Effect of urban vs rural context on effectiveness of a community intervention to prevent diarrhoea and stunting in young children in Mali

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The ProblemGlobally 1.7 billion diarrhoea episodes result in approximately 2 million deaths in 2010.1 Regionally, Africa has the greatest burden. Alongside poor infant feeding, diarrhoea diseases also contribute to infant malnutrition.2-4 Despite new vaccines, treatments and public health measures,3 diarrhoea and malnutrition remain considerable public health problems in low- and middle-income countries (LMIC). The period when a child starts eating solids (usually 6-24 months called complementary food (CF)), is associated with the highest rates of diarrhoea: over 50% of all diarrhoea deaths occur at 6-11 months.1 Most low-income households in LMIC cook ingredients at home or obtain food from informal street food-sellers who prepare the goods in their homes. Therefore home food handling, preparation and storage determine the scale of food contamination.Although many studies explore the effects of improved water supply, hygiene and nutrition of infant diets on infant diarrhoea and growth development, much less attention paid to studies of food safety remain scarce. Research in this area has been too general to reduce diarrhoea through food contamination. The World Health Organisation (WHO) advocates targeted interventions to support CF safety and hygiene. Ideally CF safety needs to be accompanied with achieving optimal dietary intake for young children, which also remains a challenge in LMIC. Research shows that infant health and safety advice has limited impact on behaviour change unless accompanied by means to motivate and empower mothers in the community. Yet previous interventions targeting diet or diarrhoea have seldom drawn on cultural dramatic arts and community assets to motivate behaviour change. African communities have a particularly strong cultural heritage to underpin such potential impact.Our AimWe propose a low-cost, scalable, and adaptable community intervention to reduce diarrhoea and improve the growth of young children in urban-poor and rural Mali. We will assess the effects in both settings, to inform replication and scaling of the intervention, because the dynamics of community life vary in each.Our Previous WorkWe combine two complementary interventions shown to be effective elsewhere in LMIC. A trial in the Gambia (developed through former work in Bangladesh, Nepal and Pakistan) evaluated efforts to improve hygiene and safety of CF, while a trial in Kenya evaluated a community programme to improve breastfeeding and weaning food content.Our PlanAfter adaptation with communities, our intervention will empower local families to implement behaviour change. It will include campaign-like activities such as culturally relevant dramatic arts (drama, songs, stories), public meetings, certifications, and home visits, delivered by a small team: 5 days of community campaign visits dispersed during 35 days and including home visits by trained female volunteers, plus a reminder campaign day at 9 months. We will allocate 120 urban and rural sites in Mali by chance to receive the intervention, or not, and assess 27 households in each site after 15 months. The study is designed to quantify the influence of urban vs rural context, and to examine other societal influences (e.g. household poverty, women's work, and education, etc). Using observations, interviews, discussion groups, surveys and laboratory tests we will compare the implementation of the intervention in urban-poor and rural settings. Importantly, the intervention is designed to be sustainable through peer-education among mothers and older female volunteers (demonstrated after 32 months in Gambia), thus requiring only small levels of coordination resources from central government.