The Relationship between Healthy Housing Conditions and

Pulmonary Tuberculosis

Andri Setiya Wahyudi, Raufuddin and Ira Suarilah

Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia

Keywords: Healthy Housing Conditions, Behavior, Residential Density, Pulmonary Tuberculosis.

Abstract: Housing conditions are a factor that determine the state of hygiene and environmental sanitation. Housing

and environments that do not meet health requirements are risk factors regarding disease transmission, for

example, pulmonary tuberculosis. This research was conducted to determine the relationship between

healthy housing conditions and the incidence of tuberculosis in Palengaan, Pamekasan. This was an

observational study, based on its time and was a case-control study. Data analysis was conducted using a

Chi-square test with α = 0.05. This study assessed healthy housing conditions using the observation sheet

from the technical guidelines of the assessment regarding healthy housing conditions by the Directorate

General of Communicable Diseases Eradication and Environmental Health in 2002.The variables used,

resulting from the housing health assessment include: (a) house components; (b) sanitary facilities; and (c)

occupant behavior. Individual characteristics include: a) age; (b) gender; and (c) education, and residential

density. Based on the study results, the assessment for healthy housing conditions are associated with the

incidence of pulmonary TB; the Chi-square test indicated p = 0.000, OR = 35.10, and in three groups of

house health assessments, the behavior of occupants is associated with the incidence of pulmonary TB, with

the chi-square test p = 0.001, OR = 8.233. it can be concluded that houses with healthy conditions can

reduce the risk of pulmonary TB incidence and, in particular, poor behavior of occupants can increase the

risk of pulmonary TB incidence.

1 BACKGROUND

Public health is a science and the art of preventing

disease, prolonging life, and improving the

efficiency of life through efforts or attempts of

community organization. Community organization is

an effort to improve the environment and prevent

and combat contagious diseases. This is in line with

objectives for the prevention and improvement of

public health. The goal of public health is the whole

community, including individuals, families, and

groups both healthy and sick, especially those at

high risk in the community. Some special groups are

at risk and require supervision and guidance, for

example, patients with pulmonary tuberculosis.

Public health has basic components comprising of

humans, health (the healthy-sick concept), and the

environment.

Humans have needs that are continually evolving

and changing. Abraham Maslow in Mubarak (2009)

says that human needs are structured in a hierarchy

and the most basic needs (physiological) include

food, water, fresh air, temperature, free from illness,

rest, sleep, and activity. All these needs must be

prioritized, and a house is a means of manifestation

of these basic needs. This reflects work by Robert

Moroney in Mubarak (2009), who classifies human

needs and mentions houses as normative needs.

Human basic needs consist of food, clothing and

housing. Houses, also known as residences or homes

are a basic human needs. Every human being across

the world needs a place to live. The shape of housing

inhabited by each nation is different, and even in one

country or one city, housing can take various shapes.

Houses are become more varied; each component of

a house must fulfill health requirements, so the

inhabitants do not suffer hurt from any illness

(Azwar, 1995). The components of houses that

fulfill health requirements are expected to provide

comfort and can maintain the health of the

inhabitants; residents can avoid diseases, work

productively, and produce something meaningful.

Wahyudi, A., Raufuddin, . and Suarilah, I.

The Relationship between Healthy Housing Conditions and Pulmonary Tuberculosis.

DOI: 10.5220/0008330506570663

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 657-663

ISBN: 978-989-758-336-0

657

The population of Indonesia is continually

increasing. In addition the population spread is

becoming more uneven, mainly because of the

urbanization that is becoming more rampant every

year. This rapid growth rate will automatically

increase the community's needs for shelter or

housing. With people’s increasing levels of need for

housing, this will increase the procurement of

housing in Indonesia, primarily in urban areas. This

has led to an increase in social problems and resulted

in a slum housing environment that does not meet

health requirements. Surabaya, which is also a

metropolitan city with rapid development and

becoming a common urbanization destination, is a

target of arising social problems. Problems arising

from the needs of the community needs to be

handled by the government immediately, including

the procurement of housing for the middle to lower

economic level of the community. According to the

United Nations Conference regarding the Problem of

the Human Environment (1972), more than 1 billion

people live below standard conditions and it is likely

that the situation will get worse in the future (WHO

SEARO, 1986; WHO Commission on Health and

Environment, 2001). The housing situation is a

factor that determines the condition of hygiene and

environmental sanitation. Overcrowding and narrow

housing results in high incidences of illness,

accidents, and other issues (Sukarni, 1995).

Based on the Household Health Survey (SKRT)

conducted in 1995 (DG PPM and PL, 2002), the 3rd

leading cause of death in Indonesia is tuberculosis.

Tuberculosis, commonly referred to as TB, is closely

related to unhealthy house sanitation conditions.

Meanwhile, according to the WHO report (2007) on

Global Tuberculosis Control Surveillance, Planning,

and Financing stated that Indonesia was ranked fifth

with the highest number of tuberculosis patients in

Southeast Asia after Bangladesh, Bhutan, DPR

Korea, and India.

WHO also reports that 10 to 20 million people

with tuberculosis in the world can transmit

tuberculosis. Because of pulmonary tuberculosis, the

mortality rate is around 3 million patients each year.

This situation is increasing and almost 75% are

found in low-socio-economic developing countries

(Alsagaaf, 2008).

The Annual Risk of Tuberculosis Infection

(ARTI) including the risk of transmission of

tuberculosis infection in Indonesia, is considered

quite high and varies between 1% and 3%. Areas

with an ARTI, numbers of 1% suggest that every

year, of 1,000 residents, ten will be infected. From

the infected people, only 10% will become

tuberculosis patients. Thus, it can be estimated that,

in an area with an ARTI of 1%, among 100,000

residents there will be 100 tuberculosis patients on

average per year, 50 of which will be positive acid-

fast bacilli (MOH, 2002).

In Indonesia, tuberculosis disease is still

developing. This is related to the deterioration of the

socio-economic conditions of society, public health

service facilities that are not yet optimal, the number

of people, which is continually increasing, many of

whom do not have permanent residence. The

development of the disease is not separate from

human behavior; mainly the behavior of the

inhabitants in the house (Sukarni, 1995).

Based on the Pamekasan district health office

report in 2011, there were as many as 759 people

suffering from tuberculosis during 2010. In

Pamekasan, from 2011 to May 2018, there were 610

residents who are known to suffer from tuberculosis.

The number of tuberculosis patients is mostly

incrasing in three districts: District Palengaan,

Pasean, and District Palengaan. The number of TB

patients in the Pamekasan District is high in East

Java, and the government are trying to implement

treatment. The government said, Pamekasan District

was ranked fifth in East Java regarding cases of TB,

after Sumenep, Lumajang, Malang, and Jember.

According to the latest data from the health services

for 2012 and 2013, there are three Community

Health Centre that successfully identified TB during

2012. Palengaan Health Community Center

identified 111 patients, the Pasean Health

Community Centre identified 96 patients, and there

were 68 patients identified by the Waru Community

Health Center. For the first quarter of 2013, 22

patients came from Pasean, 19 from Palengaan, and

17 from Batumarmar Community Health Center.

It takes six months of treatment to cure the

infectious disease. If within that six months of

treatment, one day is missed, the treatment must

then start all over again. Drugs are provided free of

charge at every health service center under the

health agency. A house that becomes a home and

shelter for its inhabitants, can guarantee their health.

A house assessed as having healthy conditions has

become a determining requirement for the health

status of its inhabitants. Components of a house and

its environment that do not meet health requirements

are risk factors and a source of transmission of

various types of diseases, especially environmental

diseases (Keman, 2005). Unhealthy housing

conditions will have a negative impact on human

health; one impacting result is tuberculosis. Efforts

to control risk factors that influence the occurrence

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

658

of health threats have been regulated in Kepmenkes

RI. 829/Menkes/SK/VII/1999 regarding housing

health requirements.

Previous studies, such as research by Nur

Yasiroh (2009) and Machrita Hanum (2010) only

analyze the relationship between each component,

i.e. the physical quality of the house with the

occurrence of pulmonary TB, including physical

qualities such as ventilation, room area, floors, and

walls. The health status of housing has not yet been

studied through conducting a healthy house

assessment in relation to the occurrence of

pulmonary tuberculosis. Therefore, the researchers

want to determine the relationship between TB

occurrence rates in the work area of Kedurus Health

Center, with the results of a healthy housing

assessment.

The purpose of this research is to analyze the

relationship between healthy housing conditions and

the occurrence of Pulmonary TB in the Palengaan

District of Pamekasan Regency.

2 METHODS

Case Control Research is an epidemiologically

designed study that examines the relationship

between exposure (factor research) and disease by

comparing case groups and control groups based on

their exposure status (Murti, 1997).

Case Population: Pulmonary TB patients with

positive BTA diagnosis in the Karang Pilang district

and undergoing examination at Kedurus Community

Health Center from January to December 2012.

Population control: Communities in the area who

did not have pulmonary TB during the same period

with the same age and sex and who were neighbors

of the patient in the case population.

Research variables: there are two types, which

are dependent variables and independent variables.

The dependent variable in this study is the

pulmonary TB patients with BTA positive test

results; the independent variable is comprised of

several components, such as: 1. house construction;

2. sanitation facility (clean water facility, latrine, and

waste disposal facility); 3. Inhabitants' behavior; and

4. The density of inhabitants (house ceiling, wall,

floor, bedroom window, window of family room,

ventilation, kitchen smoke hole, lighting).

3 RESULTS

3.1 Characteristics of the Respondents

3.1.1 Respondents’ Age

The case groups and control groups in this study

have the same proportion of age groups. In the case

and control groups, the largest age group is the 21 to

30-year age group, with nine respondents (29%).

The results of this study describe the distribution of

age almost evenly in each age group and the same

thing occurred in the case groups and control groups.

According to Crofton (2002), there is almost no

difference in the risks of developing pulmonary TB

before puberty. The highest occurrence of

pulmonary tuberculosis is usually during young

adulthood. In women, the prevalence peaks at age

40–50 years, and later decreases, whereas in men the

prevalence continues to increase until at least 60

years old.

The results of this study have the same

percentage between case groups and control groups.

This is because during the selection of controls,

matching techniques that equalized age were used,

therefore the researchers do not expect age to be

factor associated with the occurrence of pulmonary

TB. Thus, the results do not support the theory

presented by Crofton (2002). Based on other studies,

according to DG, PPM, & PL (1999), tuberculosis

can occur in all age groups, and not just in adults,

hence the matching results of this study.

3.1.2 Respondents’ Gender

The case group and control group in this study have

different gender proportions. In the case group, the

highest number of respondents is male with 19

respondents (61.3%), while in the control group, the

dominant respondents are also male respondents

with 19 respondents (61.3%).

Crofton (2002) mentions that there is almost no

difference in the risks between men and women of

infection with the TB bacteria regarding the age of

puberty. The number in males is quite high at all

ages, whereas, in women, it tends to decrease

beyond the age of fertility.

The equality of proportions in both groups is due

to the selection of controls using matching

techniques that equalized gender, therefore the

researchers do not expect gender to be one of the

factors associated with the occurrence of pulmonary

TB.

The Relationship between Healthy Housing Conditions and Pulmonary Tuberculosis

659

Based on the theory presented by Crofton (2002),

the risks between men and women are no different;

all people can suffer from Pulmonary TB. According

to Crofton's (2002) statement, the number of males

is greater, based on research results. This is true yet

still cannot be proven with certainty, because the

results of male control groups suggest a larger

number of those who do not suffer from pulmonary

TB.

3.1.3 Respondents’ Education

Level of education is not directly related to the

occurrence of infection by TB germs, but an

educated person and a high level of education will

usually be the same as for a capable person. Capable

means that the person tends to have sufficient

economy to provide adequate nutrition and healthy

housing although this is not yet ascertained. An

educated person has broad knowledge that can affect

a person's behavior. This also cannot be ascertained.

The results showed that the education level of

respondents has a different percentage. In the case

group, as well as the control group, the level of

education of respondents is the same, i.e.

respondents with junior high school education have

a large number in each group. However, the

numbers are not identical. In the case group there

were 25 respondents (80.6%) while in the control

group there were 30 respondents (96.8%).

The relationship between respondents’ education

status with the occurrence of pulmonary tuberculosis

was based on calculation results using a Chi-square

statistic test: (p) = 0.104> (α = 0.05), meaning H0

accepts that there is no relationship between

educational status and the occurrence of pulmonary

TB.

The higher level of education in the control

group indirectly illustrates that the control group

respondents have more ability and knowledge, but

based on the results of research with the analysis

using the Chi-square statistical test, the education

level of respondents is not related to the incidence of

pulmonary TB. In the case group, there were many

respondents who had completed junior high school.

Good education cannot directly affect one's behavior

or ability, so the unconfirmed theory is indeed

refuted by the results of this study.

3.2 House Health Assessment

Table 1: The distribution of respondents based on the

house health assessment in Palengaan District.

Health

Assessment

Case

Control

Total

Healthy

House

16.1

87.1

51.6

Unhealthy

House

83.9

12.9

48.4

Total

100

P: 0.000

OR: 35.10

Table 2: The distribution of respondents based on house

components in Palengaan District.

House

components

Case

Control

Total

Healthy house

58.1

77.4

67.7

Unhealthy

house

41.9

22.6

32.3

Total

100

P: 0.174

Table 3: The distribution of respondents based on

sanitation facilities in Palengaan District.

Sanitation

facilities

Case

Control

Total

Healthy

house

96.8

100

98.4

Unhealthy

house

3.2

1.6

Total

100

P: 1.000

Table 4: The distribution of respondents based on

inhabitant’s behavior in Palengaan District.

Inhabitant’s

behavior

Case

Control

Total

Healthy

16.1

61.3

38.7

Unhealthy

83.9

38.7

61.3

Total

100

P: 0.001

OR: 8.233

Table 5: The distribution of respondents based on

residential density in Palengaan District.

Residential

density

Case

Control

Total

Dense

19.4

9.7

14.5

Sparse

80.6

90.3

85.5

Total

100

P: 0.473

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

660

4 DISCUSSION

Although houses may vary, each component of a

house must fulfill health requirements, so the

inhabitants do not suffer from any illnesses (Azwar,

1995). Components of houses that fulfil health

requirements should provide comfort and maintain

the health of inhabitants, so they can avoid disease,

work productively, and produce something

meaningful.

Housing conditions can determine the level of

hygiene and environmental sanitation. Overcrowded

and narrow housing results in high incidences of

illness, accidents, and other issues (Sukarni, 1995).

Based on Kepmenkes RI No. 829/Menkes/SK/

VII/1999, technical guidelines for the assessment of

healthy homes have been formed to improve housing

conditions. The home parameters evaluated in the

healthy house assessments include three groups of

assessment components, comprised of housing

components, sanitation facilities, and inhabitants

behavior. It aims to assess whether the house has

met the criteria of healthy housing conditions or the

opposite.

The results indicate that there are differences in

the proportion of home health assessments held by

the respondents in the two groups. The proportion of

The dominant evaluation in the case group

assessment was unhealthy, with 26 respondents

(83.87%). The same assessment in the control group

indicated only four (12.9%) respondents with

unhealthy housing. The result of statistical test

shows that P = 0.000 < (α = 0.05), which indicates

that there is a relationship between house health

status and Pulmonary TB incidence. Thus, the

results of this study support several theories that

have been described previously.

Environment is a factor that causes the

occurrence of disease. The environment referred to

in this case is the physical environment of the house.

Poor environment can certainly disrupt the balance

in the process of interaction, involving two other

factors: the agent and the host. The process runs

dynamically and if one is disturbed it can affect the

other, causing the occurrence of disease on the host

(Mubarak, 2009). Unhealthy environmental

conditions will also increase the disease-causing

agent to develop and will facilitate the process of

disease transmission, in this case, pulmonary TB.

The assessment of a healthy house includes three

important things, one of which is the components of

the house. The results of the component assessment

were obtained based on the total score of eight

variables comprising of ceilings, walls, floors,

bedroom windows, living room windows,

ventilation, kitchen smoke holes, and lighting. The

provision of residential health requirements

according to Kepmenkes No.829/Menkes/SK/VII/

1999; components and arrangement of houses are

also listed within it.

According to The American Public Health

Association (APHA) in Azrul Azwar, healthy

housing must be built in such a way that it can be

maintained, including the temperature of the

environment, and the meeting of basic physical

needs. This is to prevent heat loss or excessive heat

(body temperature) and to ensure lighting and home

ventilation is sufficient so that fresh air can be

experienced. According to the Directorate General

of Human Settlements (1997), healthy housing

should include foundations, walls, ceilings, floors, a

roof, and ventilation. Houses with good components

in accordance with health requirements, should

protect inhabitants from disease.

Results indicate that in the case group, there

were 18 respondents (58.10%) with healthy housing

and in the control group there were 24 respondents

assessed with healthy housing (77.4%). Thus, the

results of statistical tests show the value (p) =

0.174> (α = 0.05) means that H0 is accepted,

indicating that there is no relationship between the

healthy components of housing and the incidence of

pulmonary TB.

This result is because most of the respondents in

both the case and control groups have healthy house

components. This resulted in no significant

difference, so there was no relationship. The

assessment of healthy housing in the case group

occurred due to healthy criteria being met regarding

the eight variables. If one variable is badly rated, the

house can still be judged as healthy, because of the

high value of the other variables.

The components of a healthy house are

important, but they must also be accompanied by

healthy behavior and maintenance. House

components of just one example of physical

environmental factors. The physical environment

can have an effect if it is in an unhealthy condition,

so as much as possible it needs to remain in good

health, via a healthy maintenance process.

Behavioral factors and people's lifestyle today still

cause harm to health, hence a higher awareness is

required.

According to Krieger and Higgins (2002),

healthy housing should provide facilities and

infrastructure that includes the availability of clean

water and sanitation of waste disposal. The concept

of healthy housing involves the sociological and

The Relationship between Healthy Housing Conditions and Pulmonary Tuberculosis

661

technical approaches to risk factor management:

qualification, adaptation to the surrounding

environment, management and maintenance of the

house with the surrounding environment, and the

concept of healthy house, include the availability of

sanitation facilities and clean water, adequate means

for cooking and washing, means for the disposal of

human waste or other waste, and, most importantly,

the provision of drinking water (WHO Commission

on Environmental Health, 2001).

For the assessment of healthy housing in this

study, the second assessment group assessed the

availability of sanitation facilities in which there are

four variables. These variables include facilities for

clean water, sewerage, waste water disposal, and

garbage disposal.

Results indicate that almost all respondents in the

case group and control group have healthy sanitation

facilities. The results of the statistical test achieved

the value (p) = 1.00> (α = 0.05) and shows that there

is no relation between sanitation facilities and the

incidence of pulmonary TB. This is because the two

groups have no significant differences meaning that

there is no relationship.

The cause is like the components of the house

that have been analyzed beforehand between the

case group and the control group for the appropriate

availability of sanitation facilities; one inappropriate

variable does not affect the result of the assessment

because the other variables are appropriate and

considered healthy.

Pulmonary TB disease is closely related to poor

home sanitation, but the most influencing factors of

poor sanitation are the components of the house.

House sanitation assessments include four variables:

the availability of clean water, sewerage channels,

latrines, and waste. However, these are not the main

reasons for the transmission of pulmonary TB. Thus,

if the results of the assessment of home sanitation

meet the healthy criteria, this does not mean it can

be free from pulmonary TB. This is due to host

factors and other affecting environmental

components.

Behavior is the activity of an organism. Human

behavior is the activity of a human. Factors that

influence the emergence of behavior can be genetic

and environmental. Genetic factors are a basic

concept for the development of subsequent human

behavior, while the environment is the land

condition for the behavior it develops (Notoatmodjo,

2003).

According to Notoatmodjo (2003), health

behavior is a response of a person or organism

against the stimulus that is associated with an

incidence of disease, the health care system, food,

and environment. Stimulus in health behavior

consists of four basic elements. One of the key

elements is the behavior towards a disease.

The human response to a disease can be passive

in knowing and perceiving or it can be acting upon

that knowledge. This behavior towards corresponds

to levels of disease prevention including, among

other things, improving and maintaining health

behavior, disease prevention behavior as a response

to prevent the occurrence of disease, and behavior

related to the search for treatment, either through

health services or using traditional medicine.

The results indicate that there is a difference in

the percentages of inhabitants’ behavior between the

case group and the control group. In the case group

there were only five inhabitants (16.1%) who

demonstrated healthy behavior. In the control group

the number with healthy behavior was greater, at 19

respondents (61.3%). The results of the statistical

test show the value (p) = 0.001 < (α = 0,05),

meaning there is a relationship between the behavior

of inhabitants and incidences of Pulmonary TB.

Thus, the results of this study support several

theories that have been described previously.

Behavior is one example that can affect the host.

Behavior can increase or reduce sensitivity to illness

and, of course, bad behavior can degrade the health

status of the host (Mubarak, 2009).

This is of course in accordance with the

hypothesis of this study; relationships that occur and

increase the incidence of pulmonary TB. Thus, in

the process it will be conducted by one factor (host)

and will affect the process and other variables

(agents and environment) through the disease

(Pulmonary TB).

Healthy houses should have a bedroom width of

at least 8m

and it is recommended that no more

than two people use one bedroom space. The floor

area of the building must also be adjusted to the

number of inhabitants.

The area of the building should be at least 3m

for each family member (Notoatmodjo, 2003).

Residential density is the floor area of a room in

a house divided by the family members occupying

the room, so 4m

per person would meet the health

requirements for residential density. This is like the

opinion expressed by Lubis (1997), who states that

residential density is the number of people in a

living space compared to the floor area that has

exceeded existing provisions.

Based on the results of the research the seven

respondents (22.58%) in the case group lived in

densely populated houses, while three respondents

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

662

(9.68%) in the control group lived in densely

populated houses for (p) = 0.30> (α = 0.05), which

indicates there is no relationship between the density

of residence and incidence of pulmonary TB.

Compared with previous research by Machrita

Hanum (2010), the results of this study are not the

same. Previous studies have suggested that

residential density is associated with pulmonary

tuberculosis incidence. This difference may be due

to the present research being conducted in non-

densely populated areas, so that between case groups

and control groups there are no significant

differences.

In other studies by Isye (2005) and Nur Yasiroh

(2009), the results indicate the same thing;

residential density is not related to healthy housing,

although the cause is different.

5 CONCLUSIONS

Home health assessments were based on the Chi-

square statistic test with the result (p) = 0,000 <α =

0.05, which indicates that house health is related to

pulmonary TB incidence. A healthy house can

reduce the incidence of pulmonary TB, while

unhealthy housing has a 35.10 times greater risk of

having pulmonary tuberculosis compared to healthy

houses.

Health Officers are expected to monitor and

improve sanitation of housing and settlements, and

to further improve counseling regarding a clean and

healthy life to create a healthy environment. In this

case, healthy behavior was assessed to maintain the

health of the house. Supervision should be

conducted once each year, then counseling is

provided at least three times a year in accordance to

the recommendations in the technical guidelines of

healthy housing.

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