Effects of household concrete floors on child health

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PROJECT SUMMARY Soil-transmitted helminth infections and diarrhea are responsible for a large burden of morbidity and mortality among children under 5 years and are associated with increased growth faltering, anemia, impaired child development, and mortality. The primary public health interventions to prevent enteric infections are household water, sanitation, and hygiene (WASH) interventions. However, recent WASH intervention trials found only modest impacts on enteric infection prevalence in children. Observational studies have found that children in households with concrete floors have a lower prevalence of diarrhea and soil-transmitted helminth infection than those in households with soil floors. However, these findings may be strongly confounded by household wealth. We propose a randomized trial in rural Bangladesh to measure whether installing concrete floors in households with soil floors reduces child enteric infection. We will randomize 800 eligible households with pregnant women and install concrete floors before the birth cohort is born. We will collect follow-up measurements when children are ages 6, 12, 18, and 24 months. Our team is comprised of experts in environmental and infectious disease epidemiology, including Bangladeshi scientists. We have extensive experience implementing large-scale health intervention trials in Bangladesh and other low resource settings. Aim 1 is to measure the effect of household concrete floors on household fecal contamination and child soil contact and ingestion over time. The primary endpoint is Ascaris lumbricoides prevalence at any follow-up measurement. Secondary endpoints include prevalence of other soil-transmitted helminths and diarrhea. Other outcomes include maternal quality of life and stress. Aim 2 is to measure the effect of household concrete floors on household fecal contamination and child soil contact and ingestion over time. We will detect soil- transmitted helminths (N=800) in floor swabs and E. coli in floor, child hands, and sentinel toy samples in a random subsample (N=220). In a subsample (N=60), we will conduct video observations to estimate the frequency of child soil contact and ingestion. We will estimate the incremental cost-effectiveness ratio for both maternal and child outcomes using disability adjusted life years. This trial will determine whether concrete floors reduce enteric infection, and investigate mechanisms for how floors impact health, or if they do not, why. Household concrete floors are an innovative potential health intervention that may have additional benefits that we will measure in this study, including reducing the bandwidth tax that low-income families experience by making it easier to maintain a hygienic home environment, and in turn improve quality of life. Our findings will provide rigorous, policy-relevant evidence about whether concrete flooring installation should be delivered as a public health intervention to reduce child enteric infection. More broadly, this study marks a paradigm shift in intervention design for improving child health by expanding its scope to include housing improvements.