**10. Housing risk factors for respiratory conditions**

**Respiratory diseases N (%) Pneumonia 127 (34.5)** Pulmonary tuberculosis (All) 108 (29.4) -Uncomplicated 79 (21.5) +Cor-pulmonale 14 (3.8) +Pleural effusion 9 (2.5) +Massive hemoptysis 4 (1.1) +Pneumothorax 2 (0.5) Acute asthma 90 (24.5) Acute exacerbation of COPD 38 (10.3) Upper airway obstruction 2 (0.5) Malignant Pleural effusion 2 (0.5) Acute chest syndrome 1 (0.3)

Infectious respiratory disease Adult

Noninfectious respiratory disease Adult

 Tuberculosis Pneumonia

 Tuberculosis HIV-related infection

Children

 COPD Asthma

 Sarcoidosis Children Asthma

HIV-related infections

Acute respiratory infection

 Occupational lung disease Pulmonary malignancies

HIV-related malignancies

**Table 4.** Respiratory diseases seen at the emergency room of the Federal Medical Centre Ido-Ekiti, south western,

Source: Olufemi et al. [35].

Source: Akanbi et al., 2009.

102 Housing

**Table 3.** Classification of respiratory disease.

Nigeria, from November 2004 to December 2010.

Numerous studies have shown that people who live in poor housing are at increased risk of exposure to the determinants of respiratory diseases [39]. A substandard housing may increase exposures to biological (e.g., moulds, mites, roaches), chemical (e.g., lead, carbon monoxide, volatile organic compounds), and physical (e.g., extreme temperature, fine particles, radon) hazards leading to a wide range of adverse health outcomes, especially respiratory diseases [40–43]. Adequate housing therefore remains critical to human health, comfort and general well-being [43]. Thus, understanding the link between housing and respiratory health condition is of importance in designing effective strategies to improve quality of life. Crowding, poor air quality within homes as a result of inadequate ventilation, and the presence of mould and smoke contribute to poor respiratory health in general and have been implicated in the spread and/or outcome of tuberculosis (TB) [44–46]. Therefore, housing risk factors for respiratory conditions can be broadly classified into three namely; structural, biological and chemical factors. Specific aspects of these risk factors are described below:

disease transmission, including tuberculosis, as well as the accumulation of indoor pollutants and dampness, which are factors in the development of allergies and asthma [49]. Room ventilation is usually expressed in terms of air changes per hour [45, 50]. Studies in hospitals and health care facilities have shown that poor ventilation design or construction have contributed to the transmission of infection, particularly among clinical personnel in patient rooms with fewer than two air changes per hour [51]. Poor ventilation have been associated with failing respiratory health [40, 52]. In the same wise, Livebuga et al. also found that the

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Moisture damages on walls, roofs, floors, leaking pipes, cracked walls, broken window seals are all platforms for occurrence of house hazards and for the growth of visible moulds and mildews leading to poor housing quality. About 60% of households suffer roof leakage, cracked walls and broken floors with increased risk of pneumonia due to mould and damp development [54]. Dampness has been repeatedly linked to a number of health outcomes, including respiratory symptoms, nausea and vomiting and general ill health. Fakunle et al. [17] in a study reported that housing quality and conditions among cases were major contributory factors to ARI when compared with the controls (**Table 6**). The study reported that more cases than controls reside in houses with poor housing quality (OR = 2.5; CI = 1.3–5.1, p < 0.05). In a large proportion of houses of cases than controls, there were presence of damp walls (OR = 2.9; 95% CI = 1.1–8.1). Children under five living in houses with presence of old/deteriorated furniture were found to be thrice more likely to develop ARIs than children residing in houses without such furniture. More houses among cases than controls were built using muds (OR = 4.6; 95% C.1 = 1.6–12.8) [17]. This study suggests that a link exists between housing quality and the prevalence of respiratory conditions among children under 5 years.

A study carried out by Ana et al. [55] showed that the genera of fungi isolated in the indoor environment of day care centers included *Aspergillus, and Penicillum* spp., which have been related to asthma and other allergic respiratory diseases. Some of these species, such as *Penicillium* and *Aspergillus* can also induce type III allergy (IgG mediated), while at high concentrations, may also initiate combined type III and IV reaction manifested as hypersensitivity

**Building condition Cases Control OR (95% CI) p-Value** Presence of damp roof Yes 15 (22.7%) 6 (9.1%) 2.9 (1.1–8.1) 0.03

Presence of algal growth on walls Yes 19 (28.8%) 4 (6.1%) 6.3(2.0–19.6) 0.001

**Table 6.** Condition of houses visited among children under-five with and without ARI.

No 51 (77.3%) 60 (90.0%)

No 47 (71.2%) 62 (93.9%)

presence of mould proved to increase the risk of Asthma and Bronchitis [53].

*10.1.3. Housing quality and dampness*

**10.2. Biological factors**

*10.2.1. Bioaerosols*

Source: Fakunle et al. [17].

#### **10.1. Structural factors**

#### *10.1.1. Overcrowding*

Limited air movement in an enclosed place have been known to be a contributory housing risk factor to respiratory challenges in developing countries as shown in **Plate 2**. Udoh and Uyanga reported that the major predictor for bronchitis and cough in a study carried out in Akwa Ibom Nigeria was overcrowding [15]. Lienhardt reported that overcrowding is a risk factor for respiratory infection and for increased risk of disease after infection [47].

Studies in developing countries have found that the average area of habitable space per person is well below the WHO recommendation of 12 m2 [48]. As reported by Ana and Umar, the mean number of occupancy among children under the age of 5 admitted in a tertiary health facility for ARIs was 6.0 ± 1.5 as compared to 4.0 ± 1.0 among controls [55]. A positive association was found between the level of occupancy and indoor total bacterial count. This suggests that the number of persons in the household is directly proportional to the level of bacteria build-up in the indoor environment.

#### *10.1.2. Inadequate ventilation*

Transmission of *respiratory condition* to a non-infected person is more likely if there is poor ventilation. Inadequate ventilation is associated with a higher risk of airborne infectious

**Plate 2.** (A) Overcrowding condition in a typical community in Nigeria. (B) Overcrowding condition in a typical school setting in Nigeria.

disease transmission, including tuberculosis, as well as the accumulation of indoor pollutants and dampness, which are factors in the development of allergies and asthma [49]. Room ventilation is usually expressed in terms of air changes per hour [45, 50]. Studies in hospitals and health care facilities have shown that poor ventilation design or construction have contributed to the transmission of infection, particularly among clinical personnel in patient rooms with fewer than two air changes per hour [51]. Poor ventilation have been associated with failing respiratory health [40, 52]. In the same wise, Livebuga et al. also found that the presence of mould proved to increase the risk of Asthma and Bronchitis [53].

#### *10.1.3. Housing quality and dampness*

housing therefore remains critical to human health, comfort and general well-being [43]. Thus, understanding the link between housing and respiratory health condition is of importance in designing effective strategies to improve quality of life. Crowding, poor air quality within homes as a result of inadequate ventilation, and the presence of mould and smoke contribute to poor respiratory health in general and have been implicated in the spread and/or outcome of tuberculosis (TB) [44–46]. Therefore, housing risk factors for respiratory conditions can be broadly classified into three namely; structural, biological and chemical factors. Specific aspects of these risk

Limited air movement in an enclosed place have been known to be a contributory housing risk factor to respiratory challenges in developing countries as shown in **Plate 2**. Udoh and Uyanga reported that the major predictor for bronchitis and cough in a study carried out in Akwa Ibom Nigeria was overcrowding [15]. Lienhardt reported that overcrowding is a risk

Studies in developing countries have found that the average area of habitable space per per-

mean number of occupancy among children under the age of 5 admitted in a tertiary health facility for ARIs was 6.0 ± 1.5 as compared to 4.0 ± 1.0 among controls [55]. A positive association was found between the level of occupancy and indoor total bacterial count. This suggests that the number of persons in the household is directly proportional to the level of bacteria

Transmission of *respiratory condition* to a non-infected person is more likely if there is poor ventilation. Inadequate ventilation is associated with a higher risk of airborne infectious

**Plate 2.** (A) Overcrowding condition in a typical community in Nigeria. (B) Overcrowding condition in a typical school

[48]. As reported by Ana and Umar, the

factor for respiratory infection and for increased risk of disease after infection [47].

son is well below the WHO recommendation of 12 m2

build-up in the indoor environment.

*10.1.2. Inadequate ventilation*

setting in Nigeria.

factors are described below:

**10.1. Structural factors**

*10.1.1. Overcrowding*

104 Housing

Moisture damages on walls, roofs, floors, leaking pipes, cracked walls, broken window seals are all platforms for occurrence of house hazards and for the growth of visible moulds and mildews leading to poor housing quality. About 60% of households suffer roof leakage, cracked walls and broken floors with increased risk of pneumonia due to mould and damp development [54]. Dampness has been repeatedly linked to a number of health outcomes, including respiratory symptoms, nausea and vomiting and general ill health. Fakunle et al. [17] in a study reported that housing quality and conditions among cases were major contributory factors to ARI when compared with the controls (**Table 6**). The study reported that more cases than controls reside in houses with poor housing quality (OR = 2.5; CI = 1.3–5.1, p < 0.05). In a large proportion of houses of cases than controls, there were presence of damp walls (OR = 2.9; 95% CI = 1.1–8.1). Children under five living in houses with presence of old/deteriorated furniture were found to be thrice more likely to develop ARIs than children residing in houses without such furniture. More houses among cases than controls were built using muds (OR = 4.6; 95% C.1 = 1.6–12.8) [17]. This study suggests that a link exists between housing quality and the prevalence of respiratory conditions among children under 5 years.

## **10.2. Biological factors**

#### *10.2.1. Bioaerosols*

A study carried out by Ana et al. [55] showed that the genera of fungi isolated in the indoor environment of day care centers included *Aspergillus, and Penicillum* spp., which have been related to asthma and other allergic respiratory diseases. Some of these species, such as *Penicillium* and *Aspergillus* can also induce type III allergy (IgG mediated), while at high concentrations, may also initiate combined type III and IV reaction manifested as hypersensitivity


**Table 6.** Condition of houses visited among children under-five with and without ARI.

pneumonitis [56]. Airborne fungi may be harmful to human health, but may also destroy the building itself (**Plate 3**), particularly wooden parts, such as roofs and walls. Inadequate ventilation is one of multiple factors that contribute to the development of mould in a home [57]. Household humidity and encumbered space may also contribute to mould growth in a house. However, mould have been implicated in increased susceptibility to respiratory infection, asthma and allergies among children [58]. Dales et al. found an association between exposure to indoor fungal contamination and altered T-cell differentiation in children [59].

A recent study by Ana et al. [60] designed to determine the burden of airborne microbes in houses that predispose children under the age of 5 years to acute respiratory infections revealed that the indoor airborne bacterial load in houses of children under-5 years with ARI (9.6 × 102 cfu/m3 ) was higher than the acceptable limit (≤5.0 × 102 cfu/m3 ) proposed by the American Industrial Hygiene Association (AIHA) for residential locations compared to houses of children under-five without ARI (3.5 × 102 cfu/m3 ) (**Figure 4)**.

#### **10.3. Chemical factors**

#### *10.3.1. Tobacco smoke among parents*

It has been postulated that cigarette smoke may impair the pulmonary defense mechanism, resulting in airways that are more susceptible to infection; however, there are no published studies to support this hypothesis [61]. A study carried out by Adegoke et al. [62] investigated the effect of tobacco smoking on lung function indices among male undergraduate students. They revealed that smokers had significantly reduced FVC (3.42 ± 0.42 vs. 3.87 ± 0.4 liters; p = 0.03), FEV1 (2.39 ± 0.37 vs. 3.22 ± 0.38 liters; p = 0.001) and FER (%) (70.7 ± 7.58 vs. 82.3 ± 4.05; p = 0.01). Among the smokers, a relationship was observed between years and numbers of cigarettes smoked and lung function. The proportion of participants with FER below the age-matched reference was significantly higher among smokers than non-smokers

(40.4 vs. 6.7%) p = 0.021. [25] in their study reported parental smoking or any other smoker in the house as a risk factor for ARIs in children under the age of 5 (OR = 4.7; CI = 0.9–2.17, p < 0.05). This could be due to the accumulation of emissions from cigarette smoking in the indoor environment as a result of inadequate ventilation [63]. Furthermore, indoor air pollution, arising from tobacco smoking in the home showed significant effects on respiratory symptoms (Cough, Wheezing, Pneumonia, Bronchitis and Asthma) among children [64, 65].

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**Figure 4.** Mean indoor TBC among cases and controls as compared to AIHA Guideline. Source: Ana et al. [60].

impair phagocyte functioning of the lower respiratory system and thus reduce immunity. A systematic review of 33 papers indicated that passive smoking (second hand smoking) and smoking were associated with an increased risk of tuberculosis. The review further revealed that compared to non-smokers, smokers had an increased risk of having active tuberculosis

About 3 billion people in developing countries including Nigeria rely on firewood or charcoal for their daily cooking purposes [67]. According to the World Health Organization (WHO), smoke-induced diseases are responsible for the death of 4.3 million people every year, making it one of the most lethal environmental health risks worldwide [68]. The largest burden of mortality due to biomass fuel is borne by women and young children (**Figure 3**). Among the 4.3 million who die from the consequences of smoke emission each year, 500,000 are children under five that die due to acute respiratory infections (ARI). Young children are particularly vulnerable for two reasons: First, they are usually with their mothers during the cooking process and thus inhale large loads of particulate emission. In a recent systematic review, it was

) and nitrogen dioxide (NO<sup>2</sup>

) which

Tobacco and cigarette smoking emits sulfur dioxide (SO2

*10.3.2. Exposure to Biomass fuel used for cooking and heating*

and testing positive on tuberculin skin test [66].

**Plate 3.** (A) Damped roof in a building in Bere Area of Ibadan, and (B) mould growth on wall and ceiling of a typical house in Ibadan.

Housing Quality and Risk Factors Associated with Respiratory Health Conditions in Nigeria http://dx.doi.org/10.5772/intechopen.78543 107

**Figure 4.** Mean indoor TBC among cases and controls as compared to AIHA Guideline. Source: Ana et al. [60].

(40.4 vs. 6.7%) p = 0.021. [25] in their study reported parental smoking or any other smoker in the house as a risk factor for ARIs in children under the age of 5 (OR = 4.7; CI = 0.9–2.17, p < 0.05). This could be due to the accumulation of emissions from cigarette smoking in the indoor environment as a result of inadequate ventilation [63]. Furthermore, indoor air pollution, arising from tobacco smoking in the home showed significant effects on respiratory symptoms (Cough, Wheezing, Pneumonia, Bronchitis and Asthma) among children [64, 65]. Tobacco and cigarette smoking emits sulfur dioxide (SO2 ) and nitrogen dioxide (NO<sup>2</sup> ) which impair phagocyte functioning of the lower respiratory system and thus reduce immunity. A systematic review of 33 papers indicated that passive smoking (second hand smoking) and smoking were associated with an increased risk of tuberculosis. The review further revealed that compared to non-smokers, smokers had an increased risk of having active tuberculosis and testing positive on tuberculin skin test [66].

#### *10.3.2. Exposure to Biomass fuel used for cooking and heating*

pneumonitis [56]. Airborne fungi may be harmful to human health, but may also destroy the building itself (**Plate 3**), particularly wooden parts, such as roofs and walls. Inadequate ventilation is one of multiple factors that contribute to the development of mould in a home [57]. Household humidity and encumbered space may also contribute to mould growth in a house. However, mould have been implicated in increased susceptibility to respiratory infection, asthma and allergies among children [58]. Dales et al. found an association between exposure

A recent study by Ana et al. [60] designed to determine the burden of airborne microbes in houses that predispose children under the age of 5 years to acute respiratory infections revealed that the indoor airborne bacterial load in houses of children under-5 years with

the American Industrial Hygiene Association (AIHA) for residential locations compared to

It has been postulated that cigarette smoke may impair the pulmonary defense mechanism, resulting in airways that are more susceptible to infection; however, there are no published studies to support this hypothesis [61]. A study carried out by Adegoke et al. [62] investigated the effect of tobacco smoking on lung function indices among male undergraduate students. They revealed that smokers had significantly reduced FVC (3.42 ± 0.42 vs. 3.87 ± 0.4 liters; p = 0.03), FEV1 (2.39 ± 0.37 vs. 3.22 ± 0.38 liters; p = 0.001) and FER (%) (70.7 ± 7.58 vs. 82.3 ± 4.05; p = 0.01). Among the smokers, a relationship was observed between years and numbers of cigarettes smoked and lung function. The proportion of participants with FER below the age-matched reference was significantly higher among smokers than non-smokers

**Plate 3.** (A) Damped roof in a building in Bere Area of Ibadan, and (B) mould growth on wall and ceiling of a typical

) was higher than the acceptable limit (≤5.0 × 102 cfu/m3

) (**Figure 4)**.

) proposed by

to indoor fungal contamination and altered T-cell differentiation in children [59].

houses of children under-five without ARI (3.5 × 102 cfu/m3

ARI (9.6 × 102 cfu/m3

106 Housing

**10.3. Chemical factors**

house in Ibadan.

*10.3.1. Tobacco smoke among parents*

About 3 billion people in developing countries including Nigeria rely on firewood or charcoal for their daily cooking purposes [67]. According to the World Health Organization (WHO), smoke-induced diseases are responsible for the death of 4.3 million people every year, making it one of the most lethal environmental health risks worldwide [68]. The largest burden of mortality due to biomass fuel is borne by women and young children (**Figure 3**). Among the 4.3 million who die from the consequences of smoke emission each year, 500,000 are children under five that die due to acute respiratory infections (ARI). Young children are particularly vulnerable for two reasons: First, they are usually with their mothers during the cooking process and thus inhale large loads of particulate emission. In a recent systematic review, it was

been implicated in the prevalence of respiratory conditions and morbidity among humans, especially children under the age of 5 years in Nigeria. Therefore, against the backdrop of these effects of poor housing quality, it is imperative that measures such as health policy changes regarding construction of homes, better ventilation of kitchens and homes, and use of environmentally friendly, low-emission and energy-efficient cooking stoves should be put in place, if the prevalence of respiratory conditions among Nigerian children must be mitigated. Also, more should be done in the aspect of strengthening community health program, raising housing awareness, encouraging good self-help environmental sanitation among households, and the development of good and effective master/development plan for

Housing Quality and Risk Factors Associated with Respiratory Health Conditions in Nigeria

, Linda Olayinka-Alli<sup>3</sup>

, Olamide Omigbile<sup>6</sup>

3 Environmental Health Tutor's Department, University College Hospital, Ibadan, Nigeria 4 Department of Epidemiology and Medical Statistics, University of Ibadan, Ibadan, Nigeria

[1] Bornehag CG, Sundell BJ, Bonini S, Custovic A, Malmberg P, Skerfving S, Sigsqaard T, Verhoeff A. Dampness in buildings as a risk factor for health effects, EUROEXPO: A multidisciplinary review of the literature on dampness and mite exposure in buildings

[2] Breysse P, Farr N, Galke W, Lanphear B, Morley R, Bergofsky L. The relationship between housing and health children at risk. Environmental Health Perspectives.

[3] Federal Ministry of works and Housing (FMNandH). Report on the launching of Global Campaign for Good Urban Governance in Nigeria, Abuja. Nigeria: Urban and Regional

[4] Kuroshi PA, Bala K. Development of housing finance in Nigeria. Nigerian Journal of

Planning Department, Federal Ministry of Works and Housing; 2002

Construction Technology and Management. 2005;**6**(1):7-18

1 SIREN, Department of Medicine, University of Ibadan, Ibadan, Nigeria

6 Blue Gate Public Health Promotion Initiative, Ibadan, Nigeria

and health effects. Indoor Air. 2004;**14**:243-257

2004;**112**(15):1583-1588

2 Department of Clinical Nursing, University College Hospital, Ibadan, Nigeria

5 Department of Community Medicine, Osun State University, Osun State, Nigeria

, Mayowa Aridegbe<sup>4</sup>

http://dx.doi.org/10.5772/intechopen.78543

109

and Ibiwunmi Saliu<sup>6</sup>

,

physical planning.

**Author details**

Temilade Bello5

**References**

Adekunle Fakunle1,6\*, Johnson Ogundare<sup>2</sup>

, Opeyemi Elujulo<sup>6</sup>

\*Address all correspondence to: fakunz@yahoo.com

**Plate 4.** Mother and child exposed to biomass emissions.

found that children's particulate emission exposure is similar to their mothers' [69]. Second, in comparison to adults, the still growing bodies of young children are more susceptible to ARI, leading to a high death rate in this age group [70].

In a study on the concentration of indoor air pollutants due to the use of firewood for cooking and its effects on the lung function of women living in the selected homes in Nigeria, Ana et al. [71] reported that the concentration of PM10 and gaseous emissions such as CO and NO<sup>2</sup> significantly exceeded the WHO limits by several folds. Chronic exposure to such high levels of indoor air pollutants particularly the respirable particulate matter as shown in **Plate 4** could possibly compromise the lung function status of women [71]. Olufunmilayo and Chi [72] reported that there is increased likelihood of ARI symptoms associated with children aged 1–2 years old in communities where indoor-biomass is used by households in North-Western and South Southern Nigeria Communities. A majority of households burn biomass fuels in open fireplaces, consisting of simple arrangements as three rocks, a U-shaped hole in a block of clay, a pit in the ground or in poorly functioning earth or metal stoves. However, the process of combustion in most of these stoves is incomplete, resulting in substantial emissions, which in the presence of poor ventilation produce very high levels of indoor pollution [73]. A case-control study carried out by Fakunle et al. [74] in Ibadan revealed that Children underfive carried by their mothers while cooking were 3.2 times more likely to develop ARIs.

#### **11. Conclusions**

That a man requires good quality housing has become a fact that cannot be entirely invalidated if he must enjoy a healthy life and wellness. However, several studies have reported that as opposed to the intents of man, built environment does not usually protect their inhabitant from various physical, social, economic and mental hazards, especially housing with poor quality. This therefore suggests that the quality of housing plays a major role in the health status and overall well-being of its resident, even though everyone has the right to decent and good standard of living. Overcrowding, poor ventilation, use of biomass fuel, mould growth in houses, dampness and poor quality have been identified as major predictors that have been implicated in the prevalence of respiratory conditions and morbidity among humans, especially children under the age of 5 years in Nigeria. Therefore, against the backdrop of these effects of poor housing quality, it is imperative that measures such as health policy changes regarding construction of homes, better ventilation of kitchens and homes, and use of environmentally friendly, low-emission and energy-efficient cooking stoves should be put in place, if the prevalence of respiratory conditions among Nigerian children must be mitigated. Also, more should be done in the aspect of strengthening community health program, raising housing awareness, encouraging good self-help environmental sanitation among households, and the development of good and effective master/development plan for physical planning.
