Understanding male engagement in child health and nutrition in urban informal settlements: A formative participatory exploration

Improving child health requires primary prevention, quality health services and community action to address the underlying drivers of health and wellbeing. Whilst there is recognition that the health system encompasses both the suppliers of policy, services, and interventions, and the communities and households intended to benefit from them; in health systems research the focus has primarily been on the supply-side with little attention given to the demand-side of this equation.

Gender roles and relations play an important role in child health and nutritional status. In many sub-Saharan African (sSA) settings, childcare and health is predominantly a female domain with men largely absent or only involved in perceived severe or serious cases. Similarly, intentionally or unintentionally, child health programmes in sSA countries predominantly focus on women. While women are perceived as responsible for children, paradoxically they must negotiate decision-making and resources with other family members, including men. By exclusively focusing on women without considering family dynamics or the broader social context, these programmes may inadvertently reinforce harmful gender divisions and practices related to child health and nutrition. Evidence suggests that programmes targeting women might be more effective if men's roles are considered and transformed to affirm more equitable gender relations. For example, in the 'Men in Maternity' programme in New Delhi, India, husbands were encouraged to play an active role in their wives' antenatal and post-natal care with improved outcomes in the intervention compared to the control groups. Similarly, the IMAGE intervention in Limpopo South Africa used a participatory approach to engage men and challenge behaviours in relation to intimate partner violence and HIV transmission; resulting in a significant reduction in the risk of physical and sexual violence by an intimate partner even up to two years after introduction of the intervention.

Informal settlements (referred to colloquially as 'slums') house a significant proportion of the world's urban population particularly in low- and middle-income countries; with this number set to rise with increasing urbanization. Throughout their life-course, these populations suffer from disproportionately higher burden of illness compared to the general population. In Kenya where this work will be undertaken, studies show that slums in the capital city of Nairobi have higher child and under-five mortality rates compared to the national, urban and rural averages with long and complex pathways to seeking care; frequently involving the use of informal systems of healthcare prior to, or concurrently with, engaging formal health facilities. Furthermore, following treatment in the formal health system, ill or recovering children are 'discharged back' into their homes and communities. Without proper understanding of the complexities and dynamics operating at the household and community levels, hospital-initiated interventions are likely to be less effective and sustainable.

Focusing on the demand-side of the health system, the proposed work seeks to answer if and how participatory approaches can strengthen male involvement in child health and nutrition for better outcomes. Specifically:1) To understand men's and women's perspectives of the actual, desired and perceived role of men in child health, and related barriers and facilitators; and 2) Use an in-depth participatory approach to engage men and other stakeholders in co-creating a context-specific, feasible, and scalable male engagement intervention package for improved and more responsive health service delivery.

Improving child health requires primary prevention, quality health services and community action. Whilst there is recognition that the health system encompasses both the suppliers of policy, services, and interventions, and the communities and households intended to benefit from them; in health systems research the focus has primarily been on the supply-side with little attention given to the demand-side of this equation.

Gender roles and relations play an important role in child health and nutritional status. In many sub-Saharan African (sSA) settings, childcare and health is primarily a female domain with men largely absent or only involved in perceived severe or serious cases. Similarly, intentionally or unintentionally, child health programmes in sSA countries predominantly focus on women. While women are perceived as responsible for children, paradoxically they must negotiate decision-making and resources with other family members, including men. By exclusively focusing on women without considering family dynamics or the broader social context, these programmes may inadvertently reinforce harmful gender divisions and practices related to child health and nutrition. Evidence suggests that programmes targeting women might be more effective if men's roles are considered and transformed to affirm more equitable gender relations. Furthermore, following treatment in the formal health system, ill or recovering children are 'discharged back' into their homes and communities. Without proper understanding of the intricacies and dynamics operating at the household and community levels, hospital-initiated interventions are likely to be less effective and sustainable.

Focusing on user-centred perspectives and the demand-side of the health system, the proposed work seeks to answer if and how participatory approaches can strengthen male involvement in child health and nutrition for better outcomes.

This study will provide new evidence towards strengthening healthcare delivery for young children. Drawing on participatory health research approaches and focusing on user-centered perspectives, the study will provide empirical evidence on how gendered social norms, perceptions and practices interact with male engagement in child health and nutrition; and together with relevant stakeholders co-design a context-specific, feasible and scalable intervention package for future trial.

The knowledge produced from this work could potentially be translated into pragmatic child health programme and policy guidelines to improve health service delivery and ultimately health outcomes for young children. This study will also raise the profile of male-centred gender research in health in Kenya, thereby contributing to global debates on demand-side focused health systems strengthening. In the initial phase of the study, qualitative work will be undertaken targeting a range of male and female community members and representatives. The participatory phase will exclusively focus on selected men's groups.

At the community level, the findings from the initial qualitative phase will be discussed with the participatory groups to form the basis for further discussions and consultations. The participatory nature of the study means that knowledge will necessarily be co-created with community members, leading to collaboratively designing appropriate interventions for future trials; and developing strategies to build networks of support to ensure sustained change at the local level. Additionally, findings from the broader study will be shared with community health workers (CHWs) and community health extension workers - who are ideally intended to act as a link between the community and formal health system - on how men and women in the community would want to be engaged in child health and nutrition. This feedback-sharing to broader community stakeholders will be in the form of interactive group meetings. The research team will also aim to facilitate dialogue between the selected participatory groups (which will consist of typical community members) and CHWs. It is hoped that these dialogues will promote mutual understanding between healthcare recipients and providers. To facilitate discussion and increase accountability and transparency between the demand and supply side during these dialogues, we will potentially draw on existing tools such as the community scorecard toolkit. The exact nature and structure of these dialogues will, however, be agreed upon with all relevant stakeholders. As part of the feedback strategy, we will also engage with frontline health workers and mid-level managers in the major facilities within or neighbouring the study area, as agreed upon with the participatory group members. They will be involved as crucial stakeholders in child health, who impact on community views of, and engagement with, the formal health system.

In addition to producing policy briefs, we will organize two interactive workshops with county and sub-county health officials (i.e. policy makers and implementers) and the participatory group members, to disseminate and discuss study findings and proposed future interventions for trial; and deliberate on meaningful ways of incorporating the produced evidence into future child health programmes and current policies. We will also invite representatives from organizations that fund child health programmes to attend the interactive workshops, in a bid to promote the principle of more inclusive programme designs that take into account all relevant stakeholders in child health.