Sustainable day-care for 1-4 year olds in disadvantaged urban communities in Dhaka, Bangladesh

我们的合作伙伴CIPRB通过一项自然实验表明，与没有接受日托的儿童相比，农村地区1-4岁儿童的社区日托有效地将全原因死亡、溺水和受伤的风险降低了44%、82%和88%。我们希望调整这一模式，以便能够适当、可行和可持续地提供这种模式，使城市弱势社区受益。低收入国家(LIC)正在经历快速且失控的城市化。这在孟加拉的达卡可以清楚地看到，那里的城市人口年增长率为3.6%[6]，估计有400万居民生活在贫民窟中。城市化正在改变性别动态：达卡22%的女性现在外出工作(11%非贫民窟)[9]。由于贫民窟的家庭支持有限，妇女要么把孩子留给年长的兄弟姐妹--通常是后来辍学的姐妹--要么就是邻居。这种有限的监督导致高伤害率、恶劣的卫生状况和有限的营养，导致50%的贫民窟儿童发育迟缓(33%非贫民窟儿童)。托儿所提供了一种全面的解决方案，使妇女能够工作，同时知道她们的孩子是安全的、受到照顾的，并有机会获得儿童早期发展(ECD)。我们的合作伙伴CIPRB在孟加拉国农村地区提供日托服务方面拥有丰富的经验[9]。在CIPRB农村模式的基础上，我们计划开发和完善一个可持续的日托模式，该模式基于幼儿发展和改善1-4岁儿童营养和卫生的原则。财务可持续性是长寿和扩大规模的关键。我们计划在贫民窟附近设立日托中心，以便以适当的费用向非贫民窟社区的父母提供服务。这一方法旨在促进两个社区之间的融合，潜在地促进贫民窟儿童的社会流动。目标和方法：1)为了了解日托需求的范围和性质，我们将对200个来自贫民窟和非贫民窟社区的5岁以下儿童家庭进行调查，并进行定性访谈，以了解妇女、照顾者、男子和社区领导人对托儿的看法。2)共同制定一个原型、综合的、自给自足的儿童日托模式我们将建立一个由儿童保育专家、社区代表、当地政府官员、捐助者和(I)非政府组织组成的技术工作组。该小组将利用CIPRB、(I)非政府组织模型和水利部(不包括在本提案中)正在进行的系统审查的结果来开发原型模型和所需的所有材料。该小组还将制定一份变革理论草案来指导评估。3)测试和完善综合自我维持模式，我们将实施为期六个月的日托模式。在此期间，我们会协助一群日间托儿所的使用者和员工反思该模式的运作情况，并作出改善。我们的定性研究人员将观察这一过程，并采访用户，以了解如何进一步改进该模型。我们将评估模式成本，以及非贫民窟日托服务使用者的费用可在多大程度上支持可持续提供服务。4)为设计一项更大规模评估的试点研究，我们将评估日托服务模式的可行性，然后改进在日托服务使用者和潜在对照小组中招募、评估和跟进的方法。这将需要在同一样本的200个家庭中重复调查。我们还将在儿童开始接受日托时和六个月后对他们进行评估。我们将使用我们的整体分析来完善我们的变革理论。在整个研究过程中，我们将与当地政府和捐赠者密切接触，以了解并影响在达卡扩大日托规模的计划，目标是城市穷人。我们将从我们的变革理论和与政策制定者的讨论中确定最合适的结果衡量标准。我们预计这些疾病将包括ECD、发育迟缓和受伤。

Our partners, CIPRB, have shown, through a natural experiment, that community day-care for 1-4 year old children in rural areas is effective in reducing risk of all-cause mortality by 44%, drowning by 82% and injuries by 88%, compared to children not in day-care [9]. We wish to adapt this model so it can be appropriately, feasibly and sustainably delivered to benefit urban disadvantaged communities. Low-income countries (LICs) are experiencing rapid and uncontrolled urbanisation. This can clearly be seen in Dhaka, Bangladesh with an annual urban population growth of 3.6% [6], and an estimated 4 million inhabitants living in slums. Urbanisation is changing gender dynamics: 22% of women in Dhaka now work outside the home (11% non-slum) [9]. With limited extended family support in slums, women must either leave children with elder siblings - often sisters who then drop-out of school - or neighbours. This limited supervision contributes to high rates of injuries, poor hygiene and limited nutrition, resulting in 50% of slum children suffering stunting (33% non-slum). Child day-care presents a holistic solution, allowing women to work whilst knowing their children are safe, cared-for and have opportunities for early childhood development (ECD). Our partners, CIPRB, have extensive experience of delivering day-care in rural Bangladesh [9]. Building on CIPRB's rural model we plan to develop and refine a sustainable day-care model based on principles of ECD and improving nutrition and hygiene for 1-4 year olds. Financial sustainability is key for longevity and scale-up. We plan to place day-care centres adjacent to slums so services at a suitable fee can be provided to parents in non-slum neighbourhoods. This approach is designed to promote integration between the two communities, potentially facilitating social mobility for slum children. Objectives and methods, to:1) Understand the extent and nature of demand for day-care we will survey 200 households with children under 5 from slum and non-slum communities, and conduct qualitative interviews to understand perceptions of childcare among women, carers, men and community leaders. 2) Co-produce a proto-type integrated, self-sustaining, child day-care model we will establish a technical working group of childcare experts, community representatives, local government officials, donors and (I)NGOs. The group will draw on CIPRB's, (I)NGO models and findings of a systematic review being conducted by UWA (not included in this proposal) to develop a prototype model and all materials required. The group will also develop a draft theory of change to guide the evaluation.3) Test and refine an integrated self-sustaining model, we will implement the day-care model for six months. During this time, we will facilitate a group of day-care users and staff to reflect on how the model is working and make changes for improvement. Our qualitative researchers will observe the process, and interview users to understand how to further improve the model. We will assess model costs and the extent that fees from non-slum day-care users can support sustainable delivery.4) Inform the design of a pilot study for a larger evaluation to assess the cost-effectiveness of the day-care model, we will assess the feasibility and then refine methods for recruitment, assessment and follow-up among day-care users and a potential comparator group. This will involve repeating the survey among the same sample of 200 households. We will also assess children when they start at day-care and six months later. We will use our overall analysis to refine our theory of change. Throughout the study we will engage closely with local government and donors to understand and influence plans to scale up day-care across Dhaka, targeting the urban poor. We will identify the most appropriate outcome measures from our theory of change and discussions with policy makers. We expect these will include ECD, stunting and injuries.