Effect of improved housing on illness in children under 5 years old in northern Malawi: cross sectional study

Introduction

Poor quality housing is generally accepted to be an important contributor to ill health.1 Rates of disease have been associated with the quality and specific attributes of a house as well as the conditions that those qualities impose.2^–11

Although the importance of housing for health is recognised, 1 12 13 few well designed studies have quantified this impact, especially in the developing world. The objective of this study was to assess the impact on children's health of a housing improvement project in rural Malawi. We examined the effect on illness of living in improved housing compared with living in traditional housing.

Participants and methods

The study was conducted in collaboration with Ekwendeni Hospital, Homeless International UK, and Habitat for Humanity International in the town of Ekwendeni, Malawi. Traditional houses in the area are constructed of mud brick walls with thatch roofing, hard packed mud floors, and possibly a pit latrine. Houses are usually about 25 m² and consist of two or three rooms. Houses constructed under the Habitat for Humanity programme in Ekwendeni have fired mud bricks, tile roofing, concrete foundation, and a pit latrine. Habitat houses have a mean size of 30 m2 and three rooms. The cost of a habitat house at the time of the study was about $550 (£370), offset by a 10 year no interest loan. Habitat houses were built next to or replaced the traditional house of the intended owner and were non-systematically dispersed throughout the communities among traditional houses.

Participants in the habitat programme were selected by a village habitat committee. Applicants had to be unable to provide adequate housing for themselves because of financial, social, or physical reasons and to have shown their commitment to the programme by spending a standardised amount of time helping to build another applicant's house.

Results

Table 1 shows the numbers of houses included in each survey. We found no significant differences in socioeconomic and demographic variables between the habitat and traditional houses (Table 2). Overall, the comparability of the non-housing socioeconomic characteristics in the two groups suggests that any differences between the two groups are likely to be due to differences in housing.

Table 3 shows the proportion of children under 5 years with various illnesses. The percentage of children with any or each of the three illnesses is lower in the habitat houses than the traditional houses.

Table 4 shows the results of the multivariate analysis to determine the relation between housing and the health of children under 5 years old. Although none of the unadjusted odds ratios are significant, all the relations are roughly of the same magnitude and direction. When access to safe water was controlled for, children in habitat houses were 45% less likely to have any illnesses (odds ratio=0.55, 95% confidence interval 0.34 to 0.75) than children in traditional houses. The incidence of respiratory infection was also significantly reduced among children in habitat houses.

The reduced rate of overall illness in children in habitat houses remained after adjustment for other potential confounding factors (0.56, 0.35 to 0.91; Table 4). However, the effect on individual illnesses was not significant. Interactions between housing type and water source and between housing type and method of disposal of excreta were not significant.

Discussion

This study shows that the five year housing programme significantly improved the health of children under 5 years old. Children living in an improved house had 44% reduced odds of respiratory infection, gastrointestinal illness, or malaria. Access to a safe water source, having above average knowledge about the methods used to prevent malaria, and owning a private latrine were also significantly associated with lower odds of some illnesses. These associations were independent of the level of education and occupation of the head of the household. The size of the effect of housing was roughly equivalent for respiratory infections, gastrointestinal disorders, and malaria. Incorporating bed nets or ceilings into houses may increase the health benefits of better housing by reducing malaria further.

Our investigation has several limitations. Firstly, there is potential for bias in the selection of people into the housing programme by the habitat village committee. The similarity in the sociodemographic profiles between the two groups, however, suggests selection bias was minimal. Secondly, mothers could have misreported respiratory infection and gastrointestinal disorders. However, the hospital had a long association with the communities in this area, which has resulted in trust between the interviewer and interviewee. The final limitation is that disposal of excreta was improved in some traditional houses, with 38% having private latrines. We controlled for method of disposal in the final model.

The effect sizes in our study are similar to those reported for many other health interventions, such as improving water and sanitation, that receive more attention and financial support. Programmes in which simultaneous improvements in housing, water, and sanitation are combined with education on how to take advantage of these improved resources are likely to have the greatest effect on health.