or at least the severity of the event) can result in
delay in presentation to medical services and in-
creased mortality and morbidity. In the UK, very
little research has examined public knowledge of
MI symptoms. Our study investigated the knowledge
of MI symptoms and the relationship between age,
gender and occupational position on knowledge in
a sample of the population in the West Midlands of
England, UK.
Methods
An interviewer-assisted questionnaire was adminis-
tered in a street survey in Birmingham city centre in
the UK during 2 weeks in March 2009. Based on spe-
cific Birmingham City Council guidelines, no ethical
approval was required for this type of survey. To try
and allow as broad a range of respondents as possible
to be included, we interviewed equal numbers of peo-
ple on each day of the week Monday to Friday during
working hours. We asked every third person to partici-
pate in the survey. The first item in the questionnaire
enquired about district of residence. Only respondents
living within five miles of the central business district
were accepted into the survey. Anyone <18 years of
age was excluded. As this was a street survey and in-
terpreting facilities could not be provided, non-English
language speakers were excluded. The response rate
was 58%.
The format for gathering information in our survey
was designed after referencing similar studies in the
literature.8,11,14,15 Questions asked about age, marital
status, occupation, previous MI and whether a first-
degree relative had experienced an MI. Each respond-
ent’s occupation was recorded verbatim for later
coding by the Standard Occupational Classification
(SOC) 2000.22 We classified unemployed or retired
respondents according to their last occupation. We
added two further categories: students and unclassifi-
able, i.e. respondents who had never worked.
We assessed MI symptom knowledge by first asking
each respondent, ‘Please tell me as many symptoms of
a heart attack as you can’. Responses were recorded
verbatim until the respondent claimed to know no more.
For the purpose of analysis respondents’ verbatim
responses were categorized under the appropriate medi-
cal terms. We defined a priori seven typical symptoms
170 Family Practice—The International Journal for Research in Primary Care
of an MI.3 Any respondent could score between 0 and 7,
depending on the number of typical symptoms they
identified correctly.
We used SPSSä for data analysis.23 The chi-square
statistic tested the independence of symptom knowl-
edge and age, sex and experience of an MI. We did
not include marital status data in the analysis. Approx-
imately normal distributions of scores legitimized the
use of Student’s t-test to compare performance across
groups defined by age, sex and experience of MI.
Equal variances were assumed and tests were two-
tailed. Analysis of variance and a Bonferroni post-hoc
test compared performance across groups defined
by occupational classes. We set alpha at 0.05 for all
analyses.
Results
Demographics
In total, 302 respondents completed the questionnaire.
Ages ranged between 18 and 89 years, with a mean of
45 and SD of 18. The sample included 141 (46.7%)
people aged >45 years and it was almost equally split
between men and women, 143 (47%) and 159 (53%),
respectively. Almost half the sample (45.4%) was
unemployed. In descending order of frequency, the
classes were professional, 18.5%; skilled trades, 13.6%;
administrative and secretarial, 10.3%; managers and
senior officials, 9.9%; elementary, 8.9%; student, 8.3%;
associate professional and technical: 7.9%; sales and
customer service, 7.3%; process, plant and machine
operatives, 6.6%; unclassifiable, 5.0%; and personal
service, 3.6%. Fourteen respondents (4.6%) had experi-
enced an MI. One hundred respondents (33.1%) knew
a first-degree relative who had had an MI. Seven
respondents were in both categories.
Figure 1 shows the entire range of 30 symptoms
listed by the respondents, arranged in decreasing order
of frequency. Highlighted by shading are the seven
symptoms defined a priori to be typical of an MI. Cen-
tral chest pain was most frequently mentioned (75%),
followed by arm pain (40%), shortness of breath
(35%), fainting or dizziness (21%) and sweating
(21%), all typical symptoms. Feeling sick or being sick
(8%) and neck or jaw pain (6%), both typical symp-
toms, were mentioned with comparable frequency to
the atypical symptoms collapse (10%) and unable to
speak or swallow (7%).
Nine per cent of the sample failed to identify any of
the seven typical MI symptoms, 21% could identify
one symptom, 30.5% two symptoms and only 40%
could identify more (Table 1).
The mean number of typical symptoms identified by
the sample was 2.20, with a SD of 1.28. Table 2 shows
the mean overall score for groups defined by age, sex
and MI experience.
The total number of typical MI symptoms identified
by respondents did not differ significantly across
groups defined by sex or age (<46 versus >46 years).
Respondents with a history of MI identified signifi-
cantly more typical symptoms (3.5 versus 2.1 symp-
toms), t = 4.02, P < 0.001. They were significantly
more likely to identify the following symptoms: feeling
or being sick (28.6% versus 7.6%), chi-square (2, N =
302) = 7.8, P < 0.01; sweating (57.1% versus 20.1%),
chi-square (2,N = 302) = 10.7, P < 0.01; neck and jaw
pain (21.4% versus 5.6%), chi-square (2,N = 302) =
5.7, P < 0.05 and arm pain or numbness (71.4% versus
41.3%), chi-square (2, N = 302) = 4.9, P < 0.05.
Respondents related to someone who had suffered
an MI identified significantly more typical symptoms
(2.6 versus 2.0), t = 3.67, P < 0.001. They were signifi-
cantly more likely to identify the following symptoms:
feeling sick or being sick (15.0% versus 5.4%), chi-
square(2, N = 302) = 7.8, P < 0.01 and sweating
(31.3% versus 17.3%), chi-square (2, N = 302) = 7.3,
P < 0.01.
Figure 2 shows the mean overall score (with 95%
confidence intervals) for each occupational class.
Groups differed significantly in their mean overall
scores, F(10,301) = 2.17, P = 0.02. Specifically, re-
spondents in professional occupations had significantly
higher overall scores than those in skilled trades
(2.8 versus 1.8 symptoms, respectively). All other
occupational groups did not differ significantly.
Discussion
In this study, we assessed public knowledge in respect
of MI symptoms in Birmingham, the UK’s second
largest city. Chest pain, arm pain and shortness of
breath are three symptoms among the seven we de-
fined as typical of an MI. These symptoms were identi-
fied correctly by 75%, 40% and 35% of respondents,
respectively. The remaining four symptoms were
poorly identified. Nine per cent of the sample failed
to identify any symptoms and 60% identified just two
or fewer. An MI can present with a subset of typical
symptoms and such restricted symptom knowledge
could result in considerable patient delay. Respond-
ents also appeared to conflate the symptoms of an MI
with those of a stroke. For example, being unable to
speak or swallow was mentioned more frequently than
neck or jaw pain.
We did not find significant differences in knowledge
across groups defined by age and sex, corroborating
the findings of Goff et al. and Zhang et al.8,14 Older
patients might have been expected to know more
about MI symptoms for a number of reasons: they at-
tend more closely to information on MI because it is
more relevant to them; they visit health centres more
frequently where health information is available; they
 Public knowledge of the symptoms of MI 171

central chest pain 75.5

arm pain or numbness 40.1

shortness of breath 35.1
fainting or dizziness 20.8

sw eating 20.5

collapse 9.9
feeling sick or being sick 8.1

anxiety 7.8
unable to speak or sw allow 6.8
cyanosis 5.9

palpitations 5.9
neck pain or jaw pain 5.9
fatigue 5.3

shaking 4.7
paralysis 4.3

pallor 3.7

high temperature 3.4

bloated or painful stomach 3.4
facial droop 2.8

back pain 2.8

memory loss 2.5
loss of vision or double vision 1.6

confusion 1.6
urinary incontinence 0.9
headache 0.9

dry mouth 0.9

limp neck 0.3
ankle sw elling 0.3

coughing up blood 0.3

skin rash 0.3

0 10 20 30 40 50 60 70 80
Percent of respondents (N=302)

FIGURE 1 Range and frequency of symptoms

TABLE 1 Number of typical borne out. Respondents working in professional occu-

symptoms identified across the sample
Number of typical symptoms identified
0 27
1 63
2 92
3 80
4 28
5 9
6 2
7 1
might have firsthand experience of an MI and they are
arguably the target of public health education pro-
grammes about the disease. This expectation was not
pations identified significantly more typical symptoms
than those in skilled trades. Perhaps, the latter group
n % of sample takes less interest in health issues or is exposed to
a lesser amount of health information or takes less in-
8.9 terest in health. The underlying trend might also be re-
20.9
30.5 lated to educational level.
26.5 A limited number of surveys have addressed MI
9.3 symptom knowledge among the public, as we dis-
3.0
cussed in the introduction, and they allow an opportu-
0.7
0.3 nity to put our results in context. Our respondents
generally had better knowledge than those in Asian14
and older Western studies12 but poorer knowledge
than those in the American REACT survey8 and Lon-
don survey.11 In the REACT trial, the proportion of
respondents correctly identifying chest pain or
172 Family Practice—The International Journal for Research in Primary Care

discomfort, arm pain or numbness, and shortness of Inevitably, there are weaknesses to the study. The
breath was 90%, 67% and 51%, respectively. In the street survey method used may have resulted in selec-
London study, the figures were 87%, 62% and 56%. tion bias. This needs to be borne in mind when consid-
The superior performance in the REACT study8 is ering the generalizability of the results and their
probably due to educational campaigns about MI implications for future research. A central city loca-
which ran in the months preceding the survey. Why tion tends to exclude people not normally venturing
our sample under-performed relative to the London into the centre from their homes in the suburbs.
survey is unclear, but selection bias might play a role. Disabled, infirm and very old residents are likely to
Since an MI can present with different combinations be under-represented. The survey was carried out dur-
of symptoms, and without chest pain in a third of ing weekdays and people in the city centre at week-
cases,13 a case could be made that future public health ends may differ from those there during the week.
messages should stress the diversity and variability of Non-English language speakers were excluded due to
typical symptoms, thereby bringing people’s beliefs in- the context in which the survey was carried out. Our
to line with reality. sample also included a disproportionate number of un-
employed people but this number included a large
TABLE 2 Mean number of typical symptoms identified by age, sex and contingent of retired people as well as people of work-
MI experience ing age. Clearly, this limits the generalizability of the
findings. It cannot be assumed that greater knowledge
Groups N Number of SD Student’s t P of MI symptoms will lead to patients presenting earlier
typical to emergency departments and receiving earlier and
symptoms
more appropriate treatment. The threshold for pa-
identified
tients presenting with symptoms who do not have an
MI may be lowered, particularly as several of the
Age –1.49 0.14
Age <45 161 2.09 1.23 symptoms of MI are non-specific.
Age >46 141 2.31 1.32 Our survey nevertheless gives a revealing assess-
Sex –1.62 0.11 ment of public knowledge of MI symptoms across
Male 143 2.07 1.30
Female 159 2.31 1.25
broad demographic groups. Medical knowledge is in-
MI Experience creasingly disseminated to a general audience in acces-
Respondent had an MI 14 3.50 1.83 4.02 0.001 sible forms so becoming the property of the public as
Respondent not had MI 288 2.13 1.21 well as the medical professional. Improvements in
Relative had an MI 100 2.57 1.37 3.67 0.001
Relative not had an MI 202 2.01 1.18
health education and wider access to health informa-
tion via the Internet should improve public knowledge

mean number of seven typical symptoms listed

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
2.33
managers and senior officials (30)

2.79
*professional occupations (56)

2.17
associate professional & tech occupations (24)

2.35
admin & secretarial occupations (31)

1.80
*skilled trades occupations (41)

1.91
personal service occupations (11)

2.18
sales & customer service occupations (22)

process, plant &machine operatives (20) 1.95

1.85
elementary occupation (27)

2.00
unclassifiable (15)

2.00
student (25)
2.20
total

FIGURE 2 Mean number of typical symptoms identified by occupational class; *difference significant at P < 0.05
 Public knowledge of the symptoms of MI
of relatively common emergency medical conditions,
such as an MI.
Conclusions
Our results indicated a relatively limited knowledge of
typical MI symptoms among a sample of the public
surveyed in England’s second largest city.24 While
some symptoms were commonly recognized, e.g. chest
pain or discomfort, others, e.g. neck and jaw pain,
were poorly identified. A lack of knowledge about
symptoms is important because it can extend patient
delay in summoning the emergency services and viti-
ate treatments such as thrombolysis and percutaneous
angioplasty. Such delays could be mitigated by public
health campaigns elucidating the range as well as the
nature of typical MI symptoms. As we did not find
any significant association between symptom knowl-
edge and age or gender, although previous MI experi-
ence either personal or family appeared to increase
symptom knowledge, whether there are clear target
groups for education campaigns is debateable. How-
ever, our results showed poorer knowledge of symp-
toms among non-professional groups—a trend likely
due to educational level. In general practice, there-
fore, it seems sensible to focus educational campaigns
about MI particularly at non-professional groups.
Acknowledgements
The views expressed in this publication are not neces-
sarily those of the National Institute for Health
Research, the Department of Health, NHS Partner
Trusts, University of Birmingham or the Collabora-
tions for Leadership in Applied Health Research and
Care for Birmingham and Black Country Theme
Management/Steering Group.
Declaration
Funding: SG was funded by the National Institute for
Health Research through the Collaborations for Lead-
ership in Applied Health Research and Care for Bir-
mingham and Black Country programme.
Ethical approval: none.
Conflict of interest: none.
References
1 22
Scarborough P, Bhatnagar P, Wickramasinghe K et al. British
Heart Foundation Health Promotion Research Group. Coro-
nary Heart Disease Statistics 2010. British Heart Foundation
Statistics Database. http://www.bhf.org.uk/publications/view-
publication.aspx?ps=1001546 (accessed 23 September 2011).
2 24
Collinson J, Flather MD, Fox KA et al. Clinical outcomes, risk
stratification and practice patterns of unstable angina and myo-
cardial infarction without ST elevation: prospective registry of
173
acute ischaemic syndromes in the UK (PRAISUK). Eur Heart
J 2000; 21: 1450–7.
3
Kumar P, Clarke M. Clinical Medicine. London: Saunders Ltd,
2008.
4
Peters RJG, Mehta S, Yusau S. Acute coronary syndromes without
ST segment elevation. BMJ 2007; 334: 1265–9.
5
Chen W, Woods SL, Puntillo KA. Gender differences in symptoms
associated with acute myocardial infarction: a review of the re-
search. Heart Lung 2005; 34: 240–7.
6
NICE (National Institute for Health and Clinical Excellence).
Technology Appraisal Guidance 52: Guidance on the Use of
Drugs for Early Thrombolysis for the Treatment of Acute Myo-
cardial Infarction. London: National Institute for Clinical Ex-
cellence, 2002.
7
Grech ED, Ramsdale DR. Acute coronary syndrome: ST segment
elevation myocardial infarction. BMJ 2003; 326: 1378–81.
8
Goff DC Jr., Sellers DE, McGovern PG et al. Knowledge of heart
attack symptoms in a population survey in the United States:
the REACT Trial. Arch Intern Med 1998; 158: 2329–38.
9
Thrombolytic Treatment, Use of Aspirin, Beta Blockers and
Statins after a Heart Attack 2004/5–2007/8, England and Wales
(Table). British Heart Foundation. http://www.bhf.org.uk/
heart-health/statistics/treatment-and-rehab/drugs.aspx
(accessed on 23 September 2011).
10
Horne S, Weston C, Quinn T et al. The impact of pre-hospital
thrombolytic treatment on re-infarction rates: analysis of the
Myocardial Infarction National Audit Project (MINAP). Heart
2009; 95: 559–63.
11
Donohoe RT, Haefeli K, Moore F. Public perceptions and experi-
ences of myocardial infarction, cardiac arrest and CPR in
London. Resuscitation 2006; 71: 70–9.
12
Bury G, Murphy AW, Power R et al. Awareness of heart attack
signals and cardiac risk factors among the general public in
Dublin. Ir Med J 1992; 85: 96–7.
13
Canto JG, Shlipak MG, Rogers WJ et al. Prevalence, clinical
characteristics, and mortality among patients with myocardial
infarction presenting without chest pain. JAMA 2000; 283:
3223–9.
14
Zhang QT, Hu DY, Yang JG. Public knowledge of heart attack
symptoms in Beijing residents. Chin Med J 2007; 120: 1587–91.
15
Horne R, James D, Petrie K et al. Patients’ interpretation of symp-
toms as a cause of delay in reaching hospital during acute myo-
cardial infarction. Heart 2000; 83: 388–93.
16
Khan MS, Jafary FH, Faruqui AM et al. High prevalence of lack of
knowledge of symptoms of acute myocardial infarction in
Pakistan and its contribution to delayed presentation to the
hospital. BMC Public Health 2007; 7: 284.
17
Limbu YR, Malla R, Regmi SR et al. Public knowledge of heart at-
tack in a Nepalese population survey. Heart Lung 2006; 35:
18
164–9.
Lutfiyya MN, Lipsky MS, Bales RW. Disparities in knowledge of
heart attack and stroke symptoms among adult men: an analy-
sis of behavioral risk factor surveillance survey data. J Natl Med
Assoc 2008; 100: 1116–24.
19
Greenlund KJ, Keenan NL, Giles WH et al. Public recognition of
major signs and symptoms of heart attack: seventeen states
and the US Virgin Islands. Am Heart J 2001; 147: 1010–16.
20
Fang J, Keenan N, Dai S. Disparities in adult awareness of heart
attack warning signs and symptoms- 14 States 2005. MMWR
Morb Mortal Wkly Rep 2008; 57: 175–9.
21
Tullmann DF, Dracup K. Knowledge of heart attack symptoms in
older men and women at risk for acute myocardial infarction.
J Cardiopulm Rehabil 2005; 25: 33–9.
Standard Occupational Classification. Office for National
Statistics. http://www.ons.gov.uk/ons/guide-method/classifications/
archived-standard-classifications/standard-occupational-
classification-2000/index.html (accessed on 23 September 2011).
23
SPSS Version 13. Chicago, IL: SPSS Inc.
Medland A. Portait of the West Midlands. Office for National
Statistics, 2011 http://www.ons.gov.uk/ons/cci/nugget/
.asp?id=2233 (accessed on 23 September 2011).