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、优质卫生服务和社区行动，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；在卫生系统研究中，重点主要放在供应方，很少注意这一等式的需求方。性别角色和关系在儿童健康和营养状况方面发挥着重要作用。在许多撒哈拉以南非洲(SSA)地区，儿童保育和保健主要是女性的领域，男性基本上缺席或仅在被认为严重或严重的情况下参与。同样，无论是有意还是无意，南非南部非洲国家的儿童健康方案主要侧重于妇女。虽然妇女被认为对孩子负有责任，但矛盾的是，她们必须与包括男子在内的其他家庭成员谈判决策和资源。由于这些方案只侧重于妇女，而不考虑家庭动态或更广泛的社会背景，因此可能无意中加强了有害的性别差别和与儿童健康和营养有关的做法。有证据表明，如果考虑男子的作用并将其转变为确认更公平的两性关系，以妇女为目标的方案可能会更有效。例如，在印度新德里的“孕期男性”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，干预的结果有所改善。同样，南非林波波的形象干预活动采用参与性办法，让男性参与，并挑战与亲密伴侣暴力和艾滋病毒传播有关的行为；结果，即使在实施干预措施两年后，亲密伴侣实施身体暴力和性暴力的风险也大大降低。非正式住区(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；随着城市化程度的提高，这一数字将会上升。在他们的整个生命过程中，这些人口遭受的疾病负担比一般人口高得不成比例。在将开展这项工作的肯尼亚，研究表明，首都内罗毕的贫民窟的儿童和五岁以下儿童死亡率高于全国、城市和农村的平均水平，寻求护理的道路漫长而复杂；往往涉及在使用正式医疗设施之前或同时使用非正式医疗保健系统。此外，在正规卫生系统接受治疗后，患病或康复的儿童将“出院”回到他们的家庭和社区。如果没有对家庭和社区一级运作的复杂性和动态的适当了解，医院发起的干预措施可能不那么有效和可持续。拟议的工作侧重于卫生系统的需求方面，试图回答参与性方法是否以及如何能够加强男性对儿童健康和营养的参与，以获得更好的结果。具体地说：1)了解男性和女性对男性在儿童健康中实际、期望和感知的作用以及相关障碍和促进者的观点；以及2)使用深入参与的方法，让男性和其他利益攸关方共同创建一套针对具体情况、可行和可扩展的男性参与干预方案，以改进和更迅速地提供卫生服务。

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.