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Randomized Controlled Trial
. 2025 Feb 17;25(1):639.
doi: 10.1186/s12889-025-21469-1.

Better floors, better health: a theory of change for an improved household flooring intervention in rural communities in Kwale and Bungoma counties, Kenya

Stella Kepha #  1 , Hugo Legge #  2 , Katherine E Halliday  3 , Victoria Ochwal  4 , Lynne Elson  5   6 , Jacinta Mwongeli  7 , William E Oswald  3   8 , Beatrice Kakoi  7 , James Wambua  7 , Charles Mwandawiro  1 , Ulrike Fillinger  4 , Rachel Pullan  3 , Doris Njomo  1
Affiliations
Randomized Controlled Trial

Better floors, better health: a theory of change for an improved household flooring intervention in rural communities in Kwale and Bungoma counties, Kenya

Stella Kepha et al. BMC Public Health. .

Abstract

Background: Household flooring is increasingly being investigated as a determinant of health, however the pathways through which flooring may impact health and wellbeing are not yet well understood. The SABABU study is a cluster-randomised controlled trial evaluating the impact of an improved flooring intervention on soil-transmitted helminthiasis, tungiasis, and enteric infections in Bungoma and Kwale counties, Kenya. This paper presents the findings from a theory of change development process that was undertaken as part of the formative research phase of the SABABU project.

Methods: A co-creation workshop (n = 1), stakeholder meetings (n = 2), and community meetings (n = 2) were held with a range of participants including community members (n = 36), village-level leaders (n = 28), and local government stakeholders (n = 14) to draft and refine the theory of change framework. These meetings were informed by a previous formative research phase conducted in study communities - comprised of household observations, in-depth interviews, and focus group discussions with community members - to investigate daily routines, use of space within homes, and attitudes towards home improvement.

Results: The theory of change framework demonstrates how the improved household flooring intervention aims to 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 psychological 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.

Conclusion: This study presents a theory of change framework mapping the pathways through which an improved flooring intervention may impact health and wellbeing. The results 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.

Keywords: Enteric; Housing Flooring; STH; Theory of Change; Tungiasis.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Ethical approval for this study was obtained from the Kenya Medical Research Institute (KEMRI) Scientific and Ethics Review Committee (SERU No.4157) and the London School of Hygiene & Tropical Medicine (LSHTM) Ethics Committee (22916). All research activities were undertaken in accordance with the Declaration of Helsinki. Written informed consent to participate was obtained from all subjects. Subjects who were unable to read or write gave informed consent through a thumb print and had the consent form countersigned by a literate individual who witnessed the consenting process and who was not part of the SABABU study team. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Map of Kenya highlighting sub-counties in which study sites were located
Fig. 2
Fig. 2
The SABABU theory of change framework
Fig. 3
Fig. 3
SABABU household flooring intervention cascade
See this image and copyright information in PMC

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