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

问题2010年，全球有17亿例腹泻病导致约200万人死亡。2 -4尽管有新的疫苗、治疗和公共卫生措施，3腹泻和营养不良仍然是低收入和中等收入国家（LMIC）的重大公共卫生问题。婴儿开始吃固体食物的时期（通常为6-24个月，称为补充食品（CF））与腹泻发病率最高有关：超过50%的腹泻死亡发生在6-11个月。因此，家庭食品的处理、准备和储存决定了食品污染的程度，尽管许多研究探讨了改善供水、卫生和婴儿饮食营养对婴儿腹泻和生长发育的影响，但对食品安全的研究仍然很少。这方面的研究过于笼统，无法减少食物污染引起的腹泻。世界卫生组织（WHO）提倡有针对性的干预措施，以支持CF的安全和卫生。理想情况下，CF安全性需要伴随着实现幼儿的最佳膳食摄入量，这也仍然是LMIC的一个挑战。研究表明，婴儿健康和安全建议对行为改变的影响有限，除非同时采取措施，激励社区中的母亲并赋予她们权力。然而，以前针对饮食或腹泻的干预措施很少利用文化、戏剧艺术和社区资产来推动行为改变。非洲社区拥有特别强大的文化遗产，可以支撑这种潜在的影响。我们的目标我们提出一种低成本、可扩展和适应性强的社区干预措施，以减少腹泻，改善马里城市贫困和农村地区幼儿的成长。我们将评估在这两种情况下的效果，告知复制和扩展的干预，因为社区生活的动态在each.Our Previous WorkWe结合联合收割机两个互补的干预措施被证明是有效的其他地方在LMIC。在冈比亚的一项试验（通过之前在孟加拉国、尼泊尔和巴基斯坦的工作开发）评估了改善CF卫生和安全的努力，而在肯尼亚的一项试验评估了一项改善母乳喂养和断奶食品含量的社区计划。我们的计划在与社区适应后，我们的干预措施将使当地家庭能够实施行为改变。它将包括类似纪念活动的活动，如与文化相关的戏剧艺术（戏剧、歌曲、故事）、公众会议、认证和家访，由一个小团队提供：在35天内分散进行为期5天的社区活动访问，包括训练有素的女性志愿者的家访，加上9个月的提醒活动日。我们将在马里随机分配120个城市和农村地点，接受或不接受干预，并在15个月后对每个地点的27户家庭进行评估。这项研究旨在量化城市与农村背景的影响，并审查其他社会影响（如家庭贫困、妇女的工作和教育等）。通过观察、访谈、小组讨论、调查和实验室测试，我们将比较城市贫困地区和农村地区干预措施的实施情况。重要的是，干预措施旨在通过母亲和老年女性志愿者之间的同伴教育（冈比亚32个月后的情况证明）实现可持续性，因此只需要中央政府提供少量协调资源。

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.