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Promoting Health and Advancing Development through Improved Housing in Low-Income Settings

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Abstract

There is major untapped potential to improve health in low-income communities through improved housing design, fittings, materials and construction. Adverse effects on health from inadequate housing can occur through a range of mechanisms, both direct and indirect, including as a result of extreme weather, household air pollution, injuries or burns, the ingress of disease vectors and lack of clean water and sanitation. Collaborative action between public health professionals and those involved in developing formal and informal housing could advance both health and development by addressing risk factors for a range of adverse health outcomes. Potential trade-offs between design features which may reduce the risk of some adverse outcomes whilst increasing the risk of others must be explicitly considered.

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Acknowledgments

We thank Richard Smith of the London School of Hygiene and Tropical Medicine for his helpful comments.

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Authors and Affiliations

  1. Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK

    Andy Haines

  2. Department of Public Health and Policy, Institute of Psychology, Health and Society, Whelan Building, Quadrangle, The University of Liverpool, Liverpool, UK

    Nigel Bruce

  3. Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK

    Sandy Cairncross & Katie Greenland

  4. UCL Bartlett School of Graduate Studies, London, UK

    Michael Davies

  5. Institut Pasteur du Laos, Vientiane, Lao People’s Democratic Republic

    Alexandra Hiscox

  6. Laboratory of Entomology, Wageningen University and Research Centre, Wageningen, The Netherlands

    Alexandra Hiscox

  7. School of Biological and Biomedical Sciences, Durham University, Durham, UK

    Steve Lindsay

  8. Environmental Design, Robinson College, University of Cambridge, Cambridge, UK

    Tom Lindsay

  9. International Institute for Environment and Development, London, UK

    David Satterthwaite

  10. Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK

    Andy Haines & Paul Wilkinson

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Appendices

Appendix 1. Commentary on evidence relating to further health outcomes possibly associated with exposure to emissions from indoor solid fuel use

Evidence is also emerging for a number of other outcomes, which were not included in Table 1 as current evidence is limited and/or systematic reviews are not available. We are aware of one study to date of HAP exposure and CVD as an endpoint which reported an odds ratio of 2.58 (1.53, 4.32)85, but several studies of ‘intermediate’ stages and risk factors such as blood pressure have been reported. The analysis of the relationship between PM2.5 from combustion sources (outdoor pollution, second-hand smoke and active smoking) by Pope et al.82 suggests that HAP exposure (with the dose lying between second-hand and active smoking) would be associated with CVD risk.86 Based on this assumption, risks consistent with the reduction in exposure to HAP of 200 μg m−3PM2.5 of 1.204 women and 1.0734 men, respectively, have been proposed.

A small but quite consistent set of studies report an increase risk of cataract.87,88 Reviews have found inconsistent results for TB, however.89–91 There is also evidence of links with other cancers, including of the upper aero-digestive tract92,93 and carcinoma of the uterine cervix. All of these links, if confirmed, are consistent with the effects of tobacco smoke.

Kerosene is used for cooking and/or lighting fuel by some 500 million homes and has often been grouped with ‘clean’ fuels, but there are concerns about emissions as well as safety. One recent study reported a very elevated risk of TB associated with kerosene use for lighting and cooking94, and this fuel is well recognized as serious risk for burns, fires and child poisoning.95 Population data on burns and scalds are lacking. A high proportion of the 200,000 annual global burn deaths occur in developing countries, mostly in the home and associated with both liquid and solid fuel use. For every death, there are many more severe injuries, which are often inadequately treated, with severe lifelong consequences for disability and stigma. Electric lighting, whether powered through external connection or in-home solar photovoltaic units, will not only avoid the risk of burns and poisoning but also has zero emissions at the point of use (home).

Intervention studies are beginning to provide evidence that reducing exposure impacts positively on a number of these conditions. The RESPIRE trial has shown a one third reduction in severe pneumonia with use of a chimney stove that halved child exposure (OR = 0·67 (0·45–0·98) p = 0.042)96, while three cohort studies of the impacts of the Chinese national improved stove programme have shown substantial reductions of 25–50 % in lung cancer, COPD97 and adult pneumonia mortality for long-term improved stove users in coal-burning areas.

Although significant challenges in achieving large scale, exclusive use of much cleaner stoves and fuels remain, renewed efforts coordinated by the UN Foundation Alliance for clean cookstoves98 are underway to address the critical technological, financing and market development issues involved. Delivery of cleaner, safer and more efficient household energy solutions as part of an integrated health home package including water and sanitation may offer synergistic benefits in terms of health and programmatic efficiency99, but robust empirical evidence is not yet available.

Questions have been raised about whether a reduction in smoke in the home may increase the risk of vector-borne disease. A systematic review found that, while biting may increase, disease transmission was not affected.100

Appendix 2. Humidity, condensation and mold

Humidity in the dwelling can cause condensation which encourages the growth of fungal spores. Damp is also associated with an increase in house dust mites. Both of these are known allergens. This suggests a causal link between respiratory disease, in particular asthma, and damp and mold.29 In addition, there is an observed dose–response relationship noted with this finding: asthma severity increasing with increasing levels of damp and mold in the home. House dust mites require warmth and humidity to thrive, ideally between 23 and 25 °C with 80–90 % humidity. Keeping a dwelling between 40 and 60 % humidity and improving ventilation decrease the number of mites.

Mold growth occurs when the ventilation is poor and the humidity levels are high. Intervention studies have shown that increasing ventilation and reducing humidity can decrease mold.

Studies use different methods of characterising mold—experts or self-reporting and many do not include confounding factors such as smoking or house type. Even so, there is still a consistent and significant relationship found between respiratory symptoms and damp and mold in dwellings. Whether this is an exacerbation of existing disease or the initiation of new disease is as yet unclear. Reduction of exposure to house dust mites also requires user behaviour for adequate airing of bedding, washing and the fitting of pillow and mattress covers which is unlikely to be practical in low-income settings. Structural factors such as consistent heating and good ventilation do play a role in keeping the exposure down, and further research is needed to better understand the health implications in low-income settings.

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Haines, A., Bruce, N., Cairncross, S. et al. Promoting Health and Advancing Development through Improved Housing in Low-Income Settings. J Urban Health 90, 810–831 (2013). https://doi.org/10.1007/s11524-012-9773-8

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