Housing and child health in sub-Saharan Africa: A cross-sectional analysis

Autoři: Lucy S. Tusting aff001;  Peter W. Gething aff002;  Harry S. Gibson aff002;  Brian Greenwood aff001;  Jakob Knudsen aff003;  Steve W. Lindsay aff004;  Samir Bhatt aff002
Působiště autorů: Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom aff001;  Big Data Institute, Nuffield Department of Medicine, University of Oxford, United Kingdom aff002;  The Royal Danish Academy of Fine Arts, Schools of Architecture, Design and Conservation, Copenhagen, Denmark aff003;  Department of Biosciences, Durham University, Durham, United Kingdom aff004;  Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom aff005
Vyšlo v časopise: Housing and child health in sub-Saharan Africa: A cross-sectional analysis. PLoS Med 17(3): e32767. doi:10.1371/journal.pmed.1003055
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pmed.1003055



Housing is essential to human well-being but neglected in global health. Today, housing in Africa is rapidly improving alongside economic development, creating an urgent need to understand how these changes can benefit health. We hypothesised that improved housing is associated with better health in children living in sub-Saharan Africa (SSA). We conducted a cross-sectional analysis of housing conditions relative to a range of child health outcomes in SSA.

Methods and findings

Cross-sectional data were analysed for 824,694 children surveyed in 54 Demographic and Health Surveys, 21 Malaria Indicator Surveys, and two AIDS Indicator Surveys conducted in 33 countries between 2001 and 2017 that measured malaria infection by microscopy or rapid diagnostic test (RDT), diarrhoea, acute respiratory infections (ARIs), stunting, wasting, underweight, or anaemia in children aged 0–5 years. The mean age of children was 2.5 years, and 49.7% were female. Housing was categorised into a binary variable based on a United Nations definition comparing improved housing (with improved drinking water, improved sanitation, sufficient living area, and finished building materials) versus unimproved housing (all other houses). Associations between house type and child health outcomes were determined using conditional logistic regression within surveys, adjusting for prespecified covariables including age, sex, household wealth, insecticide-treated bed net use, and vaccination status. Individual survey odds ratios (ORs) were pooled using random-effects meta-analysis. Across surveys, improved housing was associated with 8%–18% lower odds of all outcomes except ARI (malaria infection by microscopy: adjusted OR [aOR] 0.88, 95% confidence intervals [CIs] 0.80–0.97, p = 0.01; malaria infection by RDT: aOR 0.82, 95% CI 0.77–0.88, p < 0.001; diarrhoea: aOR 0.92, 95% CI 0.88–0.97, p = 0.001; ARI: aOR 0.96, 95% CI 0.87–1.07, p = 0.49; stunting: aOR 0.83, 95% CI 0.77–0.88, p < 0.001; wasting: aOR 0.90, 95% CI 0.83–0.99, p = 0.03; underweight: aOR 0.85, 95% CI 0.80–0.90, p < 0.001; any anaemia: aOR 0.87, 95% CI 0.82–0.92, p < 0.001; severe anaemia: aOR 0.89, 95% CI 0.84–0.95, p < 0.001). In comparison, insecticide-treated net use was associated with 16%–17% lower odds of malaria infection (microscopy: aOR 0.83, 95% CI 0.78–0.88, p < 0.001; RDT: aOR 0.84, 95% CI 0.79–0.88, p < 0.001). Drinking water source and sanitation facility alone were not associated with diarrhoea. The main study limitations are the use of self-reported diarrhoea and ARI, as well as potential residual confounding by socioeconomic position, despite adjustments for household wealth and education.


In this study, we observed that poor housing, which includes inadequate drinking water and sanitation facility, is associated with health outcomes known to increase child mortality in SSA. Improvements to housing may be protective against a number of important childhood infectious diseases as well as poor growth outcomes, with major potential to improve children’s health and survival across SSA.

Klíčová slova:

anémia – Diarrhea – Housing – Child health – Malaria – Respiratory infections – Sanitation – Water resources


1. Bhatt S, Weiss DJ, Cameron E, Bisanzio D, Mappin B, Dalrymple U, et al. The effect of malaria control on Plasmodium falciparum in Africa between 2000 and 2015. Nature. 2015;526:207–11. doi: 10.1038/nature15535 26375008

2. WHO-AFRO. Fact sheet on child health. Geneva: World Health Organisation Africa Regional Office; 2019.

3. Osgood-Zimmerman A, Millear AI, Stubbs RW, Shields C, Pickering BV, Earl L, et al. Mapping child growth failure in Africa between 2000 and 2015. Nature. 2018;555:41. doi: 10.1038/nature25760 29493591

4. UN. Sustainable Development Goals: 17 goals to transform our world Geneva: United Nations; 2015 [cited 2018 Mar 1]. Available from: http://www.un.org/sustainabledevelopment/cities/

5. Haines A, Bruce N, Cairncross S, Davies M, Greenland K, Hiscox A, et al. Promoting health and advancing development through improved housing in low-income settings. J Urban Health. 2013:810–31. doi: 10.1007/s11524-012-9773-8 23271143

6. Hackett L, Missiroli A. The natural disappearance of malaria in certain regions of Europe. Am J Epidemiology. 1931;31:57–78.

7. Krieger J, Higgins DL. Housing and health: time again for public health action. Am J Public Health. 2002;92:758–68. doi: 10.2105/ajph.92.5.758 11988443

8. Chadwick E. Report on the sanitary condition of the labouring population of Gt. Britain. Flinn M, editor. Edinburgh, Scotland: University Press; 1965.

9. Griscom J. The sanitary condition of the laboring population of New York with suggestions for its improvement. New York: Harper and Bros; 1845.

10. Tusting LS, Ippolito M, Kleinschmidt I, Willey B, Gosling R, Dorsey G, et al. The evidence for improving housing to reduce malaria: a systematic review and meta-analysis. Malaria J. 2015;14:209.

11. WHO. Housing and Health Guidelines. Geneva: World Health Organization; 2018.

12. UN. World Population Prospects, 2015 Revision. Rome: United Nations Department of Economic and Social Affairs; 2015.

13. Tusting LS, Bisanzio D, Alabaster G, Cameron E, Cibulskis R, Davies M, et al. Mapping changes in housing in sub-Saharan Africa from 2000 to 2015. Nature. 2019;568:391–4. doi: 10.1038/s41586-019-1050-5 30918405

14. Rek JC, Alegana V, Arinaitwe E, Cameron E, Kamya MR, Katureebe A, et al. Rapid improvements to rural Ugandan housing and their association with malaria from intense to reduced transmission: a cohort study. Lancet Planetary Health. 2018;2:e83–e94. doi: 10.1016/S2542-5196(18)30010-X 29615240

15. Husseini M, Darboe MK, Moore SE, Nabwera HM, Prentice AM. Thresholds of socio-economic and environmental conditions necessary to escape from childhood malnutrition: a natural experiment in rural Gambia. BMC Medicine. 2018;16:199. doi: 10.1186/s12916-018-1179-3 30382849

16. ICF International. Demographic and Health Surveys Methodology. Calverton, Maryland: ICF International; 2011.

17. DHS Program. Protecting the Privacy of DHS Survey Respondents. The DHS Program; 2019 [cited 2019 Dec 20]. Available from: https://dhsprogram.com/What-We-Do/Protecting-the-Privacy-of-DHS-Survey-Respondents.cfm

18. WHO. Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018.

19. WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Geneva: World Health Organization; 2011.

20. UN. Indicators for monitoring the Millennium Development Goals: 7.10 Proportion of urban population living in slums 2012. New York: United Nations; 2012 [2018 Jan 15]. Available from: http://mdgs.un.org/unsd/mi/wiki/7-10-Proportion-of-urban-population-living-in-slums.ashx

21. World Health Organization. Progress on sanitation and drinking water– 2015 update and MDG assessment. Geneva: WHO; 2015 [2016 Jul 16]. Available from: https://washdata.org/sites/default/files/documents/reports/2017-06/JMP-2015-Report.pdf

22. Rutstein SO. Steps to constructing the new DHS Wealth Index. Rockville, MD: ICF International; 2015.

23. Tusting LS, Bottomley C, Gibson H, Kleinschmidt I, Tatem AJ, Lindsay S, et al. Housing improvements and malaria risk in sub-Saharan Africa: a multi-country analysis of survey data. PLoS Med. 2017;4(2):e1002234.

24. Vyas S, Kumuranayake L. Constructing socio-economic status indices: how to use principal components analysis. Health Policy Plan. 2006;6:459–68.

25. DerSimonian R, Laird N. Meta-analysis in clinical trials. Controlled clinical trials. 1986;7:177–88. doi: 10.1016/0197-2456(86)90046-2 3802833

26. Kontopantelis E. A comparison of one-stage vs two-stage individual patient data meta-analysis methods: A simulation study. Research Synthesis Methods. 2018;9:417–30. doi: 10.1002/jrsm.1303 29786975

27. Kirby M, Ameh D, Bottomley C, Green C, Jawara M, Milligan P, et al. Effect of two different house screening interventions on exposure to malaria vectors and on anaemia in children in The Gambia: a randomised controlled trial. Lancet. 2009;374:998–1009. doi: 10.1016/S0140-6736(09)60871-0 19732949

28. Knudsen J, Seidlein Lv. Healthy homes in tropical zones: improving rural housing in Asia and Africa. Stuttgart/London: Axel Menges; 2014.

29. Lindsay SW, Jawara M, Mwesigwa J, Achan J, Bayoh N, Bradley J, et al. Reduced mosquito survival in metal-roof houses may contribute to a decline in malaria transmission in sub-Saharan Africa. Sci Rep. 2019;9:7770. doi: 10.1038/s41598-019-43816-0 31123317

30. Murdock CC, Sternberg ED, Thomas MB. Malaria transmission potential could be reduced with current and future climate change. Sci Rep. 2016;6:27771. doi: 10.1038/srep27771 27324146

31. Jatta E, Jawara M, Bradley J, Jeffries D, Kandeh B, Knudsen JB, et al. How house design affects malaria mosquito density, temperature, and relative humidity: an experimental study in rural Gambia. Lancet Planetary Health. 2018;2:e498–e508. doi: 10.1016/S2542-5196(18)30234-1 30396441

32. Kirby MJ, Green C, Milligan P, Sismanidis C, Jasseh M, Conway DJ, et al. Risk factors for house-entry by malaria vectors in a rural town and satellite villages in The Gambia. Malaria J. 2008;7(2).

33. Wolf J, Hunter PR, Freeman MC, Cumming O, Clasen T, Bartram J, et al. Impact of drinking water, sanitation and handwashing with soap on childhood diarrhoeal disease: updated meta-analysis and meta-regression. Trop Med Int Health. 2018;23:508–25. doi: 10.1111/tmi.13051 29537671

34. Nabwera HM, Fulford AJ, Moore SE, Prentice AM. Growth faltering in rural Gambian children after four decades of interventions: a retrospective cohort study. Lancet Global Health. 2017;5:e208–e16. doi: 10.1016/S2214-109X(16)30355-2 28104187

35. Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet. 2013;382:452–77. doi: 10.1016/S0140-6736(13)60996-4 23746776

36. WHO. Burning opportunity: clean household energy for health, sustainable development, and wellbeing of women and children. Geneva: World Health Organization; 2016.

37. Ferraro CF, Trotter CL, Nascimento MC, Jusot J-F, Omotara BA, Hodgson A, et al. Household crowding, social mixing patterns and respiratory symptoms in seven countries of the African Meningitis Belt. PLoS ONE. 2014;9:e101129. doi: 10.1371/journal.pone.0101129 24988195

38. Naghavi M, Abajobir AA, Abbafati C, Abbas KM, Abd-Allah F, Abera SF, et al. Global, regional, and national age-sex specific mortality for 264 causes of death 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390:1151–210. doi: 10.1016/S0140-6736(17)32152-9 28919116

39. Institute MG. Lions on the move II: Realizing the potential of Africa's economies. McKinsey Global Institute; 2016.

40. de Castro MC, Fisher MG. Is malaria illness among young children a cause or a consequence of low socioeconomic status? Evidence from the United Republic of Tanzania. Malar J. 2012;11:161. doi: 10.1186/1475-2875-11-161 22571516

Článek vyšel v časopise

PLOS Medicine

2020 Číslo 3
Nejčtenější tento týden
Nejčtenější v tomto čísle
Kurzy Podcasty Doporučená témata Časopisy
Zapomenuté heslo

Zadejte e-mailovou adresu, se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.


Nemáte účet?  Registrujte se