Social, environmental and policy contexts affecting the feasibility and acceptability of improving household flooring for better health in rural Kenya

Background: Homes with unimproved floors (earth, sand, or clay) are associated with increased risks of soil-transmitted parasites and enteric infections, leading to higher morbidity and reduced quality of life. This study explored the enablers and barriers to adopting improved flooring (sealed, washable, and durable) in three culturally diverse regions of Kenya - Narok, Bungoma, and Kwale - to mitigate disease burdens. Methods: Between August 2021 and July 2022, we conducted 24 focus group discussions with homeowners, stratified by age, gender, and floor type. Additionally, 28 key informant interviews with local government officials, microfinance representatives, and masonry trainers in Kwale and Bungoma provided contextual insights. Transcribed data underwent thematic analysis. Results: In the study areas, most homes were constructed by residents themselves using traditional techniques and locally sourced materials. Despite awareness of the health risks, unimproved floors remained widespread. In Bungoma and Kwale, financial constraints and competing household priorities were primary barriers to flooring improvements, while in Narok, cultural identity contributed strongly to the rejection of changes in traditional houses. Key enablers included perceived health benefits and social status, while feasibility depended on the affordability and availability of materials and skilled labour. Strengthening the role of local artisans and leveraging their social influence were seen as effective strategies to shift perceptions on cost and feasibility. Improved collaboration between health and built-environment sectors could enhance community trust and support environmental disease management. Conclusion: Communities in Kwale and Bungoma were more receptive to improved flooring, while cultural practices and preferences in Narok posed significant adoption challenges. For receptive communities, affordable flooring technologies are critical to overcoming financial barriers, while behaviour change initiatives should address cultural and perceptual concerns. However, clinical evidence on locally generated health benefits is needed to support policy decisions and budget allocations for flooring interventions. Author summary: Many households in rural Kenya still live in homes with earthen floors made of soil, sand, or clay. These floors are difficult to clean and can increase exposure to parasites and germs that cause diarrhoeal diseases, worm infections, and tungiasis, affecting health and quality of life—especially for children. Improving household floors by sealing them with durable, washable materials could reduce these risks, but little is known about whether such improvements are acceptable or feasible for communities. We carried out group discussions with homeowners and interviews with local officials, artisans, and microfinance representatives in three culturally diverse regions of Kenya: Bungoma, Kwale, and Narok. We explored how people build their homes, what they think about improved flooring, and what helps or prevents households from adopting better floors. We found that most homes were self-built using traditional methods and local materials. In Bungoma and Kwale, people recognised the health benefits of improved floors, but financial constraints and competing household needs were major barriers. In Narok, cultural identity and attachment to traditional housing strongly influenced resistance to change. Across all sites, improved floors were seen as desirable when affordable materials and skilled local artisans were available. Strengthening links between health programmes, local builders, and communities could support wider adoption. Our findings highlight that flooring interventions must be culturally sensitive, affordable, and supported by local skills. Generating local evidence on health benefits will be important for informing policy and investment decisions.