Building healthy communities in urban Brazilian slums

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.

We will address the urgent need for sustainable locally-developed interventions to improve multiple health outcomes linked to infectious diseases in low income cities, adopting an adaptive management approach through which an initial, evidence-based plan, developed through consensus between experts and stakeholders, is repeatedly re-assessed and, if appropriate, modified in the light of additional evidence. We will focus on potential comorbidity from infectious diseases with 3 different transmission routes and on interventions to mitigate risk. 1) Leptospirosis and enteric infections, environmentally transmitted. 2) Zika, Dengue and Chikungunya, caused by mosquito-borne pathogens. 3) Directly transmitted infections. Interventions will be chosen by the residents, facilitated by our team - either environmental (eg closing sewers) or behavioural (eg improving access to health visitors).

Work will be based in 3 communities in Salvador Brazil. Biannual serosurveys 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, 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. Initially, communities will use previously- and newly-collected data as a basis for identifying interventions and relevant metrics to evaluate them. Further pre-intervention metrics will be collected during months 3-9. At the end of the first year, community-specific interventions will be implemented and further data collected. After a further 9 months the management groups will undertake an evidence-based assessment of the interventions' effectiveness, leading 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 interventions.

In the broadest sense, the ultimate beneficiaries of this research will be the urban poor in low and middle income countries (LMICs), suffering a grossly disproportionate burden of serious infectious disease, and also those responsible for improving the health of these people. Within the broad and flexible opportunities of the current project, the main beneficiaries will be slum residents, young and adult, who will have the opportunity to choose, develop and evaluate interventions targeting local social and environmental determinants of health to reduce disease burden in the favelas of the Brazilian city of Salvador.
At present, one billion of the world's population lives in slum settlements, comprising 78% of the urban populations from the world's least developed countries. Residents suffer an increased burden of multiple diseases over the course of their lives because of overcrowding and poor living conditions. In the city of Salvador, Brazil, all those diseases are important in their own right, but the project is directly relevant to other slum settings in LMICs, and to the health of these communities more generally.
To decrease this multiple disease burden, interventions should target the social and environmental determinants of health that drive those health challenges. But such interventions are unlikely to be implemented in the short term by government agencies and there is a need to develop specific interventions that are context-specific and based on local evidence and community priorities to decrease the risks faced by slum residents. Community residents and local research assistants (~70) will themselves manage funds for such interventions and establish partnerships with relevant authorities through community working groups, led by young residents. This work will empower community organizations and serve as a base for their sustainable growth.
The participation of young residents in working groups to design and implement interventions will be important for their development as future community leaders. They will participate in research meetings and work closely with sanitation and public health agencies. Through paid internships, courses, and workshops offered by the team and partner agencies, this work supports young adults (>200) to either go into higher education or enter the job market.
The Municipal and State Health Departments and the Center for Control of Zoonoses (CCZ) are keen to improve directives for controlling leptospirosis based on results from the Foundaiton Project. We will collaborate throughout the life-time of the grant and jointly establish geo-technology centers in their units. Data produced through this work will help them introduce participatory approaches into their respective protocols (detailed in Pathways to Impact). Also, Drs Costa and Reis are consultants for health policy in Brazil and will translate knowledge gained in this research project into national policy and guidelines as expected by the Brazilian Ministry of Health (see letter of support).
Results will be disseminated through conventional scientific pathways including peer review scientific publications, presentations at national and international congresses, theses from doctoral and master's students trained in this project through Brazilian fellowships, monthly meetings at the study sites involving community representatives, researchers and stakeholders and annual meetings at the Brazilian Ministry of Health (see letter of support). See also Communication Plan Section.