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

获得适足、安全和负担得起的住房对人类健康具有根本作用。这包括彻底限制我们接触传染病，如引起腹泻的传染病，腹泻仍然是五岁以下儿童死亡的主要原因。减少粪便病原体环境暴露的传统方法包括确保普遍获得安全饮用水和基本卫生设施。最近的证据表明，仅凭这一点可能不足以减少贫困农村社区的高水平环境污染，需要采取变革性的跨部门办法，才能看到对儿童健康的真正影响。例如，这些方法未能解决这样一个事实，即大多数贫困农村家庭的地面是简陋的（泥土、沙子或泥土），难以消毒，为粪便病原体和其他寄生虫提供了理想的生存环境。这些地板还可能成为寄生虫感染的宿主，包括肠道线虫和沙蚤，这两种疾病都是造成相当高发病率和生活质量低下的原因。我们建议在肯尼亚三个文化和环境多样化的环境中研究地板及其对肠道和寄生虫病的影响，并旨在解决两个相关问题：1。家庭地板作为农村社区肠道和寄生虫感染风险驱动因素的重要性是什么？这在更广泛的社会和环境背景下是否有所不同？是否可以用改进的（密封、可洗涤和耐用的）材料替换现有的简陋（土、沙或土）地板来减轻感染风险？需要哪些额外的行为改变来确保产生影响？我们预计，通过防止直接接触和改善家庭卫生的中间效应，成功安装和持续维护改进的地板将减少肠道和寄生虫感染的传播。然而，这将受到当地情况的影响。因此，每一种情况下的优先事项将是探索家庭地板、水和卫生基础设施、家庭卫生行为以及更广泛的社会文化和环境背景之间的相互作用。我们计划的方法包括全面的形成性研究，与受援国社区和主要利益相关者合作开展干预措施开发，然后进行实施试验，以测试最终干预措施的效果、可行性和可接受性。我们将评估干预措施对一系列儿童健康结果的影响，包括肠道和肠道蠕虫感染的流行程度、线虫病的流行程度和胃肠道疾病的发病率。我们还将监测环境污染水平，并探讨干预对家庭日常生活和自我报告健康的影响。在实施过程中，我们将与社区、区域和国家层面的受援国和利益攸关方合作，评估干预措施对目标社区的可接受程度、在现有资源限制下的可行性以及在肯尼亚和其他地方推广的程度。这包括开展工作，了解如果干预证明是成功的，扩大干预的选择方案。这项研究首次全面评估了将改进的地板技术与量身定制的行为改变计划相结合的可行性和效果，以广泛地影响寄生和肠道结果。在这样做的过程中，我们的目标是提供重要的政策和技术指导，说明新的变革方法对社区卫生的影响和效力。这是朝着制定变革性的、社区驱动的和跨部门的办法来消除与水、环境卫生和个人卫生有关的疾病迈出的重要的第一步。

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.