An inter-disciplinary approach to understanding the contribution of household flooring to disease burden in rural Kenya

Lead Research Organisation: London School of Hygiene & Tropical Medicine
Department Name: Infectious and Tropical Diseases

Abstract

Access to adequate, safe and affordable housing plays a fundamental role in human health. This includes thorough limits our exposure to infectious diseases such as those that cause diarrhoea, which remains a leading cause of death in children under five. Conventional approaches to reducing environmental exposure to faecal pathogens include ensuring universal access to safe water and basic sanitation. Recent evidence has suggested that this alone may be insufficient to reduce the high levels of environmental contamination seen in poor rural communities, and that transformative cross-sectoral approaches will be required to see real impacts in child health. For example, these approaches fail to address the fact that most poor rural homes have rudimentary (earth, sand or dirt) floors that are difficult to sanitise, providing an ideal environment for the survival of faecal pathogens and other parasites. These floors can also host parasitic infections including intestinal nematodes and sand fleas, both of which are responsible for considerable morbidity and poor quality of life.

We propose to examine flooring and its impact on enteric and parasitic diseases in three culturally and environmentally diverse settings in Kenya, and aim to address two related questions:
1. What is the importance of household flooring as a driver of enteric and parasitic infection risk in rural communities, and does this vary across wider social and environmental contexts?
2. Can infection risk be mitigated by replacing existing rudimentary (earth, sand or dirt) floors with improved (sealed, washable and durable) materials, and what additional behaviour changes are required to ensure impact?

We expect that successful installation and ongoing maintenance of improved flooring will reduce the transmission of enteric and parasitic infections, by preventing direct exposure and through an intermediate effect of improved domestic hygiene. This will however be influenced by local context. A priority in each setting will therefore be to explore the interplay between domestic flooring, water and sanitation infrastructure, domestic hygiene behaviours, and the wider socio-cultural and environmental context.

Our planned approach involves comprehensive formative research, intervention development conducted in collaborative partnership with recipient communities and key stakeholders, and then implementation trials to test the effects, feasibility and acceptability of the resulting intervention. We will assess the impact of the intervention on a range of child health outcomes, including prevalence of enteric and intestinal worm infections, prevalence of tungiasis, and incidence of gastrointestinal illness. We will also monitor levels of environmental contamination, and explore the impact of the intervention on domestic routines and self-reported wellness. During implementation, we will work with recipients and stakeholders at community, regional and national level to assess the extent to which interventions are acceptable to target communities, feasible given existing resource constraints, and can be scaled-up across Kenya and elsewhere. This includes work undertaken to understand options for scale-up should the intervention prove successful.

This study is the first of its kind to comprehensively assess feasibility and effects of combining improved flooring technologies with tailored behaviour change programming on a wide range of parasitic and enteric outcomes. In doing so, we aim to provide important policy and technical guidance on the impact and effectiveness of new transformative approaches to community health. This is an important first step towards the establishment of transformative, community-driven and cross-sectoral approaches to building out water, sanitation and hygiene-related diseases.

Technical Summary

The quality and environmental context of housing provides important conduits through which social and environmental inequalities can translate into health inequity. We hypothesise that rudimentary flooring is an under-recognised contextual driver of health in poor rural communities, augmenting exposure to enteric and parasitic pathogens. This inter-disciplinary study seeks answer the question in what contexts does household flooring act as a driver of infection risk, and how can we intervene to mitigate this? We plan to work in three culturally and epidemiologically distinct settings across Kenya to evaluate enhanced flooring packages (EFPs) that include the provision of an improved floor, accompanied by a participant-informed behaviour change programme. In each site, formative research will focus on refining flooring specifications and technologies, and behaviour change needs. Participatory co-development approaches will then be used to design final intervention. Cluster randomised intervention trials will be used to assess the effects, feasibility and acceptability in each site. In total, 225 households will be randomised to receive the intervention or not. Primary outcomes include the prevalence of enteric infections, STH and tungiasis, assessed by repeat cross-sectional surveys. Secondary outcomes include incidence of gastrointestinal illness, environmental contamination and subjective wellbeing. A nested process evaluation will explore implementation fidelity and uptake, acceptability, feasibility and cost, whilst sustainability and scalability will be explored using an implementation science approach. Funders and governments still require clear policy and technical guidance on the impact and effectiveness of new transformative approaches to reducing the burden of diseases associated with poor water, sanitation and hygiene. This evaluation will be among the first to provide policy information on the potential impact of flooring improvements on community health.

Planned Impact

The proposed research has a number of potential direct beneficiaries, ranging from the global through the national to the individual level:

At the global level, a first beneficiary is the World Health Organization (WHO), and the proposed research has the ambition to challenge and change WHO's guidelines on sanitation and health. The WHO has recently published its strategy on WASH for accelerating and sustaining progress on neglected tropical diseases although these do not mention flooring. The proposed study seeks to move beyond conventional water and sanitation, and provide proof-of-principle for improving housing conditions to reduce transmission of multiple infections.

A second group of global beneficiaries are members of the global WASH sector, who are seeking guidance on next steps towards developing a broader, transformative WASH strategy that addresses wider environmental contamination. Third, looking to the housing sector, the majority of current research focuses on urban populations, and findings from this study would help to demonstrate market opportunities for investing in flooring for rural communities.

A fourth group of global beneficiaries are members of the global NTD coalition. Since the 2012 London Declaration brought this disparate community together, the focus of STH control has been through preventive chemotherapy and WASH has played a back seat. Demonstrating the importance of reducing environmental contamination to prevent reinfection may help change the approach to STH control.

The fifth group of global beneficiaries are funders, including the Bill & Melinda Gates Foundation, DFID and USAID, who are supporting national government to implement WASH-related interventions but are seeking new strategies and approaches. The proposed study will provide the first evidence as to the potential of reducing transmission through a flooring intervention, and the optimal strategy as to how this might be achieved. This evidence will help inform subsequent funding and resource allocation.

At the country level, the main beneficiary is the Government of Kenya (GoK), including the Ministries of Health and of Housing. The proposed study will inform the design and scaling-up of new WASH strategies not only Kenya, but also many other high burden countries. In 2009, the GoK launched its national school-based deworming programme (NSBDP), which successfully treated over 4.6 million preschool and school children in 2013. Notwithstanding these achievements, there are concerns that the school-based programme will need to continue indefinitely if allied WASH strategies cannot be developed to help reduce reinfection rates.

At the local level, communities will benefit from the study. Both intervention and control households will receive a new floor by the end of the study. In addition to the positive financial impact fo this, it should lead to health and wellbeing impacts including reduction in infection risk. CHWs will also benefit from the study as they will have the opportunity to broaden the scope of their activities and contribute to efforts to control tungaisis in their communities. We will work with the GoK to develop relevant training materials for CHWs, which could be readily adapted to other countries. Local masons will be trained and provided with a potential new means of income beyond the duration of the study.

A final group of beneficiaries are staff working on the project who will be able to develop a range of skills (e.g. project and finance management, communication, trial design and analysis, epidemiology) appropriate to their role in the project, which will be transferable to other work and sectors in the future. Specific individuals will also be able to gain training in clinical trials, monitoring and evaluation and epidemiology, and behavioural science including local students recruited under the LSHTM Collaborative Centre scheme which facilitates reduced fees and multi-site tuition.
 
Description To date, we have completed our formative research and are currently conducting a controlled trial of the resulting intervention. Key findings are thus restricted to the formative research activities.

Our formative research activities were conducted in three rural settings in Kenya (in Bungoma, Kwale and Narok) included:
- household observations to better understand floor hygiene, animal husbandry practices, caregiving, food preparation, water collection and storage, laundry activities, and meal taking.
- individual and group discussions with care-givers and household members to explore motivations underpinning daily activities, attitudes to building practices, home improvement, and the relative importance of the household floor.
A two-day co-creation workshop was held in Kwale County to review results from the formative research and to develop a theory of change, and a corresponding intervention package.

Key findings from this work include:
- Identification of proximal and distal determinants of household floor contamination with faeces in these settings, which include animal contact, child faeces disposal and floor cleaning routines.
- The design of an acceptable, affordable flooring product, which incorporates a damp proof membrane, cement stabilised murram soil (primarily of a mixture of gravel and fine sand, often with some silt and clay particles), and a thin cement screed.
As a result, we have developed a theory of change framework demonstrating how we believe the improved household flooring intervention will reduce prevalence of soil-transmitted helminthiasis, enteric infections and tungiasis and improve psychological wellbeing among children and caregivers. Reductions in infections are predicated on limited contact between improved floors and animals, regular floor cleaning, and household members conducting their daily routines on the new floors. Gains in wellbeing are tied to increased feelings of pride, self-efficacy, and social progress, as well as improved quality of life through reduced morbidity from enteric and parasitic infections. Our work is the first of its kind to present a theory of change framework mapping the pathways through which an improved flooring intervention may impact health and wellbeing.
Exploitation Route The outcomes described above may be used to further develop sustainable interventions to improve the domestic environment in rural communities in settings such as Kenya to improve health and wellbeing. In particular, findings to date can be of use to researchers or programmes that are in the design or evaluation phase of a household flooring project in Kenya or other settings where access to improved floors is limited.
Sectors Communities and Social Services/Policy

Environment

Healthcare

 
Title Evaluating Impact of Improved Floors on Health (SABABU) 
Description This intervention is the provision of an affordable, cement-stabilised household floor. The floor is sealed and washable and is intended to reduce contamination of the domestic environment with enteric pathogens, soil-transmitted helminths, and sandflies. We are currently conducting an intervention study to learn about the impact of household flooring on health in rural Kenya in two separate settings to test whether providing this (cement stabilised, washable) floor improves the health of children and their care providers. The main questions the study aims to answer are: - What is the effect of providing a sealed, washable floor on the prevalence of infections that cause diarrhoea, intestinal worms and sand flea infections? - To what extent does the intervention reduce contamination of floors with pathogens within the home? - What is its effect of the intervention on the wellbeing of caregivers and children? - Over the course of a year, do the new floors remain undamaged, with no cracks? - Do participants living with the new floors, and the masons that helped to install the floors, like them and feel they are practical and affordable? The study involves a trial, where half of the recruited households have been randomly chosen to receive the new floor in addition to some support on how to care for the floor and keep it clean. The other half of households have not received anything at first, but at the end of the research project will also receive a new floor. The trial is funded through this grant (MRC). 
Type Preventative Intervention - Behavioural risk modification
Current Stage Of Development Initial development
Year Development Stage Completed 2023
Development Status Under active development/distribution
Impact The development and installation of this new flooring protocol has required training a number (n~25) local masons, which has contributed to skills and knowledge in the wider community. 
URL https://clinicaltrials.gov/study/NCT05914363?locStr=Kenya&country=Kenya&aggFilters=status:not%20rec&...
 
Description Co-creation workshop (intervention development - higher level) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact A two day workshop was held in Kwale including 15 participants from Kwale, Narok and Bungoma (incluidng sub-county level health teams, ward administrators, county planning officers, representatives from relevant NGOs and the multidisciplinary research team) to (i) disseminate findings from our formative research activities, (ii) identify and discuss potential intervention activities, (iii) map out a theory of change for the resulting proposed intervention, and (iv) plan subsequent community-level dissemination and co-development work shops in each of the sites.
Year(s) Of Engagement Activity 2022
 
Description Determinants of floor faecal contamination in three rural settings in Kenya - A mixed methods analysis using data from the SABABU study --> given by Dr Stella Kepha 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact A presentation was given at the KEMRI Annual Scientific and Health conference, in Nairobi - attended by KEMRI researchers, academics from other national reserach institutes and universities, and interested practitioners. Resulting questions and discussion has helped shape the paper resulting from this work.
Year(s) Of Engagement Activity 2023
URL https://www.kemri.go.ke/kash-13/
 
Description Dissemination events and co-development workshops - at community level 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact In each of two study sites, 10 community members joined the study team for a full day dissemination event that included internvetion co-development to discuss and consolidate conclusions from the formative research, and explore and refine the proposed intervention activities. This resulted in a final internvetion package that was considered acceptable and feasible to community members.
Year(s) Of Engagement Activity 2022
 
Description Study introduction meetings 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Study participants or study members
Results and Impact These meetings were held at the county, sub-county and ward-level in each study site at the start of the formative phase of the project in 2021. These meetings included members of the county health management team (CHMT), other county and sub-county officers, and ward administrators and public health officers. The aim of these meetings was to introduce the study and gain stakeholder approval at the county, sub-county and ward levels of local government.
Year(s) Of Engagement Activity 2021
 
Description Village level update meetings 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact Village-level meetings with stakeholders from study villages and ward-level representatives have taken place in advance of research activities during the formative (2021) and trial (2023) phases of the project. These have typically involved community health volunteers, village elders, chiefs, assistant chiefs and when appropriate representatives from participating households and have been undertaken to ensure community awareness and buy-in around study activities.
Year(s) Of Engagement Activity 2021,2023