Understanding male engagement in child health and nutrition in urban informal settlements: A formative participatory exploration

改善儿童健康需要初级预防、优质保健服务和社区行动，以解决健康和福祉的根本驱动因素。虽然人们认识到卫生系统既包括政策、服务和干预措施的提供者，也包括打算从中受益的社区和家庭;但在卫生系统研究中，重点主要放在供应方，很少注意到这一等式的需求方，性别角色和关系在儿童健康和营养状况中发挥重要作用。在撒哈拉以南非洲的许多环境中，儿童保育和保健主要是女性的领域，男子基本上不参与或只参与被认为严重或严重的情况。同样，撒哈拉以南非洲国家的儿童保健方案有意或无意地主要侧重于妇女。虽然妇女被认为对子女负有责任，但矛盾的是，她们必须与包括男子在内的其他家庭成员就决策和资源进行谈判。这些方案只注重妇女，而不考虑家庭动态或更广泛的社会背景，可能会无意中加强与儿童健康和营养有关的有害的性别分工和做法。有证据表明，如果考虑到并改变男子的作用，以确认更公平的两性关系，针对妇女的方案可能会更有效。例如，在印度新德里的“产妇中的男子”方案中，鼓励丈夫在妻子的产前和产后护理中发挥积极作用，与对照组相比，干预措施的结果有所改善。同样，在南非林波波省实施的IMAGE干预措施采用参与性办法，让男子参与进来，并对与亲密伴侣暴力和艾滋病毒传播有关的行为提出质疑;结果，即使在采取干预措施两年后，亲密伴侣实施身体暴力和性暴力的风险也大幅降低。非正规住区（俗称“贫民窟”）居住着世界城市人口的很大一部分，特别是在低收入和中等收入国家;随着城市化进程的加快，这一数字必将上升。这些人口在其一生中，与一般人口相比，承受着不成比例的更高的疾病负担。在将开展这项工作的肯尼亚，研究表明，首都内罗毕贫民窟的儿童和五岁以下儿童死亡率高于全国、城市和农村平均水平，寻求保健的途径漫长而复杂;往往涉及在使用正规保健设施之前或同时使用非正规保健系统。此外，在正规卫生系统接受治疗后，患病或康复的儿童被“送回"其家庭和社区。如果不适当了解家庭和社区一级运作的复杂性和动态，医院发起的干预措施很可能不那么有效和可持续，重点放在卫生系统的需求方面，拟议的工作旨在回答参与性方法是否以及如何加强男性参与儿童健康和营养，以取得更好的成果。具体而言：1）了解男子和妇女对男子在儿童健康方面的实际、期望和感知作用的看法，以及相关的障碍和促进因素; 2）采用深入的参与性方法，使男子和其他利益攸关方参与共同创建一个针对具体情况的、可行的和可扩展的男子参与干预一揽子计划，以改善和更及时地提供保健服务。

Improving child health requires primary prevention, quality health services and community action to address the underlying drivers of health and wellbeing. Whilst there is recognition that the health system encompasses both the suppliers of policy, services, and interventions, and the communities and households intended to benefit from them; in health systems research the focus has primarily been on the supply-side with little attention given to the demand-side of this equation.Gender roles and relations play an important role in child health and nutritional status. In many sub-Saharan African (sSA) settings, childcare and health is predominantly a female domain with men largely absent or only involved in perceived severe or serious cases. Similarly, intentionally or unintentionally, child health programmes in sSA countries predominantly focus on women. While women are perceived as responsible for children, paradoxically they must negotiate decision-making and resources with other family members, including men. By exclusively focusing on women without considering family dynamics or the broader social context, these programmes may inadvertently reinforce harmful gender divisions and practices related to child health and nutrition. Evidence suggests that programmes targeting women might be more effective if men's roles are considered and transformed to affirm more equitable gender relations. For example, in the 'Men in Maternity' programme in New Delhi, India, husbands were encouraged to play an active role in their wives' antenatal and post-natal care with improved outcomes in the intervention compared to the control groups. Similarly, the IMAGE intervention in Limpopo South Africa used a participatory approach to engage men and challenge behaviours in relation to intimate partner violence and HIV transmission; resulting in a significant reduction in the risk of physical and sexual violence by an intimate partner even up to two years after introduction of the intervention. Informal settlements (referred to colloquially as 'slums') house a significant proportion of the world's urban population particularly in low- and middle-income countries; with this number set to rise with increasing urbanization. Throughout their life-course, these populations suffer from disproportionately higher burden of illness compared to the general population. In Kenya where this work will be undertaken, studies show that slums in the capital city of Nairobi have higher child and under-five mortality rates compared to the national, urban and rural averages with long and complex pathways to seeking care; frequently involving the use of informal systems of healthcare prior to, or concurrently with, engaging formal health facilities. Furthermore, following treatment in the formal health system, ill or recovering children are 'discharged back' into their homes and communities. Without proper understanding of the complexities and dynamics operating at the household and community levels, hospital-initiated interventions are likely to be less effective and sustainable.Focusing on the demand-side of the health system, the proposed work seeks to answer if and how participatory approaches can strengthen male involvement in child health and nutrition for better outcomes. Specifically:1) To understand men's and women's perspectives of the actual, desired and perceived role of men in child health, and related barriers and facilitators; and 2) Use an in-depth participatory approach to engage men and other stakeholders in co-creating a context-specific, feasible, and scalable male engagement intervention package for improved and more responsive health service delivery.