Integrated Health, education and environmental (HEE) intervention to optimise infant feeding practices through schools and Anganwadi networks in India

婴儿早期和儿童期是对环境和营养摄入敏感的关键时期，在此期间，生长、发育和健康在整个生命过程中和在几代人之间形成模式。这一时期的营养不良可以预测感染、发育迟缓和早期认知发育不良以及非传染性疾病的风险，但全球27%的5岁以下儿童营养不良，儿童肥胖症正在上升（1990年为4.2%; 2010年为6.7%;估计2020年为9.1%）。印度面临着儿童营养不良的三重负担：48%（6100万）的五岁以下儿童发育不良（占世界总数的三分之一;所有国家中最高），儿童肥胖症正在上升（占所有五岁以下儿童的15%），大多数人缺乏微量营养素（70%的五岁以下儿童贫血）。世界银行指出，营养和健康教育的优先地位不足是取得进展的障碍，而2016-2030年全球战略强调需要整合多部门的推动因素，解决教育、性别、卫生、水、农业和营养问题（每个妇女，每个儿童）。印度政府一直在通过三名一线工作人员骨干实施关键的营养和行为改变干预措施，但障碍包括外展、卫生水平不一、社会不平等（按性别和种姓）以及就地安置的可行性和有效性。从社会生态角度来看，这些多重推动因素在个人、家庭、社区和环境层面发挥作用。头1000天的营养（我们的重点是6-24个月的婴幼儿）可以通过获得足够的饮食多样性、清洁水、卫生设施和烹饪燃料以及所有家庭成员的文化规范和教育来形成。本研究提出了一个五阶段的参与性和跨学科的研究，探讨影响IFYC喂养方式和营养的健康-教育-环境（HEE）因素。其目的是为印度农村地区的青年综合培训班（6- 24个月）制定一套适合社会文化的、有针对性的、综合的和跨学科的高等教育方案，并测试干预措施的可接受性。我们的合作方法包括来自UCL的跨学科团队（横跨儿童健康研究所，教育研究所和工程科学学院）和专业知识;拯救儿童-印度，印度理工学院，新德里（IIT-Delhi）和贾瓦哈拉尔·尼赫鲁大学，新德里（JNU）。此外，我们还确定了四个非政府组织伙伴机构，沿着英国印度侨民成员提供背景和方案咨询。这种合作优先考虑在地方一级将现有的和个别的政府方案纳入高等教育一揽子计划的设计。为了实现这一目标，我们将与班斯瓦拉地区的选定村庄以及社会生态框架各级的利益攸关方进行接触。我们的地方合作伙伴关系将从Anganwadi中心和学校网络中识别，培训和支持当地的“社区冠军”，然后与参与学校建立“社区教育和创新中心”，但与现有系统相关联。社区冠军和英国-印度PPI小组将被邀请在24个月的研究过程的每个阶段做出贡献，从研究设计到传播。总部位于印度的研究团队和社区冠军合作伙伴关系将收集有关IFYC喂养实践，教育，卫生以及当地能源和水的获取的定性数据。在数据分析过程中，所有合作伙伴将开会，积极地将跨学科的研究结果汇集在一起，进行关联绘图，最终形成创新的高等教育一揽子计划的设计。高等教育方案将根据现有政府举措的要求量身定制，未来的资金申请将探索如何将高等教育方案扩大到印度其他邦。

Early infancy and childhood poses a crucial period of sensitivity to the environment and nutritional intake, when growth, development and health are patterned throughout the life-course and across generations. Malnutrition in this period can predict risk of infection stunting and poor cognitive development in early life and NCDs yet 27% of children globally under 5 are undernourished and childhood obesity is rising (4.2%-1990; 6.7%-2010; estimated 9.1%-2020). India faces a triple burden of childhood malnutrition: 48% (61 million) under-five's are stunted (one-third of the world's total; highest among all nations), childhood obesity is on the rise (15% of all under-five children), and most have a micronutrient deficiency (70% of the under-fives are anaemic). The World Bank identified under-prioritisation of nutrition and health education as a barrier to progress while the 2016-2030 global strategy emphasises the need to integrate multisector enablers that address education, gender, sanitation, water, agriculture and nutrition (every woman, every child). The Government of India has been implementing key nutrition and behaviour change interventions through three cadres of frontline workers but barriers include outreach, variable levels of sanitation, social-inequity (by gender and Caste) and the feasibility and effectiveness of localised integration. From a socio-ecological viewpoint, these multiple enablers operate at the individual, household, community and environmental level. Nutrition in the first 1000 days (our focus infant and young child (IFYC) 6-24 months) can be shaped by access to adequate dietary diversity, clean water, sanitation and cooking fuels, and also the cultural norms and education of all household members. This study proposes a Five-Phase participatory and inter-disciplinary study to explore the Health-Education-Environment (HEE) factors influencing IFYC feeding practices and nutrition. The aim is to develop a socio-culturally appropriate, tailored, integrated and interdisciplinary HEE package aimed at the IFYC (6- 24 months) in rural India and test the acceptability of the intervention. Our collaborative approach includes an interdisciplinary team from UCL (across the Institute of Child Health, Institute of Education and Faculty of Engineering Sciences) and expertise from; Save the Children- India, The Indian Institute of Technology, New Delhi (IIT-Delhi) and Jawaharlal Nehru University, New Delhi (JNU). Additionally, we have identified four NGO partner institutions to provide contextual and programmatic advice along with members from the British Indian diaspora. This collaboration prioritises the integration of existing and individual government programmes at a local level in the design of this HEE package. To achieve this goal, we will engage with selected villages in the Banswara region and with stakeholders across all levels of the socio-ecological framework. Our local partnership will identify, train and support local 'community champions' from a network of Anganwadi Centres and schools and later establish 'community education and innovation hubs' with participating schools but linked into existing systems. Community champions and the British-Indian PPI panel will be invited to contribute at each phase of the 24 month research process, from study design to dissemination. The India-based research team and community champion partnership will collect qualitative data about IFYC feeding practices, education, sanitation and access to energy and water in the local context. During data analysis, all partners will meet to actively draw together the interdisciplinary findings in a linked mapping exercise that will ultimately shape the design of an innovative HEE package. The HEE package will be tailored to the requirements of existing government initiatives and future funding applications will explore how the HEE package can be scaled up to additional India state