Housing and Sanitation - Community Medicine

1. HOUSING

Definition

Social Goals of Housing

1. Shelter - provides a sanitary shelter, a basic need
2. Family life - adequate space for preparation and storage of food, meeting, sleeping, individual activities; adequate housing directly impacts worker productivity and family stability
3. Access to community facilities - health services, schools, shopping areas, places of worship
4. Family participation in community life - community can offer help in times of need, pooling efforts to improve living conditions
5. Economic stability - housing is a form of investment of personal savings, providing economic stability and well-being

• Introduce social housing schemes
• Establish minimum and maximum standards
• Create financial and fiscal institutions to help low-income people obtain credit

Criteria for Healthful Housing (WHO Expert Committee)

1. Provides physical protection and shelter
2. Provides adequately for cooking, eating, washing, and excretory functions
3. Designed, constructed, maintained and used in a manner to prevent spread of communicable diseases
4. Provides protection from noise and pollution hazards
5. Free from unsafe physical arrangements and from toxic or harmful materials
6. Encourages personal and community development, promotes social relationships, reflects ecological principles, and thereby promotes mental health

Housing Standards (Environmental Hygiene Committee, 1947 - India)

• Elevated from surroundings - not subject to flooding
• Independent access to a street of adequate width
• Away from breeding places of mosquitoes and flies
• Away from nuisances (dust, smoke, smell, excessive noise, traffic)
• Soil dry and safe; subsoil water should be below 10 feet (3 metres)

• Rural areas: built-up area should NOT exceed one-third of total area
• Urban areas: built-up area may be up to two-thirds

• Pucca and impermeable - easily washed and kept dry
• Smooth and free from cracks/crevices (prevents insect breeding)
• Damp-proof
• Plinth height: 2 to 3 feet (0.6 to 1 metre)
• Mud floors NOT recommended (cause dust, not impermeable)

• Reasonably strong, low heat capacity (not absorb and conduct heat)
• Weather resistant, unsuitable for harbourage of rats/vermin
• Smooth and not easily damaged
• Standard achieved by: 9-inch brick wall, plastered smooth, coloured cream or white

• Windows opening to outside totalling 1/10 of the floor area
• One window should be high up (near ceiling) to allow escape of hot air

Housing Indicators

• Floor space, cubic space, room height
• Persons per room, rooms per dwelling
• Environmental quality (air, light, water, noise, sewage disposal)

• Cost of building, rental levels, taxes, expenditure on housing

• Frequency of illness due to inadequate sewage and garbage collection
• Frequency of illness associated with contaminated water source
• Frequency of insect-borne diseases
• Frequency of illness due to overcrowding
• Frequency of illness due to accidents
• Frequency of illness due to proximity to animals
• Access to medical facility

• Thermal comfort, acoustic comfort, visual comfort, spatial comfort

• Frequency of suicides in the neighbourhood
• Neglected and abandoned youth
• Drug abuse (including alcohol) in the neighbourhood

Rural Housing

• Katcha and damp, ill-lighted and ill-ventilated
• No windows, or only small holes provided (security reasons)
• Absence of separate kitchen, latrine, bathroom and drainage
• Animal keeping very common; humans and animals sometimes share space
• Generally kept clean inside - regularly white-washed or plastered with mud and cow dung

Public Policy on Housing (India)

• In 1952, a separate Ministry of Works and Housing was created
• Government housing programmes: public sector housing (government employees) + social housing schemes (low/middle income groups)
• State-level Housing Boards established
• Key organizations under Ministry of Works and Housing:
  1. National Buildings Organization (NBO)
  2. National Buildings Construction Corporation Ltd.
  3. Housing and Urban Development Corporation (HUDCO)
  4. Hindustan Housing Factory

2. SANITATION

Environmental Sanitation in Rural Areas

• Large percentage of rural population uses open fields for defecation
• The average Indian villager is averse to latrines - considers them meant for city dwellers
• Faeces pollutes water and soil and promotes fly breeding
• The problem of excreta disposal is bound up with beliefs and habits based on ignorance

• Mosquito breeding in collections of waste water not recognized
• Waste water flows into streets
• Solid waste/refuse thrown in front of houses; periodically used as manure
• Animal dung (cow dung) accumulated - used as manure or fuel (dried cakes)

• Wells serve as common meeting places - bathing, washing clothes, washing animals
• Tanks and ponds used for washing, bathing, ablution, and sometimes drinking
• "Holy rivers" - people drink raw water, epidemics of cholera and gastroenteritis have followed
• Step-wells associated with guinea-worm disease
• Cultural practices lead to pollution of drinking water sources

Key Sanitation Barriers (Concept)

• Prevents faecal contamination of water, food, soil
• Interrupts vector (fly, mosquito) breeding
• Reduces faeco-oral disease transmission (cholera, typhoid, dysentery, hepatitis A)

Swimming Pool Sanitation

• Includes chlorination, filtration, and regular bacteriological testing of pool water
• Addressed under Park's as a specific sanitation measure

Summary Table: Housing and Sanitation Links to Health

Socio-Economic Status (SES) in Community Medicine

1. SOCIAL CLASS - Definition and Concept

• Economic status
• Level of education
• Way of life, attitudes and expectations
• Exposure to different types and degrees of stress

• Personal characteristics - age, sex, marital status, place of birth
• Economic characteristics - occupation, type of activity
• Cultural characteristics - language, religion, caste
• Educational characteristics - literacy, level of education

2. OCCUPATION as a Measure of SES

1. Economic rewards - income and wealth which can promote health
2. Extent of authority - over other people; spills into purchasing power and lifestyle
3. Extent of obligations - demanded by the community
4. Degree of status - social prestige independent of personal characters (e.g., medical practitioners in India enjoy higher status)
5. Values and life styles - life goals, pleasures, friendships, relationships

3. SOCIOECONOMIC CLASSIFICATION SCALES (India)

A. Kuppuswamy's Scale (Urban)

Note: The income component is updated periodically to account for inflation (using the Consumer Price Index).

B. BG Prasad's Classification (Modified - Urban & Rural)

• Class I - Upper
• Class II - Upper Middle
• Class III - Middle
• Class IV - Lower Middle
• Class V - Lower

C. Udai Pareek's Scale (Rural)

1. Caste
2. Occupation
3. Education
4. Land holding
5. Housing
6. Farm power
7. Material possession
8. Participation in community activities
9. Interaction with outside world
10. Achievement orientation
11. Level of aspiration

• High SES
• Medium SES
• Low SES

D. Obasi's Classification (modified for India)

• Upper class
• Middle class
• Lower class

E. Modified BG Prasad (Commonly used in India - Rural)

4. COMPONENTS OF SES - Detailed

a. Education

• Determines health literacy, hygiene practices, nutrition knowledge
• Influences family planning acceptance, immunization uptake
• Women's education is especially important - linked to IMR and maternal mortality
• A single index of education: literacy rate

b. Income

• Directly affects access to food, housing, healthcare
• Per capita income is the most commonly used index
• Poverty line defined in India based on minimum calorie intake (2400 kcal/day rural; 2100 kcal/day urban)

c. Occupation

• Best single indicator of SES
• Determines income, lifestyle, exposure to hazards
• Occupational hazards affect health directly

5. SOCIAL CLASS AND HEALTH

Diseases with inverse class gradient (more common in lower classes):

• Tuberculosis
• Rheumatic fever
• Rheumatoid arthritis
• Bronchitis
• Accidents and injuries
• Mental illness (neurosis, psychosis)
• Nutritional deficiencies
• Infant and maternal mortality

Diseases with positive class gradient (more common in higher classes):

• Ischaemic heart disease (historically upper class; now shifting)
• Diabetes mellitus
• Appendicitis
• Peptic ulcer

6. FACTORS EXPLAINING SOCIAL CLASS DIFFERENCES IN HEALTH

1. Differences in material living standards - nutrition, housing, sanitation
2. Differences in health-related behaviour - smoking, drinking, diet, exercise
3. Differences in psychosocial stress - unemployment, insecurity, lack of control
4. Differences in access to and utilization of health services
5. Differences in early life conditions - low birth weight, childhood nutrition
6. Differences in work hazards - exposure to dust, chemicals, physical strain

7. POVERTY AND HEALTH

• The poor have higher rates of morbidity and mortality
• They suffer more from infectious diseases, malnutrition, maternal and child health problems
• Limited access to safe water, sanitation, and healthcare
• The poor are often doubly burdened: they have more disease AND less access to care

Poverty Line (India):

• Rural: 2400 kcal/day minimum caloric intake
• Urban: 2100 kcal/day minimum caloric intake
• Below Poverty Line (BPL) defined accordingly

8. SOCIAL MOBILITY

• Upward mobility - movement to higher social class; generally associated with improved health
• Downward mobility - movement to lower class; associated with deterioration in health
• Social mobility in India is affected by caste system, especially in rural areas

9. MEASURING SES - Summary

10. KEY POINTS FOR EXAMS

• Best single indicator of SES = Occupation
• Kuppuswamy scale is for urban; uses 3 variables; max score 29
• Udai Pareek scale is for rural India; uses 11 variables
• BG Prasad classification is updated periodically using CPI
• Lower SES = higher rates of TB, malnutrition, IMR, maternal mortality
• Women's education is the strongest predictor of child survival
• Poverty line based on minimum caloric intake (2400 kcal rural, 2100 kcal urban)