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

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WHO Housing and Health Guidelines.

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The WHO Housing and health guidelines (HHGL) provide evidence-based recommendations for healthy housing conditions and interventions. This chapter introduces the WHO approach to healthy housing, outlines the key risks to health associated with the housing environment, and assesses the burden of disease associated with housing. Subsequently, the objectives, rational, target audience, scope, and co-benefits of the HHGL are introduced, as well as the relationship between the social determinants of health, housing and health.

1.1. Housing and health

1.1.1. WHO approach to healthy housing

Healthy housing is shelter that supports a state of complete physical, mental and social well-being. Healthy housing provides a feeling of home, including a sense of belonging, security and privacy. Healthy housing also refers to the physical structure of the dwelling, and the extent to which it enables physical health, including by being structurally sound, by providing shelter from the elements and from excess moisture, and by facilitating comfortable temperatures, adequate sanitation and illumination, sufficient space, safe fuel or connection to electricity, and protection from pollutants, injury hazards, mould and pests. Whether housing is healthy also depends on factors outside its walls. It depends on the local community, which enables social interactions that support health and well-being. Finally, healthy housing relies on the immediate housing environment, and the extent to which this provides access to services, green space, and active and public transport options, as well as protection from waste, pollution and the effects of disaster, whether natural or man-made (1).

1.1.2. Key health risks related to housing

Exposures and health risks in the home environment are critically important because of the large amount of time people spend there. In high-income countries, around 70% of people’s time is spent inside their home (2). In some places, including where unemployment levels are higher, and where more people are employed in home-based industries, this percentage is even higher (3). Children, the elderly, and those with a disability or chronic illness are likely to spend most of their time at home, and are therefore more exposed to health risks associated with housing (2). Children are also at increased risk of the harms from some of the toxins that are present in some housing, such as those in lead paint (4).

Housing will become increasingly important to health due to demographic and climate changes. The number of people aged over 60 years of age, who spend a larger proportion of their time at home, will double by 2050 (5). The changing weather patterns associated with climate change also underline the importance of housing providing protection from cold, heat and extreme weather events (6).

Poor housing can expose people to several health risks. For example, structurally deficient housing, due to poor construction or maintenance, can increase the likelihood that people slip or fall, increasing the risk of injury. Poor accessibility to homes may expose their disabled and elderly residents to the risk of injury, stress and isolation. Housing that is insecure, sometimes due to affordability issues or weak security of tenure, is stressful. Housing that is difficult or expensive to heat can contribute to poor respiratory and cardiovascular outcomes, while high indoor temperatures can increase cardiovascular mortality. Indoor air pollution harms respiratory health and may trigger allergic and irritant reactions, such as asthma. Crowded housing increases the risk of exposure to infectious disease and stress. Inadequate water supply and sanitation facilities affect food safety and personal hygiene. Urban design that discourages physical activity contributes to obesity and related conditions, such as diabetes, and poor mental and cardiovascular health. Unsafe building materials or building practices, or building homes in unsafe locations, can expose people to a range of risks, such as injury due to building collapse.

Housing in slums (the preferred term of UN-Habitat) and informal housing pose particular risks to health. Currently, around 1 billion people live in slum conditions today (7), which often develop due to exclusion from planning processes. According to UN-Habitat, a “slum household” is a group of individuals under the same roof, in an urban area, lacking one or more of the following: durable housing (housing which fails to provide shelter from the elements); sufficient living space; security of tenure; sanitation and infrastructure; and access to improved (uncontaminated) water sources. Slum dwellers are therefore exposed to many of the risks associated with housing, such as structurally defective dwellings, inadequate housing facilities and overcrowding, but also face particular health risks from poor sanitation and unsafe electric connections, toxic building materials, unvented cooking facilities, and unsafe infrastructure, including roads. In addition, such settlements are sometimes in locations that are more likely to expose occupants to hazards such as landslides, floods and industrial pollution. In relation to well-being, the lack of legal title to homes is stressful and can expose slum dwellers to the risk of forced eviction (8).

Slums and informal settlements often house migrants, refugees and internally displaced persons. More people are on the move now than ever before. There are an estimated 1 billion migrants in the world today: 250 million international migrants, and 763 million internal migrants. This number includes 65 million people, who have been forcibly displaced and require urgent housing solutions (9).

1.1.3. Prevalence of poor housing conditions

Large numbers of people live in poor housing conditions. For example, 6% of households in Latin America and the Caribbean (compared with 0.4% in the European Union) have more than three people per room (10). Some 9% of the global population has no access to an improved (uncontaminated) drinking-water source. Nearly half of all people using poor quality or contaminated drinking-water sources live in sub-Saharan Africa, while one fifth live in South Asia (11). In addition, 41% of the world’s population cook and heat their housing using open fires and simple stoves that burn solid fuels. These result in polluted indoor air (12) and inadequate ventilation.

Globally, many houses have structural defects. For example, 15% of the European population live in housing with a leaking roof, or damp walls, floors or foundations, or rot in window frames, floors and other structural elements (13). Almost 20% report that their housing did not protect them against excessive heat during summer, while 13% report that their housing was not comfortably warm during winter (13). In the United Kingdom, 72% of adults with mobility problems reported that the entry to their housing was not properly accessible (14). In the United States of America, 5.2% of the housing stock is classified as inadequate, having either severe or moderate physical problems such as deficiencies in heating, plumbing or upkeep (15).

1.1.4. Burden of disease associated with housing

Health conditions related to housing present an important health burden. Some of this is attributable to poor access to water and poor indoor environmental quality. Water, sanitation and hygiene (WASH) were responsible for 829 000 deaths from diarrhoeal disease worldwide in 2016. This constitutes 1.9% of the global burden of disease measured as disability-adjusted life years (DALYs) (16). In 2016, 3.8 million deaths globally were attributable to household air pollution from the use of solid fuels for cooking, almost all of which occurred in low- and middle-income countries (17). About 15% of new childhood asthma in Europe can be attributed to indoor dampness, representing over 69 000 potentially avoidable DALYs and 103 potentially avoidable deaths every year (18).

Housing also contributes to the burden of disease through exposing people to dangerous substances or hazards, or to infectious diseases. For example, almost 110 000 people die every year in Europe as a result of injuries at home or during leisure activities, and a further 32 million require hospital admission because of such injuries (19). In Europe, it has been estimated that 7500 deaths and 200 000 DALYs are attributable to lack of window guards and smoke detectors (18). Approximately 10% of hospital admissions per year in New Zealand are attributable to household crowding (20). In 2012, India recorded over 2600 deaths and 850 of various injuries resulting from the collapse of over 2700 buildings (21). In Kyrgyzstan, household crowding causes 18.13 deaths per 100 000 from tuberculosis (TB) per year (18). Exposure to lead is estimated to have caused 853 000 deaths in 2013 (22).

While everyone can be exposed to the risks associated with unhealthy housing, people with low incomes and vulnerable groups are more likely to live in unsuitable or insecure housing, or to be denied housing altogether (23). Inequalities associated with housing are discussed later in this chapter.

1.2. WHO Housing and health guidelines

1.2.1. Objectives and rationale for developing the WHO Housing and health guidelines

The impact of housing on health and the prevalence of poor housing conditions around the world, as presented in section 1.1, justify the need for globally acceptable and practical guidelines that will ensure healthy housing and human safety. The underlying principle of such guidelines is for housing to give adequate protection from all potential hazards prevailing in the local environment. This principle should apply to both the existing housing stock and newly constructed dwellings. Although a number of housing and health regulatory frameworks and guidelines exist, they are not comprehensively coordinated to address all aspects of housing, human health and safety. For instance, WHO has guidelines for indoor air quality or water and sanitation but there is a lack of comprehensive, international housing and health guidelines highlighting that these can be a fundamental way of improving population health (1). While improving housing may not be the top policy priority in all countries, reliable global guidance for shaping current and future policy is the first step to protect people living in a range of climatic conditions from unhealthy housing. This is a critical public health priority. The improvements recommended by these guidelines relate to a large array of housing aspects, including vital infrastructure, the physical dwelling, the use of the dwelling, and the location of the dwelling. They must be viewed alongside each other so that policy-makers can make the most of co-benefits and synergies, while avoiding trade-offs (24). Large benefits in cost–effectiveness would arise from addressing the health risks associated with housing simultaneously and this approach is in line with WHO’s intersectoral work to create health-promoting environments (2528).

These HHGL add to existing WHO guidelines by providing evidence-based recommendations on healthy housing conditions and interventions that are not covered by the other guidelines, and by summarizing those relevant to housing and health. As sectoral guidelines, they represent a proactive step forward, highlighting the need to address the health risks associated with housing through a systems approach. By their nature, land use and building regulations act to address multiple risks, including structures and heating systems, as well as hazard avoidance. These HHGL, by providing access to the science on minimizing multiple health risks associated with housing, will be an important resource for Member States.

Implementing the HHGL will support the achievement of the Sustainable Development Goals (SDGs), including SDG 3 to ensure healthy lives and promote well-being for all age groups and SDG 11 to make cities and human settlements inclusive, safe, resilient and sustainable (29). The HHGL will also be influential for ensuring availability of sanitation for all at household level (SDG 6), meeting targets for renewable energy and energy efficiency (SDG 7) and taking action to mitigate climate change (SDG 13) (30). The importance of the sectoral approach has been recently emphasized in the New Urban Agenda for sustainable urban development established at Habitat III (31).

The HHGL contribute towards ensuring Member States meet their obligations regarding the human right to adequate housing. This right to adequate housing is recognized in international human rights laws as a component of the right to an adequate standard of living, enshrined in the Universal Declaration of Human Rights (adopted in 1948) and the International Covenant on Economic, Social and Cultural Rights (adopted in 1966). For housing to be adequate, the following seven criteria must be met: security of tenure; availability of services, materials, facilities and infrastructure; affordability; habitability; accessibility; location; and cultural adequacy (32, 33). Thus, the HHGL will inform regulations that aim to address and fulfil the above criteria of adequate housing. While the HHGL provide global recommendations, their implementation and prioritization will vary by local context and will require national and local adaptation.

1.2.2. Target audience

The main target audience for the guidelines is policy-makers who are responsible for housing-related policies and regulations, enforcement measures, and initiating intersectoral collaborations that seek to support healthy housing from a government perspective.

The guidelines are also of direct relevance to the daily work of implementing actors such as government agencies, architects, builders, housing providers, developers, engineers, urban planners, industry regulators, financial institutions, as well as social services, community groups, and public health professionals. These stakeholders are ultimately required to ensure that housing is built, maintained, renovated, used and demolished in ways that support health.

1.2.3. Scope

As already noted, “healthy housing” is associated with several factors, inside and outside the home. The HHGL do not address all possible risk factors related to housing but focus on priority areas that have not yet been addressed by existing WHO guidelines and where robust evidence is available. These were identified by the Guideline Development Group (GDG) established for this work (see Chapter 2).

The priority areas addressed by the HHGL are as follows:

  • inadequate living space (crowding) (Chapter 3)
  • low indoor temperatures (Chapter 4)
  • high indoor temperatures (Chapter 5)
  • injury hazards in the home (Chapter 6)
  • accessibility of housing for people with functional impairments (Chapter 7).

In addition to the above, existing WHO guidelines and recommendations related to housing are identified and summarized in Chapter 8 to cover the following issues:

Guidance on other aspects of housing and buildings that relate to health – including pests, food safety and ventilation – are listed in section 8.8. Despite the range of issues covered, the list of relevant elements is not exhaustive. For instance, there are still a number of housing risk factors (such as lighting, height of ceilings and buildings, electric security, housing surroundings and fuel poverty) that have not been covered in the HHGL at this time. WHO is planning to continue investigating and working on other housing-related risk factors to health and to provide future guidance. At the same time, the HHGL do not distinguish between permanent housing and housing that is intended to be temporary, such as emergency shelter arrangements. However, the GDG recognizes that implementing the HHGL is likely to be more challenging in informal and emergency housing and will require different priorities, depending on the context. General implementation considerations and WHO’s role in supporting these are discussed in Chapter 9. Important supplementary guidance relevant to emergency shelter arrangements are further provided by the Sphere Project (34). Homelessness, which is the most extreme denial of the right to adequate housing, is not discussed as part of the HHGL (35).

1.2.4. Co-benefits

Co-benefits arise from addressing the key health risks associated with housing. In many cases, a dwelling poses multiple risks to healthy housing. For example, a house may have poor indoor air quality, be cold, and have multiple injury hazards. Housing risks should therefore be viewed holistically and as components of an inter-related system in order to take advantages of the co-benefits presented by different interventions. For example, correcting structural defects reduces the risk of injury, improves thermal comfort, and reduces exposure to outdoor pollutants.

Housing interventions can also have indirect co-benefits for health. Improving thermal insulation, weatherization and ventilation, and installing energy-efficient heating (Chapters 4 and 5) can improve indoor temperatures that support health, while also lowering expenditure on energy (24, 36) and reducing carbon emissions (37).

Improving housing conditions also supports other positive social outcomes. As discussed in Chapter 3, reducing crowding supports good health outcomes, but also contributes to improved educational outcomes, as children are able to study more effectively (38). Improving thermal comfort through installing insulation and heating reduces days off school and work (39). Improving housing can also create jobs and stimulate investment (40). Therefore, addressing health risks associated with housing is likely to particularly benefit low-income and vulnerable groups, as these groups are more likely to live in inadequate housing.

In recent years, some countries have instituted new “green” standards for construction practices. These standards are aimed at addressing the design, location, and site of housing; promote water conservation and energy efficiency; encourage the use of building materials beneficial to the environment; and promote healthy living conditions (41). Some green housing elements that are typically included in such standards are associated with health outcomes, including: energy efficient heating; improved ventilation; building materials free from formaldehyde, lead and asbestos; sound insulation; and no carpets in kitchens and bathrooms (42).

The HHGL aim to ensure that occupants of green housing also enjoy health benefits (18, 43). Studies of green and energy efficient housing improvements and their influence on health have recently been comprehensively reviewed (44, 45).

1.2.5. Social determinants, housing and health

Choices of housing types, quality, size and location are shaped by a number of economic, social and demographic factors. These factors affect the features that the house will provide to its occupants (e.g. durability, building materials, accessibility etc.) and whether they can afford the cost of operating and maintaining it. The cost of maintaining and operating a house is of importance to human health and safety and includes: the purchase of safe drinking-water and of electricity or other fuel for heating the home (27). Transport infrastructure can also be considered as an operational aspect of housing affordability, because it influences how much people need to pay to travel between their homes and work and other places.3

Globally, across low-, middle- and high-income countries, low-income earners are more likely to live in housing that exposes them to health risks. For example, in Cambodia, toilet facilities are only available to 29% of households in the lowest income quintile, compared with 79% of households in the highest income quintile (47, 48). In Guatemala, 89% of the lowest income quintile have dirty floors, compared with 4% of the highest income quintile (4951). In the United States of America, repeated hospitalizations for childhood asthma are correlated with residing in the census tract areas with the highest proportion of crowded housing conditions, the largest number of racial minorities and the highest neighbourhood-level poverty (18, 52, 53).

This inequality in housing conditions goes beyond whether people are rich or poor. In some countries certain groups, including indigenous people, minority populations, single parent families, disabled people and women, are more likely to live in unsuitable housing (5457).

Poor health outcomes in turn can contribute to poor economic outcomes. Poor health can be expensive, because of the costs of treating illnesses. In addition, poor health can affect people’s capacity to earn or save money (58). This creates a cycle between poor health and poor household, local and national economic outcomes. At the same time, housing that is expensive relative to income can affect health, in particular for people on low incomes. High housing costs can compel people to cut back on other essentials that are connected to health, including food, energy and health care (5961). Difficulty with paying rent and mortgage costs exposes people to risks of eviction and foreclosure (62), and increases the likelihood that people have to move often (35, 63, 64). These factors – eviction, foreclosure and residential mobility – have each been associated with adverse educational and economic effects and poor health outcomes (62, 65, 66).

Interventions that create healthy homes can help to break this cycle by improving health and broader social and economic outcomes, yielding important benefits for decades into the future. These housing-related interventions need to be complemented by policy interventions relating to education, employment, transport, child care, health systems, taxation, wages, benefit levels and job security. Each of these factors can affect incomes and thus affect people’s ability to pay for housing that keeps them healthy (27). Providing affordable housing can help people to afford housing that fits their needs while improving their health (67, 68). Affordable housing, such as public housing, can be promoted through funding a supply of affordable dwellings, or through providing subsidies, such as housing vouchers or tax mechanisms (e.g. low-income housing tax credits) (68, 69).



Under the Right to Adequate Housing, it is understood that housing is not affordable if its cost threatens or compromises the occupants’ enjoyment of other human rights; housing cannot be considered affordable if a household spends more than 30% of its disposable income on rent, operation, and maintenance costs (33, 46).

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