Housing Standards, Household Health and Disease Nexus in the Buea Municipality

Housing has considerably evolved over time and space in terms of standards but much still needs to be desired since some household diseases are intricately linked to housing standards with profound effects on the health of the occupants. This study seeks to examine the physical characteristics of houses and their standards in relation to health and disease. Data was collected through observations and interviews. Field data reveals that over 70% of the housing standards have improved over the past two decades. This notwithstanding, there is a positive correlation between standard/substandard housing on the one hand and disease/poor health conditions on the other. This is mostly linked to housing type, structural layout and environmental conditions as observed in parts of the rapidly urbanising settlement of Buea; a university town and regional capital of the Southwest in Cameroon. In order to reduce the proliferation of communicable diseases like typhoid, cholera and malaria, housing upgrading and refurbishments should be matched with local planning objectives if improved health is to be anticipated by the population in this tropical settlement.


Introduction
The affordability of housing has clear implications on health. This is because the shortage of affordable housing limits families in individual choices about where they live thereby, relegating lower income families to substandard housing in unsafe, overcrowded neighbourhoods with higher rates of poverty and fewer resources for health promotion like in New Bell neighbourhood in Douala (Fombe, 2005). The intimate nexus between housing, its evolution and impact on health is not new. Florence Nightingale (1912) quoted that "the connection between housing and the dwelling of population is one of the most important that exist". It must be noted that there is a clear link between housing evolution, housing standards and the proliferation of various diseases like cholera, malaria, skin diseases among others. The living homes around the marshes of Bonaberi-Douala record the highest incidence of malaria (Ehumka, 2010) due to their substandard nature and appalling environment. In the United Kingdom, evidence in the early 2000s examining the relationship between housing quality and health have largely been developed by two separate traditions of investigation; that of social science and epidemiological and or medical research. But no matter the field that points out the relationship between housing and health, evidence from either fields point to the fact that housing quality affects health. According to the Housing and Urban Development Department (1965), there are 13 performance requirements to encompass housing standards. They include sanitary facilities, food preparation and refuse disposal, space and security, thermal environment, illumination and electricity, structure and material, interior air quality, water supply, lead-based paint, access, site and neighbourhood as well as smoke detectors. Eze B. (2008) indicates that indoor air pollution among low income communities in Lagos revealed that people living in houses with minimal ventilation reported extremely high incidences of blocked or running noses, (86%) chronic cough and eye irritation (79%) as well as shortness of breathe (57%). According to the National Agency for Housing (SIC) (2006) only 28% of urban dwellers have standard housing, with a massive 62% having poor to inadequate housing, whereas 70% have substandard. To supplement the need for housing, the agency has undertaken several housing schemes nationwide. Housing in Buea has experienced some remarkable changes only in recent times due to increasing demand by university students for standard housing. However, given this improvement there is a sluggish drive towards the upgrading of the housing environment. This has affected health conditions of the population. Like in other towns of sub-Saharan Africa, Buea is prone to tropical diseases such as malaria, cholera, and dysentery among others. The quality of housing is supposed to be at least of average standard so as to reduce the proliferation of these tropical diseases.
A closer study of Buea suggests that housing quality determines the rate of diseases people suffer from. Most of the housing environment is characterized by the use of sub-standard corrugated iron sheets and non-durable materials such as wood for the walls. The absence of toilet systems and piped water has further compounded the housing standards. Due to land scarcity in the study area, houses have been constructed haphazardly creating situations where toilets are poorly located or pathways and streets are absent. Little attention has been paid by most environmental health and planning officials to the social and structural conditions underlying housing materials, which may directly affect susceptibility to toxic exposures themselves. This incorporates a range of social and physical determinants of environmental pollution, illustrating how these conditions result in health and illness. In most Third world cities, little attention is accorded to the problem of disease that result from poor housing and environmental conditions probably due to rapid and uncontrolled urbanization. The study seeks to illustrate the importance of the housing environment in determining the state of health of the population with reference to the southern part of Buea.

The Study Matrix
Buea is an urban settlement situated at the foot of Mount Fako. It is located between latitude 4°14″ north of the equator and longitude 9°20″ east of the Greenwich Meridian. Figure 1 illustrates the location of Buea in Fako Division on the southern slope of Mt. Cameroon. Besides being the capital of the Southwest Region, Buea is a university and colonial settlement which has grown to attain a current population of over 200,000 from 46,000 in 2000 (Fombe & Balgah, 2012). Generally, parts of Buea are built on the risk zone of Mount Fako. This region is characterized by various physical pressures of hazard phenomena with soils composed principally of volcanic bombs and scoria that render the region rough and stony. Buea is situated along the Cameroon Volcanic Line; some 30km from the Sea (Gulf of Guinea). The rainfall pattern is modified in the Mount Cameroon area by the highland which interrupts the movement of air masses causing considerable orographic rainfall. Buea records an annual rainfall of 3500mm (IRAD, Ekona, 1993). Temperatures are considerably high with low annual variations. The mean annual temperature is 23°C while the monthly temperature reveals a minimum of about 20°C in the month of June and July accounted for by heavy rainfall in these months.

Methodology
This study was undertaken in five neighourhoods in southern Buea based on their recent rate of housing transformation and changing landscape resulting from rapid construction of houses. The methodology for the study involved both primary and secondary data. Secondary sources of data collection was invaluable through documents from the municipal archives, published and unpublished materials from resource centers, journals and articles amongst others. Primary data was collected using both the stratified and systematic random sampling techniques. The population of southern Buea was stratified into workers and non-workers with each stratum comprising 10% of respondents who have lived in the area for over 20 years so as to appreciate the changes on space. Within each stratum, the respondents were randomly interviewed to obtain their views regarding the evolution in building structure, materials and cost of land within the time frame. The opinion of different inhabitants of this zone was also considered as information concerning health problems, the environment they live in as well as the state of housing was needed. Resource persons like the Chief of Molyko, Council officials were also interviewed to obtain information concerning housing evolution, building and construction code, risk prone areas and development perspectives for the area.
A total of 80 questionnaires were distributed to each of the stratum in the five neighbourhoods (Bonduma, Bokoko, Molyko, Bomaka and Bolifamba). Some of these neighbourhoods like Bomaka and Bolifamba have developed on ceded land from the Cameroon Development Corporation (CDC) which has incorporated most of their retired unskilled workers, while Molyko has experienced a very rapid and unprecedented growth in housing due to the creation of the University of Buea in 1993 and the urgent need for housing to accommodate students and staff. The sample size of each stratum was based on the population of each settlement sampled using the 2005 National Population Census results to ensure a representative sample. 79% of interviewees responded to the questionnaires and the data analyzed was based on this sample size. This was complemented by 10 interviews conducted with the chiefs and notables in the various localities. The Chi-square was used in testing the statement that "the poor physical state of housing in Buea has led to the proliferation of communicable diseases in the southern section".
The study examines the different housing types, and shows how health correlates with housing standards. The health parameters used in the study are malaria, cholera, typhoid and the common cold and are based on the Housing Quality Performance Requirements of the Department of Housing and Urban Development (1965). Six of the parameters (space and security, illumination and electricity, structure and material, water supply, access as well as the site and neighbourhood) are used.

Conceptual View
For many years, the housing environment has been acknowledged as one of the main settings that affects human health. Living and housing conditions therefore become the basis of many factors influencing residential health. While no commonly agreed upon definition of healthy housing exist, there is consensus on how housing conditions may affect health. Epidemiological findings suggest that there is a strong association between housing conditions and health effects. This study seeks to illustrate that housing environmental conditions in Buea are a key factor influencing the prevalence of diseases such as malaria, cholera, typhoid, and common cold.
There is a lack of fundamental research on housing and health in the context of current urbanization trends which have not been well understood in terms of both the positive and the negative aspects on health and well-being (Fuller-Thomson et al, 2000). Under the overarching theme of the urban environment and health, housing and health has been defined as a priority issue by the WHO (2006). Healthy housing must be a comprehensive concept taking into consideration a variety of factors contributing to the quality of housing and the housing environment. Housing is a complex construct that cannot be represented merely by the physical structure of the home. The WHO understanding of housing is therefore based on a four layer model of housing, taking into consideration the physical structure of the dwelling, the meaning of home (for a family and each individual), the external dimension of the immediate housing environment, as well as the community with all neighbours. For each individual dimension, there is an array of direct or indirect health effects, or as a limitation of the quality of life of the resident as shown in Figure 2 to be home, dwelling, community and immediate environment all having an effect on health and inter-related.
A home perceived as safe and intimate provides major psychosocial benefits. It represents a protected refuge from   Malaria shows the highest disease rate within substandard housing structures (  Vol. 7, No. 4;2014 diseases. These include malaria, cholera, typhoid and common cold (Catarrh, cough among others). Though, the diseases vary with locality, it is nonetheless evident that they are the most dominant health concerns identified by the local residents.
In order for housing to be seen as standard, it must be durable and structurally stable, have adequate lighting, heating and ventilation, physical accessibility, possess suitable environmental quality and health related factors and have adequate security. Without the above qualifications, it is seen as inadequate, substandard or very poor housing. Based on the data obtained from 4 locations in lower Buea (Bonduma, Molyko, Bomaka and Bolifamba), standard housing constitute over 60%, substandard housing 25% while very poor housing represents 15%. On the other hand, four main diseases were noticed to be prevalent in all 4 locations and these diseases include malaria, typhoid, cholera and common cold. But as far as these diseases are concerned, malaria and common colds are generally more prevalent (51.7% and 25% respectively), while cholera (5.0%) and typhoid (18.3%) are rare but found in lower Bolifamba. The disease prevalence according to the three categories of housing is illustrated in Table 2. Malaria is a generally rampant disease although respondents in some locations raised concerns about the prevalence of other diseases like typhoid. In lower Bolifamba, typhoid and cholera outbreaks are often reported such as the outbreak in July 2012 in Bolifamba, Bomaka and parts of Muea (Regional Hospital, Buea 2013). Sanitary Officials indicated that housing morphology, encroachment of inhabitants onto river valleys and poor waste disposal attitudes are generally neglected in most of the neighbourhoods under study. Cholera outbreaks as well as typhoid are more common in Bolifamba. These are areas with streams that are used as wash points for vehicles that easily contaminate the water source used by some residents. Generally, the rate of disease prevalence (malaria and common cold) tends to be dominant in the very poor and substandard housing neighbourhoods like Bolifamba.
As observed, there is a correlation between housing and health with a high degree of disease occurrence in cases of inadequate and poor housing. This relationship was tested statistically using the chi-square (X 2 ) test based on the data collected on housing standards and its impact on health. Using the formula for the chi-square test the results for the expected and the observed frequency for each category was obtained, indicating a table value of chi square with degree of freedom 9 at 0.05% level of significance as 16.92. Since the table value with degree of freedom 9 at 0.05% level of significance (16.92) is greater than the calculated value (1.97), it was obvious to conclude that poor housing development in Buea is not a direct cause of the proliferation of communicable diseases in the study sites. Other causes like the environment, water problems, poor education, hygiene and sanitation have been known to substantially contribute to poor health conditions.

Housing, Environment and Health
Generally marshy and poorly drained environments affect the health and wellbeing of the residents in the southern section of Buea. Malaria is highly prevalent within zones of low environmental quality like Bolifamba and Muea. Some areas like Ndongo in Molyko with standard structures were also noted to exhibit a high rate of malaria mainly due to indiscriminate waste disposal, marshy environments and the availability of stagnant pools of water that propagate mosquitoes. Furthermore, the high rate of population influx and high land values (Note 1) has forced some people to occupy flood prone environments as shown in Figure 6. Such environments especially within Malingo Street are noted to be susceptible to floods during the rainy season and marshy in the dry season. This condition creates a breeding ground for mosquitoes and related infectious parasites (Holy Child Health  Vol. 7, No. 4;2014 being of those who seek shelter in it. For many in the southern section of Buea, this seems an elusive concept. The population should be aware that housing must therefore be a comprehensive concept taking into consideration a variety of internal and external factors contributing to its quality. Even though the evolution in housing standards has taken a decisive turn, the outcome leaves much to be desired in this rapidly expanding regional capital of the Southwest. Consequently, the health and standards of the population need to be upgraded as part of its sustainable development drive aimed at meeting the challenges of the Millennium Development Goals. A healthy home is not a specially designed house; it is also a residential setting that is capable of fulfilling the expectations of the residents (WHO, 2006). To achieve this goal implies the collective efforts of both the resident population and the local planning authorities who must address the problems linked to housing and environmental standards.

Recommendations
In order to reduce the proliferation of communicable diseases like typhoid, cholera and malaria, housing upgrading and refurbishments should be matched with local planning objectives if better health by the population is to be anticipated. This responsibility is to be borne by the population and housing developers. The need to adhere to the use of conventional building materials such as cement for walls is inevitable especially given the unstable nature of the environment that is prone to volcanic and earthquake tremors.
Building and construction regulations have to be strictly enforced to ensure that the population does not encroach unto wetlands and river valleys where they build substandard housing and are eventually exposed to very poor environmental/health conditions. The local planning authority is more concerned with raising income than ensuring the health of the population through the granting of building permits in 'unauthorised' sites or poorly erected structures and later become complacent in addressing the issues when health related problems arise. The enforcement of standards and building norms imply the use of durable materials, supply of vital housing facilities like electricity, ensure proper ventilation and environmental housing quality.
From a holistic perspective, housing characteristics and standards can be ensured by adequate surveys, planning and provision of basic services like water, electricity, drainage, streets, and waste clearance facilities by the planning institution.