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在人类健康方面发挥着根本作用。这包括彻底限制我们接触传染病，例如导致腹泻的传染病，腹泻仍然是五岁以下儿童死亡的主要原因。减少环境接触粪便病原体的传统办法包括确保普遍获得安全用水和基本卫生设施。最近的证据表明，单靠这一点可能不足以减少贫穷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实的影响。例如，这些方法未能解决大多数贫穷农村家庭的地面很简陋（泥土、沙子或泥土），难以消毒，为粪便病原体和其他寄生虫的生存提供了理想的环境。这些地板也可以宿主寄生虫感染，包括肠道线虫和沙蚤，这两者都是相当高的发病率和生活质量差的原因。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，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的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？2.能否通过用改进的（密封、可清洗和耐用）材料替换现有的基本（泥土、沙子或泥土）地板来减轻感染风险，以及需要哪些额外的行为改变来确保影响？我们预计，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，防止直接接触，并通过改善家庭卫生的中间效果。然而，这将受到当地环境的影响。因此，每种环境的一个优先事项将是探讨家庭地板、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，与受援社区和主要利益相关者合作开发干预措施，然后进行实施试验，以测试所产生的干预措施的效果，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患病率、通济病的患病率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的健康的影响。在实施过程中，我们将与社区、区域和国家各级的受援者和利益攸关方合作，评估干预措施在多大程度上为目标社区所接受，在现有资源限制的情况下可行，并可在肯尼亚和其他地方扩大规模。这包括开展工作，了解如果干预措施证明成功，扩大规模的备选方案。这项研究是第一次全面评估改进的地板技术与定制的行为改变编程相结合对广泛的寄生虫和肠道结果的可行性和影响。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，对社区卫生的新的变革性方法的影响和有效性。这是为建立变革性、社区驱动和跨部门办法，以消除水、环境卫生和与毒品有关的疾病而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.