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Hygiene and Environmental Health Module: 4. Healthful Housing

Study Session 4  Healthful Housing

Introduction

Our health depends not only on personal hygiene but also on the hygiene of our homes and housing. We spend much of our daily time in our home and our physical and mental development takes place there. This study session describes the basic hygiene requirements of housing to ensure that it is appropriate for our health. Factors affecting housing sanitation and possible interventions will be discussed. We will also closely examine the status and effect of indoor air pollution. You will learn the linkages between our health and environmental needs with respect to housing.

Learning Outcomes for Study Session 4

When you have studied this session, you should be able to:

4.1  Define and use correctly each of the key words printed in bold. (SAQ 4.1)

4.2  Describe the links between healthful housing and health. (SAQs 4.2 and 4.3)

4.3  Describe the main features of model rural housing and how it supports the health of its inhabitants. (SAQ 4.4)

4.4  Describe factors involved in indoor air pollution and its prevention. (SAQ 4.5)

4.5  Explain the elements/activities that are needed for planning healthful housing promotion. (SAQ 4.6)

4.6  Describe the criteria that are used for evaluating the effectiveness of healthful housing practice. (SAQ 4.6)

4.1  What is healthful housing?

Every family and individual has a basic right to a decent home and a suitable living environment. Housing is a basic prerequisite for health. This right is noted in the constitutions of many countries, including Ethiopia. However, a significant proportion of the population in rural and urban areas in Ethiopia does not possess suitable healthful housing.

Housing is a term that we use for a physical structure in which we live.

  • Just stop reading for a moment and ask yourself: what is housing?

  • You may say housing is a shelter where we sleep and live, or a place in which we cook our food, or a place where a child grows, or a place where we get clean water for drinking.

You will probably have a long list like this. The question is, then, how will you provide a complete understanding of housing so that members of your community understand you?

If you look for definitions of housing in books, you may find different answers. The Oxford Essential Dictionary defines housing as ‘flats and houses for people to live in’. Housing is also considered as a dwelling or physical shelter that is used for living purposes. Many of these definitions focus on the nature of housing as a physical structure or shelter.

The public health understanding of housing goes beyond this. The World Health Organization uses the term ‘residential environment’, rather than ‘housing’, which they define as:

the physical structure that man uses for shelter and the environs of that structure including all necessary services, facilities, equipment, and devices needed or desired for the physical, mental, and social wellbeing of the family and individual.

Note the key words in this definition. It combines the idea of shelter with the complete development of health and is equivalent to a definition of healthful housing. The definition has three elements:

  • The physical structure or building that provides the shelter.
  • The necessary services, facilities, equipment and devices that are used by an individual, for example, a bedroom for sleeping or a latrine for human waste excretion.
  • The goal of housing is preserving one’s health. This is the purpose of a physical building and its immediate environment.

Do not get confused with different terms such as housing sanitation, housing hygiene, hygiene of housing, residential environment and healthful housing. They mean almost the same thing.

Your role in the provision of healthful housing must be clear. You are an advocator and communicator of appropriate information and advice. You will need partners to help you in the work towards healthful housing; these are members of your local community, elders and local government staff.

4.2  Basic requirements of healthful housing

In order to understand further what housing is, WHO has adopted four basic requirements:

  • satisfaction of physiological needs
  • protection against infection
  • protection against accidents
  • protection against psychological and social stresses.

4.2.1  Satisfaction of physiological needs

Human physiology (the functioning of our bodies) is highly dependent on the immediate environment. Our environment should supply the necessary services and facilities for our physiological needs. For example:

Breathing

Breathing is a physiological process that utilises oxygen for energy production and expels the waste as carbon dioxide (CO2). Housing must allow adequate fresh air to get into the house and used air to get out. This ventilation of air is facilitated by a window. The area of the window surface through which air can pass must be proportional to the floor area of the room in order to get adequate air supply per given time. A guide of 10% (light and air admitting window area divided by floor area) is assumed to be adequate for residential housing.

  • The floor dimensions of a room are 3 m wide and 4 m long. Calculate the size of the window that could supply adequate ventilation.

  • Floor area = 3 × 4 m = 12 m2

    The window should be 10% of the floor area. 10% of 12 m2 is 1.2 m2. The size of the window needed is therefore 1 m wide by 1.2 m height if you had one window, or 0.8 m by 0.8 m each if you had two windows.

Getting clean and fresh air through the window could be compromised by household activities. Interference with breathing due to smoke and gases from the use of fuels such as wood or dung is common. Inefficient combustion releases many toxic chemicals that can affect our skin, eyes and lungs.

Seeing

This is the ability to observe the immediate environment using our eyes. Naturally, visual physiology requires adequate light in order to effectively see or look at an object. Adequate light is also important for reading, watching TV and attending class lectures in a school. The physical structure of housing provides the required light through two sources: artificial light from electric sources and natural light through the windows from the sun. The minimum recommended light-admitting window area is similar to that for breathing.

Sleeping

Sleep is a time when our body must get complete rest in order to be refreshed for the next day. Sleeping requires a separate room and should be free from any disturbance such as noise and indoor air pollution. The housing structure should provide adequate space in the form of a bedroom that is reasonably free from any environmental hazard that could disrupt sleeping. Separate bedrooms for children and adults are, in many families, a necessity.

Body heat regulation

Housing helps us to regulate our body heat, which means it helps us to keep warm or to keep cool.

  • How does housing help us regulate our body heat?

  • It protects us from the weather, helping us to keep cool by shading us from the heat of the sun, or to keep warm by protecting us from cold, wind and rain.

The exchange of heat between our body and the immediate environment is dependent on the difference of temperature between the two. Relatively cold air is useful to take away excess heat through the process of convection. Convection is involved when there is a heat exchange between our body and relatively cold air moving across the body. Heat loss by conduction is involved when body heat is transferred to a colder surface by direct touch. The third mechanism for heat transfer is radiation, when body heat is lost directly to the immediate environment because of a temperature difference between two objects. Our housing should be suitable to help us regulate our body heat.

Eating

Eating food is linked with the digestive system of our physiology. A kitchen for food preparation and a separate space/room where a family gets together for meals are necessary to satisfy our housing needs for eating.

4.2.2  Protection against infection

Healthful housing is essential for the prevention of a number of diseases that you have learned about in the Communicable Diseases Module. Poor housing is associated with a wide range of diseases. Categories of communicable diseases due to poor housing include:

  • Diarrhoeal diseases (acute watery diarrhoea, dysentery, shigellosis, typhoid fever and other faeco-orally transmitted diseases) because of poor personal hygiene, absence or poor utilisation of latrines and poor waste management.
  • Tuberculosis, measles and other droplet infections due to poor ventilation and crowding.
  • Acute and chronic lung diseases due to indoor/cooking smoke. Indoor smoke causes eye infection and irritation.
  • Skin infections such as scabies and ringworm due to crowding as a result of limited housing space.
  • Typhus fever and relapsing fever are possible due to crowding. Lice can easily travel from an infected person to the next nearby one.
  • Disturbance of human comfort as a result of the bites of insects such as bedbugs and fleas.
  • Breeding sites of rats in poor housing.

We want to make sure that our housing provides the necessary service and facilities to ensure the prevention of communicable diseases and protection of our health. These are summarised in Table 4.1. Household hygiene, personal hygiene, food hygiene and safe water supply are critical interventions for the prevention of infections in rural areas.

Table 4.1  Housing facilities and services needed for protection against infections.
NeedsFacilities/services needed in the residential environment
Drinking water supply and its safe handlingAccess to protected water source; safe household water storage and utilisation
Safe human waste managementPresence and proper utilisation of latrines
Safe solid waste managementPresence of solid waste storage and disposal
Safe liquid waste managementPresence of liquid waste removal facilities (seepage pit, drainage pit)
Maintenance of personal hygiene practicePresence of handwashing facilities
Food safetyPresence of hygienic kitchen; proper storage and handling of kitchenware
Vector control (flies, bedbugs, fleas)Application of environmental controls; periodic cleaning of floors and walls; separate animal shed; proper dung management

You will learn more about these facilities and services in later sessions of this Module.

4.2.3  Protection against accidents

  • What accidents could be possible because of poor housing?

  • Poor housing can contribute to several types of accident including burns and electric shocks (if there is an electricity supply).

Table 4.2 shows several types of accident in the home and indicates the housing conditions that may cause them.

Table 4.2  Possible home injuries and their contributory causes.
InjuryConditions that may cause the injury
Person falling over causing broken bones, bruising etc.Slippery floor; steps that are too high or too low
Building materials falling on peoplePoor structure of roof and walls
BurnImproper use of fuel; damage to electrical wires
Carbon monoxide poisoning (see Box 4.1)Not extinguishing fire sources while sleeping
Chemical poisoning (a child drinking pesticide, handling drugs, etc.)Improper handling and storage of chemicals
Lack of air, breathing problemsNo separate kitchen; keeping children close by while cooking with wood or dung fuel
Electric shockElectrical wire is damaged by a rat; incorrect installation; overloading a circuit, etc.
Box 4.1  Carbon monoxide (CO) poisoning

Carbon monoxide (CO) is a toxic gas that is given off in incomplete combustion, when fuels don’t burn properly. You can’t see, smell or taste carbon monoxide, so it is very difficult for people to detect; this makes it very dangerous.

When we breathe in, oxygen is taken in through the lungs and carbon dioxide is breathed out. Haemoglobin in the red blood cells is used to carry oxygen to various parts of the body.

O2 + haemoglobin = oxyhaemoglobin

If there is carbon monoxide in the breathed-in air, it combines with haemoglobin more easily than oxygen does.

CO + haemoglobin = carboxyhaemoglobin

CO reduces the oxygen-carrying capacity of the blood and poisons the body. It can lead to illness and even death.

4.2.4  Protection against psychological and social stresses

Remember that housing was defined as more than just a shelter. Poor housing can contribute to psychological and social stresses. These stresses cannot be physically observed but they may be revealed in the words people use to describe how they feel. We know that stress is not good for a healthy person. For example, the absence of a school in a village can be a stressful condition for a family with school-age children. Poorly built housing or the absence of water in a household could be a source of stress. On the other hand, the presence of a church or mosque pleases those who want to have access to them. The presence of playgrounds for children, markets, kebele and police offices, and recreational sites are some of the facilities that could alleviate human stresses. The satisfaction of psychological and social requirements through the presence of these facilities is very important to any organised village or community. These facilities are important for any existing as well as new settlements that include individual housing.

The objective of a healthful housing programme is to satisfy all or most of the above basic requirements. Improvements can be suggested based on priorities. Poor housing sanitation, overcrowding, insufficient daylight and poor ventilation are characteristics of tukuls in rural areas of Ethiopia.

4.3  Protecting people at special risk

Handling the housing conditions of people who have been displaced because of war, flooding, earthquakes, ethnic conflicts and epidemics requires special consideration. This group of people is vulnerable to communicable diseases, physical and sexual abuse, hunger, thirst, and various types of injury. They are likely to be socially and mentally stressed. The provision of shelter (tents and other types of shelter), food, plenty of water and accident prevention is most important. The representatives of displaced populations can be organised into a committee to assist the facilitation of relief assistance. The government needs to have similar organisation to work effectively.

4.4  Factors affecting healthful housing

Poverty, education, climate, culture and population mobility are the main factors that affect the structure of housing, i.e. the size, shape and design.

Figure 4.1 shows various types of tukuls (rural housing) that reflect different climatic and cultural variations. Big tukuls have tight-plastered walls and roofs, are more spacious and are usually found in cold areas. Tukuls in pastoralist areas are smaller in size, easily constructed and relatively inexpensive. Mobile populations require housing that can be reconstituted easily whenever needed. Some cultural values may hinder specific requirements such as the use of wider windows. Lack of education is also a problem. Even in high-income households, poor knowledge of the links between housing and health may be a barrier to the construction of healthful housing.

Structure of housing in different areas of Ethiopia
Figure 4.1  Structure of housing in different areas of Ethiopia. (Photos: Abera Kumie)

You should note that these factors affecting housing conditions are broad issues and not something that anyone can tackle alone, but you should be aware of these factors because they may be relevant in your villages.

4.5  Guidelines for model housing

Here are suggested operational guidelines for the basic structural needs of a model tukul or other rural house.

4.5.1  Location of housing

The location of a tukul must be free from flooding and any potential natural disaster.

4.5.2  Size of housing

Based on the requirement to satisfy physiological needs, a minimum of 9–10 m2 per individual is advised. This square unit is adequate for all purposes and services that our body needs. For a family of five, the total area required therefore is about 50 m2. The wall height should not be less than 2 m depending on the length of the central axis of the tukul.

4.5.3  Type and size of rooms

Rooms for sleeping (bedroom), eating meals (dining room or salon) and storage (store room) are important (Figures 4.2 and 4.3). Sleeping rooms for children and adults should be separate if possible. Animal sheds and kitchen must not be part of the main rooms (sleeping and salon), but should be placed outside. Partitions should be used to create separate areas within the house although in a traditional tukul, it is not possible to have partitions that reach up to the ceiling. Based on the available literature, the space requirements are as follows:

  • a living room (dining room or salon) 3–5 m2 per person
  • bedroom(s) at 5–6 m2 per person, with a minimum room area of 8–12 m2
  • a kitchen (greater than or equal to 7 m2)
  • a store (5 m2).
2  Traditional tukul
Figure 4.2  Traditional tukul: front view and floor plan.
A housing unit with corrugated iron sheet roof
Figure 4.3  A housing unit with corrugated iron sheet roof and its floor plan.

4.5.4  Windows

As has been noted above (Section 4.2.1), the proportion of window surface area to floor area must be 10% at minimum. It is good to locate the window facing south, south-east or south-west so that adequate sunlight can be possible throughout the day. The presence of two windows is advisable for effective ventilation.

4.5.5  Structure of the walls

Walls must be well plastered with local materials both on the interior and exterior. Smooth interior walls are less likely to harbour insects such as bedbugs and cockroaches.

4.5.6  Kitchen

The kitchen must be totally separate from the main house. It must have an improved stove with a chimney for cooking injera and other foods.

4.5.7  Latrines and handwashing facilities

Latrines and handwashing facilities are explained in more detail in later sessions of this Module.

Good housing has a latrine and handwashing facilities to maintain personal hygiene and the prevention of infections.

4.5.8  Cleanliness

The interior of the dwelling and the immediate environment must be clean. Any type of solid waste and faecal matter must not be seen within and around the house.

4.6  Indoor air pollution

Cooking activities inside the main tukul, where family members spend most of their time, generates smoke that is hazardous to health. Mothers, children and elders are the ones who are most exposed to the effects of smoke. The usual type of fuel that is used for cooking and heating in the rural areas is biomass, i.e. animal dung (kubet) (Figure 4.4), crop residues and wood. Biomass fuel is understood to be inferior to, say, kerosene, because it is not energy-rich when burned. An inadequate supply of oxygen to the fire and wetness of the fuel increases indoor smoke. Biomass fuel generates visible smoke which is composed of a number of chemicals that are hazardous when breathed in. Carbon monoxide and tiny carbon particles (tilashet) are dangerous if inhaled.

Dung for fuel drying in the sun
Figure 4.4  Dung for fuel drying in the sun. (Photo: Pam Furniss)

Indoor air pollution occurs when the air inside a tukul is predominantly smoke instead of clean air (Figure 4.5). The presence of indoor air pollution is associated with acute respiratory infections, bronchitis and chronic lung diseases among children and mothers. You can help to prevent indoor air pollution by:

Indoor air pollution
Figure 4.5  Indoor air pollution. (Photo: Abera Kumie)
  • Advising the family to use an efficient stove that minimises fuel consumption and therefore smoke emission. The improved stove must be equipped with a chimney.
  • Promoting the separation of the kitchen from the main house.
  • Promoting the separation of animal sheds from the main house because fresh animal dung and urine produce bad odours when decaying.
  • Advising mothers to cook without involving children in the kitchen.
  • Recommending that a window be installed and left open until cooking is finished.

4.7  Planning for the improvement of healthful housing

How can you help to promote healthful housing? This is a question you should ask yourself once you have read this session. So far this session on healthful housing has focused on helping you to gain a scientific understanding of housing in terms of its definition, public health importance and basic housing requirements. Using this knowledge, you can consider how you can contribute to the improvement of housing conditions in your operating area.

4.7.1  Defining problems associated with healthful housing

The first step is to identify any housing problems in your area of interest using the above descriptions. Design a checklist and then make a quick survey to collect data on housing. A randomly selected sample of tukuls (say 30) is adequate for this exercise. At the end of the survey you should be able to list and prioritise the problems. Cultural and economic factors need to be identified. The findings will support your discussion with the community. The possible solutions must be indicated for each problem in concrete terms. The feasibility of using local materials should be studied as well. You should also indicate possible solutions in the form of proposed interventions that could be tackled without much additional investment.

4.7.2  Working with the local government

You cannot improve all the housing alone. You will need to discuss the survey findings with the members of the local government (kebele officials). They will be willing to provide you with additional advice and enrich your intervention.

4.7.3  Working with the community

You must be smart on how to implement the housing improvement programme you have designed. You should involve willing household heads in housing improvement and use these people to start your intervention. You can use these model households as examples for the rest of the community to follow. Once you have gained experience in handling this challenge, you can evaluate what can be done to expand these interventions.

4.7.4  Strategies for housing improvements

Designing a plan of action for housing improvement

Assuming that you have done a housing survey and identified related housing problems, you need to prepare a plan of action that contains the list of activities with the objectives and time for implementation. Focus on those that you can do in partnership with the community and local leaders.

Monitoring and evaluation must be a part of your plan of action. Monitoring reflects the routine checking of your planned housing activities, while evaluation focuses on the effect that you have brought about as a result of your activities. You have to ask yourself what achievements you have made and what it was not possible to do. Revisiting and modifying the plan of action in such cases will be important. Some indicators that can help you evaluate the housing conditions are the proportion of households with improved housing space, separated animal sheds, proper windows and improved stoves.

Public education

The understanding of housing problems by the people who will benefit from the improvements is very important. You can discuss the housing problems with a targeted audience. You can gain additional information based on the community members’ reaction. This is useful to support your implementation plan.

Training of local craftsmen

You need to transfer your knowledge to local housing constructors in order to make them your partners. They are helpful in bridging the gaps between you and the community. The training needs to focus on the hygienic requirements of tukuls and the reasons for the poor housing in the locality. The options of housing improvements need to be sorted out with the assistance of local housing technicians.

New construction

This is the most appropriate means to implement housing improvement activities. The size of tukul, its location, the good use of partitions, and the inclusion of other facilities such as a latrine could be advised right at the beginning of the construction.

Improving deficiencies (taking remedial actions)

Many tukuls might lack one or more elements of healthful housing. These are usually the absence of windows, a separate kitchen, latrine, improved stoves and a chimney in the kitchen. You should carefully plan to fill the gaps with the advice of influential community members and consideration of local policies.

Summary of Study Session 4

In Study Session 4, you have learned that:

  1. Healthful housing can be defined as the physical structure that people use for shelter and the environs of that structure, including all necessary services, facilities, equipment and devices needed or desired for the physical, mental and social wellbeing of the family and individual. This definition makes a good link between the physical nature of the housing and the goal of health.
  2. There are four basic requirements for housing: satisfying physiological needs, protection against infections, protection against accidents, and satisfying psychological and social needs.
  3. The implementation of all housing requirements is challenging. Listing all housing problems, testing them for their feasibility and discussing the priorities with the community and local community are important in order to design housing improvement strategies in your locality.
  4. The dimension and size of a housing unit depends on satisfying the four basic requirements of housing. In addition, the local situation (economy, culture, willingness) should be considered for the implementation of housing improvements. However, there are some facilities that should not be compromised: latrine, separate kitchen, separate animal sheds, facilities for waste management and personal hygiene, and the presence of windows.
  5. Model houses are a starting point for the implementation of new housing and improving existing housing. You need to evaluate the benefits of model houses and use the evidence to mobilise other residents who are not involved in model housing.
  6. The kitchen should not be a source of indoor air pollution. The use of an improved stove with a chimney should be encouraged.
  7. Your role in the provision of healthful housing must be clear. You are the advocator and communicator of appropriate information and advice. The model house owners, elders and local government staff are your partners in the work towards a healthful housing programme.

Self-Assessment Questions (SAQs) for Study Session 4

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 4.1 (tests Learning Outcome 4.1)

Briefly describe the main factors that contribute to indoor air pollution from smoke. What effect can it have on human physiology?

Answer

The main factors leading to indoor air pollution are the structure and layout of the dwelling, the location of the fire and the type of fuel. If the fire is inside the living area of the house and there are no windows for ventilation, the air is likely to become polluted with smoke. The type of fuel is important because biomass fuels, such as animal dung, produce a lot of smoke, especially if they are not completely dry.

Smoke affects breathing and can lead to acute respiratory infections, bronchitis and chronic lung disease.

SAQ 4.2 (tests Learning Outcomes 4.1 and 4.2)

Match the four basic requirements of healthful housing with the following problems linked to housing.

Problem linked to housingThe basic requirements of healthful housing
Diarrhoea
Lack of windows
No school in the village
Injury from falling
Answer
Problem linked to housingThe basic requirements of healthful housing
DiarrhoeaProtection against infection
Lack of windowsPhysiological satisfaction
No school in the villageProtection against psychological and social stress
Injury from fallingProtection against accident

SAQ 4.3 (tests Learning Outcome 4.2)

The Communicable Diseases Module describes four categories of disease transmission mechanism. These are:

  1. faeco-orally transmitted diseases
  2. droplet infections
  3. skin (contact) infections
  4. vector-borne disease.

Name at least one disease from each category that can be related to poor housing, and describe how poor housing aids the spread of these diseases.

Answer
  1. Faeco-orally transmitted diseases. Examples: typhoid fever, acute watery diarrhoea. Poor housing may contribute to the spread of these diseases due to poor personal hygiene, absence of a latrine or poor utilisation of a latrine, and poor waste management around the home.
  2. Droplet infections. Examples: TB, influenza, measles. Due to poor ventilation in the home and crowding as a result of limited housing space.
  3. Skin (contact) infections. Examples: scabies, ringworm. Due to crowding as a result of limited housing space.
  4. Vector-borne diseases. Examples: relapsing fever, typhus fever. Due to crowding, vectors such as lice can easily travel from an infected person to someone else nearby.

SAQ 4.4 (tests Learning Outcome 4.3)

What are the requirements for a model house in terms of size, rooms (separation of rooms), ventilation, facilities and cleanliness?

Answer

The requirements for a model house are:

  1. It must be an adequate size depending on the number of people in the family.
  2. The window area to floor area proportion should not be less than 10%.
  3. The tukul must have partitions (sleeping, dining, kitchen and store rooms).
  4. The kitchen and animal sheds must be outside the main rooms.
  5. It must have a latrine and handwashing facilities.
  6. The kitchen has an improved stove with a chimney.
  7. The interior of the dwelling and the immediate environment is clean.

SAQ 4.5 (tests Learning Outcome 4.4)

Emebet cooks on an open fire in her small kitchen; she uses mostly dung and maize husks as fuel. She leaves the door open when cooking but there is no window or chimney. She has two children aged 3 and 1, and they are usually close by her when she is cooking. The cooking area is not separated from the main house.

If you were advising her how to reduce the dangers of indoor air pollution in her home, what steps would you recommend to her?

Answer

Possible advice to give to Emebet would be:

  1. Separate the kitchen from the rest of the house.
  2. Install a window and open it while cooking.
  3. Have an improved stove with a chimney.
  4. Make sure that she uses dried dung and maize husk as they will burn more cleanly and not give off such harmful smoke as damp dung and husks.
  5. Make sure the children are not exposed to smoke during cooking.

SAQ 4.6 (tests Learning Outcomes 4.5 and 4.6)

Suppose you are assessing the housing in the village where you are working to see if there are any problems.

  • a.What will you do in order to identify the problems?
  • b.What are the most important criteria you would use when judging the healthfulness of a tukul?
Answer
  • a.Prepare a checklist and visit some tukuls. Fill in the checklist based on your observations. You will be able to judge the most common housing problems. You should then list all possible housing problems that could be shared in the community. Make priorities based on discussions with the community and local government staff. Check the availability of local materials and trained technicians that can carry out housing improvements. Design a plan of action for housing improvements and implement according to a schedule.
  • b.The most important criteria are: size of a tukul based on family size; presence of partitions; presence of windows; presence of a latrine; separated kitchen and animal sheds; presence of improved stoves.