Household flooring associated with reduced infant diarrhoeal illness in Zimbabwe in households with and without WASH interventions

Abstract

Objectives: Diarrheal illness is a leading cause of childhood morbidity and mortality and has longterm negative impacts on child development. Although flooring, water, and sanitation have been identified as important routes of transmission of diarrheal pathogens, research examining variability in the association between flooring and diarrheal illness by water and sanitation is limited.Methods: We utilized cross-sectional data collected for the evaluation of Zimbabwe's Prevention of Mother-to-Child HIV transmission program in 2014 and 2017-18. Mothers of infants 9-18 months of age self-reported the household's source of drinking water and type of sanitation facility, as well as infant diarrheal illness in the four-weeks prior to the survey. Household flooring was assessed using interviewer observation, and households in which the main material of flooring was dirt/earthen were classified as having unimproved flooring and those with solid flooring (e.g. cement) were classified as having improved flooring.Results: Mothers of infants living in households with improved flooring were less likely to report diarrheal illness in the last four weeks (PD a =-4.9%, 95%CI: -8.6, -1.0). The association between flooring and diarrheal illness did not vary by the presence of improved/unimproved water (p RERI =0.91) or sanitation (p RERI =0.76). Conclusions: Our findings support the hypothesis that household flooring is an important pathway for the transmission of diarrheal pathogens, even in settings where other aspects of sanitation are sub-optimal.Improvements to household flooring do not require behavior change and may be an effective and expeditious strategy for reducing childhood diarrheal illness irrespective of household access to improved water and sanitation.

Factors affecting under-five diarrhea in households with dirt floors: a multilevel mixed-effects analysis from a national survey of Ethiopia

“…A study from Zimbabwe showed that mothers of infants living in households with improved ooring were less likely to report diarrheal illness. Further, the association between ooring and diarrheal illness did not vary by the presence of improved/unimproved water or sanitation [23]. It was also found that dirt and mud oors are a known predictor of diarrhea and parasitic infestations [23,24].…”

“…Further, the association between ooring and diarrheal illness did not vary by the presence of improved/unimproved water or sanitation [23]. It was also found that dirt and mud oors are a known predictor of diarrhea and parasitic infestations [23,24]. Eliminating a dirt oor from the home results in dramatic reductions in childhood diarrhea and Soil-Transmitted Helminth (STH) [23,25].…”

Household finished flooring and soil-transmitted helminth and Giardia infections among children in rural Bangladesh and Kenya: a prospective cohort study

“…34 A cross-sectional study in Zimbabwe reported a statistically significant 18% percent lower diarrhea prevalence in infants living in homes with finished floors. 32…”

“…Cross-sectional studies in urban and rural settings have reported associations between living in a household with a soil floor and higher risk of infection with hookworm 23 , A. lumbricoides 22,24,25 , Strongyloides stercoralis 26 , G. duodenalis 24,27 , cholera, 28 other enteric parasite infections, 29–31 and diarrhea or gastrointestinal illness. 32,33 A retrospective, matched impact evaluation of a government program in urban Mexico found that replacing household dirt floors with concrete reduced diarrhea and intestinal parasite infection in children. 34 However, this study did not describe the parasite species that were measured.…”

Does suboptimal household flooring increase the risk of diarrhoea and intestinal parasite infection in low and middle income endemic settings? A systematic review and meta-analysis protocol

“…There is increasing interest in 'healthy homes' and infectious disease, which at this stage has been primarily focused on vector control; however, there is an urgent need to assess the relationship between the built environment and its impact on enteric infection risk. While some observational studies have suggested no association between unimproved flooring and enteric pathogen risk, multiple observational studies have shown associations between unimproved flooring and diarrhoeal risk [16] as well as some enteric parasitic infections, notably STH [9]. However, no systematic review of the literature has been conducted, to our knowledge, to assess whether unimproved household flooring is an independent risk factor for enteric disease risk in low-and middle-income countries (LMIC).…”