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The health problems associated with poor housing and home conditions, inadequate water supplies and sanitation

The health problems associated with poor housing and home conditions, inadequate water supplies and sanitation


Housing is one of the traditional areas of concern for public health, though it has been relatively neglected over recent decades. But housing is important for many aspects of healthy living and well-being.  The home is important for
psychosocial reasons as well as its protection against the elements, but it can also be the source of a wide range of hazards (physical, chemical, biological).  It is the environment in which most people spend the majority of their time.  A
significant development in recent years has been the development of the Housing Health and Safety Rating System which provides a health-based assessment of housing-related hazards. The wider local environment around the home is also important in
terms of fear of crime, the accessibility of services, and the opportunity to be physically active.  Increasingly in unstable economic conditions, the affordability of housing and the potential for individuals to lose their home because of debts
they are unable to meet has become a problem for large numbers of people. 

Key definitions and terms

HHSRS Housing Health and Safety Rating System – a health-based risk assessment system for housing (in England and Wales)
Housing fitness A set of basic requirements that homes should meet in order to be considered as acceptable places to live.  Often directly or indirectly based on health criteria

Housing-related hazards

Housing and health The relationship between housing and health is multi-faceted.  A healthy home needs to have sound structure, to be free of hazards, to provide adequate facilities for sleeping, personal
hygiene, the preparation and storage of food, to be an environment for comfortable relaxation, for privacy and quiet, and to provide the facility for social exchange with friends, family and others.  The local environment is also
important in determining such factors as fear of crime, access to local services and facilities and in promoting social interaction.
HHSRS One of the most innovative initiatives on housing and health in recent decades has been the development in England (and Wales) of the Housing Health and Safety Rating System (HHSRS).  This is
a health-based risk assessment procedure for residential properties, which replaced (in 2006) the previous housing fitness standard.

The HHSRS is 'a means of evaluating the potential effect of any faults on the health and safety of occupants, visitors, neighbours and passers-by'.   The principles which underlie it are that:

  • any dwelling should be free from both unnecessary and avoidable hazards; and
  • where any hazard is necessary and unavoidable, then the likelihood of an harmful occurrence and the potential harm which could result should be reduced to a minimum

The HHSRS identified twenty-four categories of potential housing hazards.  Among the more important such hazards are:

Cold/ inadequate energy efficiency (1) Cold

In Britain, as in many countries, there is a large winter excess of deaths and morbidity, many of which (around 20,000 deaths a year) are attributable to the direct effects of cold.  Although limited, there is some evidence (and good
theoretical grounds) to suggest that vulnerability to cold is greater in homes with inadequate insulation / inadequate home heating.  Measures to improve domestic energy efficiency and the affordability of home heating (i.e. reducing fuel
) are therefore expected to have appreciable benefits to health in terms of mortality and morbidity.

In England it is estimated that around 1 in 18 dwellings are below acceptable energy efficiency standards.  The proportion is higher in older dwellings built before energy efficiency considerations were part of building regulation.

Heat (2) Heat

The relationship between dwelling characteristics and risk of heat mortality/morbidity is not accurately defined, but is becoming an increasingly important consideration given expectations of higher summer temperatures as a result of climate
change.  Dwellings that have large solar gain (south facing, large windows, rooms directly under poorly-insulted roof space) are likely to develop higher indoor temperatures, and may carry greater risks to health.
Falls and accidents (3) Falls

A high proportion of accidents occur inside the home, and they are a particular concern for the elderly and children.  In England there are around 500 deaths, 230,000 injuries a year from falls on the stairs.   Falls on the
level (tripping etc) account for 11% of non fatal accidents and 2% of deaths in home. Although it is difficult to attribute the risk to characteristics of the dwelling, poor design and maintenance is a factor in many falls.

There are around 65,000 fires in dwellings a year, resulting in 600 deaths, and 15,000 non fatal injuries.  Smoke alarms can help reduce deaths and injuries.

Damp and mould (4) Damp and mould

Interpretation of the epidemiological evidence about the health effects of damp and mould is made more complex because damp and mould tend to be worst in over-crowded dwellings, often occupied by families of low socio-economic status.
 However, damp and mould have repeatedly been linked to a number of health outcomes, including respiratory symptoms, nausea and vomiting and general ill health. 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.  Around 1 in 18 dwellings in England has appreciable dampness/mould.
Carbon monoxide (5)  Carbon monoxide

Poisoning by carbon monoxide occurs as the result of poorly ventilated and maintained combustion sources (gas boilers, fires etc).  There are believed to be around 60 deaths a year from CO poisoning, but the burden of morbidity and
mortality is probably under-estimated in official figures.  Children and fetuses are particularly vulnerable.  An area of uncertainty is whether there are significant adverse health effects from chronic low-level exposure to carbon
monoxide in the indoor air.
Radon (6)  Radon

Radon represents one of the most important housing-related hazards.  It is a naturally-occurring, radioactive gas formed as part of the decay chain of uranium-238. It readily diffuses through air, is soluble in water and it can
accumulate inside buildings.

It is a particular problem for dwellings in areas with particular geology (notably the south west and north midlands in the UK). The health hazards are well characterized and result from the short-lived, chemically reactive isotopes of
polonium, lead, and bismuth that are its daughter products. When inhaled or formed inside the lungs, these isotopes increase the risk of lung cancer.

Radon is thought to be the most important risk factor for lung cancer in Britain after smoking, accounting for around one in 20 cases.  At the action level of 200 Becquerels/metre3, there is approximately a 3% lifetime risk
of developing cancer as a result of radon exposure.  Other malignancies resulting from these exposures may include leukemia (acute lymphatic leukemia in children) and skin cancer.  A number of engineering solutions are possible to
reduce radon levels inside the home.

Other risks Other housing related hazards (mainly with rarer occurrence or small/uncertain health effects) include:
  • Asbestos and Man-made mineral fibres (MMMF) – a common material in older dwellings, but usually causing low level exposure unless disturbed
  • Electromagnetic fields (EMF) – a ubiquitous exposure, though of variable intensity; uncertain epidemiological evidence
  • Lead – mainly in old lead paint and water pipes/solder joints
  • Noise
  • Electrical hazards
  • Structural failure
  • Entrapment or collision
  • Explosions
  • Uncombusted fuel gas
  • Entry by intruders
  • Hot surfaces and materials
  • Domestic hygiene, pests etc
  • Inadequate provision for food safety
  • Contaminated water
  • Inadequate lighting
  • Poor ergonomics
  • Crowding and space – a potentially very important factor that has bearing on the risks of accidents, fires, dampness and mould, mental well-being and a range of other adverse effects
Designing for health There are many factors that contribute to healthy housing (partly governed by building regulation), but there are some trade-offs in design.  For example, in general, higher energy efficiency
is good for health (especially for lower income families that may struggle with fuel bills), but if energy efficiency means reducing ventilation rates, there may be adverse effects on indoor air quality, condensation and mould growth.
Affordability of housing In addition to traditional risk factors associated with a dwelling, it should also be remembered that the home is one of the major areas of financial expenditure for families.  The lack of
affordable housing and threat to many families of losing their home because of debts they are unable to meet has become an increasing problem, and one which often has substantial negative bearings on mental and sometimes physical health.

Key references

  • BMA.  Housing and health: building for the future.  London: British Medical Association 2003; ISBN 0 7279 1778 1
  • Howden-Chapman P.  Housing standards: a glossary of housing and health.  J Epidemiol Community Health. 2004 Mar;58(3):162-8

Useful websites

  • The (England) Housing Health and Safety Rating System (for reference)

    - Statistical Evidence to Support the Housing Health and Safety Rating System: Volume I - Project Report.  May 2003, Product Code 34HC01127a

    Statistical Evidence to Support the Housing Health and Safety Rating System: Volume Il - Summary of Results.  July 2002 - Re-Press October 2003, Product Code 34HC01127b

    Statistical Evidence to Support the Housing Health and Safety Rating System: Volume Ill - Technical Appendix.  May 2003 - Re-Press October 2003, Product Code 34HC01127c
  • University of Warwick of the Health Hazards in the Home Environment – a risk assessment methodology
  • World Health Organization European Centre for Environment and Health (Bonn) -  Housing and health

© Dr Paul Wilkinson 2009