Household Concrete floors as a health measure in sustainable development

In urban centers within developing nations, concrete is frequently everywhere: Streets, houses, patios and roofs. Some days it seems difficult to find a patch of green.

All this concrete has a health benefit, however: interrupting the spread of disease and parasites. As concrete is swept, washed and rained on, many reservoirs of pathogens and parasites – accumulations of soil and-, trash – are washed away. There isn’t much open defecation as houses have toilets and cities have sewer systems. When urban people and pets enter homes – shoes, hands, and paws are cleaner and less likely to carry pathogens and parasites than their counterparts in the rural countryside who walk on dirt paths.

Diarrheal disease kills an estimated 1.8 million people each year, the majority of whom are under five years of age; 3 million children die from parasitic diseases. Infected but surviving children face the complications of malnutrition and anemia which lead to physical stunting and slow cognitive development. Infected children attend school less and exhibit diminished school performance. These challenges reduce their opportunities to develop into productive, self-sufficient adults.

Many parasites and pathogens live in feces and soil and are transmitted to humans when ingested or touched. Fecal matter and parasites can enter houses on shoes, on animals, in unclean water and from unclean babies. Fecal matter tends to remain on dirt floors: it is difficult to see and dirt floors are hard to clean. Consequently, young children living and playing on dirt floors are more likely to ingest fecal materials and come in contact with parasites than children living on concrete floors.

The Mexican Government, under a program called Piso Firme, has installed concrete floors in over 300,000 homes of disadvantaged families living in urban slums. Approximately $150.00 in concrete is provided by the government – delivered to the homes by concrete trucks; labor for leveling off the wet concrete is provided by the family. This is a one-time cost that will provide benefit indefinitely.

Housing, Health and Happiness, a World Bank study, shows that the Piso Firme concrete floor project has achieved remarkable results in improving young children’s health and family welfare. The study shows that covering dirt floors with concrete leads to a 78% reduction in parasitic infestations, 49% reduction in diarrhea, 81% reduction in anemia and a 36 to 96 percent improvement in cognitive development in children. For the adults of the family, the concrete floors led to a 59% increase in satisfaction with housing, a 69% increase in satisfaction with the quality of life, a 52% reduction in depression and a 45% reduction in perceived stress.

However, the authors of the study advise caution in assuming that one will achieve the same results in rural settings. They point out that the treatment and control groups in their study lived in an urban setting with access to safe water, and the children were well nourished. Covering a dirt floor with concrete in a rural setting is less likely to have as much of an effect – as children have many other ways to come in contact with parasites and pathogens in the countryside’s unpaved streets, farm fields, domestic animals and potentially unsafe water supplies. Undernourished children are also more susceptible to infection and infestation.

Other studies argue that concrete floors are an effective intervention against Chagas disease, hookworm, and sand fleas. However, there is a steep cost to concrete floors for many poor families and so these studies point out that wearing enclosed shoes and maintaining good personal hygiene are also important interventions – as are keeping domesticated animals and pets away from homes in endemic disease regions.

A study from Nigeria indicates that enclosed footwear can reduce sand flea (the cause of tungiasis) infestation by 50%, and that providing concrete floors would reduce sand flea infestation by almost 75%. They also discovered that hygiene education, soap and sufficient water for hand washing and bathing lead to better overall hygiene standards that indirectly led to a lowering of infection. They suggested that eliminating disposal of waste in public areas and family compounds would reduce the quantity of sand fleas around homes. The authors therefore recommend an integrated approach to combating infection of combining hygiene education, control and containment of animals, housing improvements (including concrete floors) and health education.

What should be done first to improve child health?

Based upon these studies, concrete floors should not be a donor or NGO’s first intervention against pathogens and parasites in a rural setting. If the goal is to get children healthy quickly – and keep them healthy, then the Tier 1 activities are the most important:

Preventing Diarrhea in Children: What's First?

§ hygiene education

§ personal hygiene regimen

§ sufficient clean water for hand washing and bathing

§ hand washing

§ breastfeeding

§ point of use water purification

§ safe water storage

§ kitchen hygiene

These interventions are the quickest acting, the easiest for beneficiaries to understand and adopt, and the least expensive for the beneficiary (no cost/low cost).

The next intervention in this step-by-step approach would be a community sanitation initiative which would include consciousness raising about sanitation (open defecation in particular).

Preventing Diarrhea in Children: What's Next?

Culturally appropriate latrine construction and creating an open defecation (ODF) free environment would follow. With latrine construction, the intervention costs rise. Studies also point out that latrines may not be maintained by the community or individual households, and that in many cases cultural needs aren’t taken into account when latrines are designed resulting in people not wanting to use them.

When the community has blocked the basic routes of disease transmission through using Tier 1 level Health and Hygiene interventions including containing animals, stopping human feces from contaminating the footpaths of the community, and a clean hands consciousness, and a sanitation program – concrete floors will be a good idea.

After concrete floors, the final intervention would be a community water supply – whether a central community well or piped in water. Although water supply has many advantages such as being a labor saver and providing sufficient bathing water – it is not a substitute for point of use water purification, safe water storage, kitchen hygiene and hand washing since water can become re-contaminated between the well and consumption at a number of different steps along the way. Wells and piped-in water are also a new magnitude of cost – in the tens of thousands of dollars.

Studies on community wells and piped in water systems are not promising; recent research finds little evidence to substantial health impacts from rural water infrastructure. An expensive investment, they often fall into disrepair quickly due to poor maintenance. Consequently it is essential that the community is well enough organized to be able to take over the maintenance of somewhat technologically sophisticated, donor-funded water infrastructure project.

If you are planning to implement a concrete floor program, some things to consider:

§ Cost: meet with a builder to ascertain minimum standards (slab thickness and ratio of cement to sand to gravel) and projected costs.

§ Materials: Have the builder help you with a simple formula for calculating material quantities for different sized homes.

§ Specifications: Have the builder give you a list of specifications that the homeowner will need to comply with prior to pouring concrete (leveling, etc.).

§ Cost sharing: will the floors be provided for free – or will the beneficiaries participate in the cost?

§ Access: will you be able to get materials to the houses?

§ Labor: who will provide the labor for installing the floors? Do they have the requisite skill sets?

§ Distribution: who will receive flooring and who won’t?

References:

Cattaneo MD; Galiani S; Gertler PJ; Martinez S; Titiunik R, 20070, “Housing, Health and Happiness”, World Bank Policy Research Working Paper 4214, April 2007.

Hotez P, Hookworm and Poverty, 2008, New Your Academy of Sciences 1136: 38-44.

Collins G, McCleod T, Konfor NI, Lamnyam CB, Ngarka L, Njamnshi NL, Tungiasis: A Neglected Health Problem in Rural Cameroon, 2009, International Journal of Collaborative Health on Internal Medicine & Public Health Vol. 1 No. 1.

Ugbomoiko US, Ariza L,, Ofiezie IE, Heukelbach J, Risk Factors for Tungiasis in Nigeria: Identification of Targets for Effective Intervention, 2007, PLoS Negl Trop Dis 1(3): e 87. Dol:10:1371/journal.pntd.0000087.

Pilger D, Schwalfenberg S, Heukelbach J, Witt L, Mencke N, et al. Controlling Tungiasis in an Impoverished Community: An Intervention Study, 2008, PLoS Negl Trop Dis 2(10): e 3247. Dol:10:1371/journal.pntd.0000324.

Josepha JK, Bazileb J, Mutterc J, Shina S, Ruddlec A, Iversa L, Lyona E, Farmera P, Tungiasis in rural Haiti: a community-based response, 2006, Transactions of the Royal Society of Tropical Medicine and Hygiene, Volume 100, Issue 10, Pages 970-974, October 2006.

Muehlenab M, Feldmeiera H, Wilckea T, Wintera B, Heukelbach J, Identifying risk factors for tungiasis and heavy infestation in a resource-poor community in northeast Brazil, 2006, Transactions of the Royal Society of Tropical Medicine and Hygiene, Volume 100, Issue 4, Pages 371-380 (April 2006).