Building healthy communities in urban Brazilian slums

城市化是当今主要的公共卫生挑战之一。在低收入城市，与受污染的水和食物以及有限的卫生设施有关的传染病与空气和水污染的风险增加同时存在。社会暴力往往是流行病。年轻人是最脆弱的群体之一，但往往也是在决定自己未来时发言权最小的群体。这个项目所在的巴西萨尔瓦多市就是这些问题的典型例子。财政限制意味着迫切需要在当地制定可持续的干预措施，以改善这些环境中的多种健康结果，在选择干预措施时，我们需要一个针对健康状况不佳的共同驱动因素的框架。以社区为基础的缓解措施还必须以当地对风险决定因素的了解为基础，并加以管理，以确保这些知识能够适应当地情况。因此，在这里，我们采用了一种基于适应性管理的方法，通过专家和当地利益相关者之间的共识，反复重新评估一个初步的、基于证据的管理计划，并在适当的情况下，根据持续收集的额外证据进行修改（调整）。我们的目标是提高萨尔瓦多社区的福祉，并为世界各地城市贫民窟的类似项目提供蓝图。我们将重点讨论代表三种不同传播途径的传染病的相互影响，以及减轻其风险的干预措施。1)钩端螺旋体病和肠（肠）感染，在环境卫生条件差的地方通过老鼠、水和土壤传播。2)寨卡、登革热和基孔肯雅热，由蚊媒病原体引起，其风险与蚊子的侵扰和繁殖有关。3)直接传播感染，包括主要在国内传播的结核病，以及包括艾滋病毒在内的性传播感染。不同目的的干预措施将在基于证据的基础上，由由居民自己组成的小组从一系列可能性中选择，特别关注年轻人，由我们的团队提供便利。工作将以3个城市贫民窟社区为基础，我们已经在这些社区收集和分析了一系列传染病的数据，与居民团体建立了关系，并充分热情地致力于该计划。我们将评估干预措施之前、期间和之后疾病发病率的变化，以及居民的知识、态度和做法等多个方面的数据，公共、家庭周边和家庭地区的环境数据，露天下水道和垃圾积聚的存在、程度和位置，以及相关的水/土壤样本，以量化病原体负荷。在项目开始时，将在每个社区建立一个由居民和专家组成的工作组，他们将严格评估当前的调查结果，以确定和指导获取选择干预措施所需的额外数据。因此，在第一年，每个社区将使用以前和新收集的数据作为确定关键干预措施和评估干预措施的相关指标的基础。在第二个6个月内将收集进一步的干预前指标。然后，在第一年结束时，将实施针对社区的干预措施——环境干预措施（如关闭下水道）或行为干预措施（如改善卫生访问者的机会），随后将收集进一步的数据。再过9个月，管理小组将对干预措施的有效性进行基于证据的评估，反映结果。这将导致重新考虑、修改一套干预措施（或决定维持现状），随后进一步收集数据，并最终对干预措施以及导致其最初产生和随后适应的过程进行全面评估。

Urbanisation provides one of today's major public health challenges. In low income cities, infectious diseases, linked to contaminated water and food and limited sanitation, exist alongside increased risks of air and water pollution. Social violence is often epidemic. The young are amongst the most vulnerable but also often those with least voice in decisions about their future. The city of Salvador, Brazil, where this project is based, exemplifies these problems. Financial constraints mean that there is an urgent need for sustainable, locally-developed interventions to improve multiple health outcomes in these settings, and in selecting interventions, we need a framework that targets the common drivers of poor health. Community-based mitigations must be based, also, on local knowledge of determinants of risk, and managed to ensure that they can be adapted to the local context. Here, therefore, we adopt an approach based on adaptive management, through which an initial, evidence-based management plan, developed through consensus between experts and local stakeholders, is repeatedly re-assessed and, if appropriate, modified (adapted) in the light of additional evidence, collected on an on-going basis. Our aim is to enhance wellbeing in communities in Salvador, and provide a blueprint for similar projects in urban slums worldwide. We will focus on the interacting effects of infectious diseases that represent three different transmission routes, and on interventions to mitigate their risk. 1) Leptospirosis and enteric (gut) infections, which are environmentally transmitted via rats, water and soil where sanitation is poor. 2) Zika, Dengue, and Chikungunya, caused by mosquito-borne pathogens whose risk is associated with mosquito infestation and reproduction. 3) Directly transmitted infections, including Tuberculosis whose transmission is predominantly domestic, and sexually transmitted infections including HIV. Interventions varying in purpose will be chosen from a range of possibilities on an evidence-based basis, by groups comprising the residents themselves, with a special focus on youths, facilitated by our team. Work will be based in 3 urban slum communities where we have already collected and analyzed data on a range of communicable diseases, having established relationships with residents' groups, fully and enthusiastically committed to the program. We will evaluate changes in incidence rates for diseases before, during and after interventions, as well as data on multiple aspects of knowledge, attitudes and practices of residents, environmental data in public, peri-domestic, and domestic areas, the presence, extent and location of open sewers and trash accumulation, and relevant water/soil samples to quantify pathogen loads.At the beginning of the project, in each community, a working group of residents and experts will be established, who will critically evaluate current findings to identify and guide acquisition of additional data required to choose interventions. Thus, over the first year, each community will use the previously- and newly-collected data as a basis for defining key interventions and relevant metrics to evaluate the interventions. Further pre-intervention metrics will be collected during the second 6 months.Then, at the end of the first year, community-specific interventions will be implemented - either environmental (eg closing sewers) or behavioural (eg improving access to health visitors), following which further data will be collected. After a further 9 months, the management groups will undertake an evidence-based assessment of the interventions' effectiveness, reflecting on the outcomes. This will lead to a re-considered, modified, set of interventions (or a decision to maintain the status quo), followed by further data collection, and ultimately to a full assessment of both the interventions, and of the processes that led to their initial genesis and subsequent adaptation.