The MaaCiwara Project: Hybrid Implementation-effectiveness Cluster Randomised Controlled Trial To Evaluate A Behaviour Change Community-level Complementary Food Safety And Feeding Intervention In Urban And Rural Mali
Infant diarrhoea is globally the second highest cause of death in under-fives. Children who are transitioning from being breastfed to eating foods, are at particular risk from diarrhoea.
Diarrhoea causes one in nine deaths of children under fives worldwide and is associated with stunted growth and cognitive impairment. At particular risk are children starting to eat complementary food, due to unhygienic cooking and feeding practices; poor nutritional content of food; and play in hygienic environments.
We are examining interventions aimed at reducing the burden of diarrhoea among children eating complementary food, particularly behavioural interventions that influence food hygiene, food content and safe/hygienic play.
Behavioural interventions to improve food hygiene have been shown to be effective in rural areas, however, such interventions have not been examined in urban areas, and have not addressed food nutritional content and play in hygienic. 
environments or conditions. We aim to address those knowledge gaps through a cluster RCT in urban and rural Mali.
The study uses a mixed methods evaluation to examine a food hygiene, nutritional content, and safe play intervention which has been adapted to the local context through formative research, paying particular attention to contextual differences. The study also contains several parallel projects on stool microbiology, health economics, and attitudes to safe food.
We combine two interventions addressing the preparation and nutritional content of food for children transitioning from being exclusively breastfed to eating additional foods, known as complementary feeding (CF). These interventions were shown to be effective elsewhere in low and middle income countries. Particularly, in our previous food safety and hygiene research, a trial in the Gambia (developed by drawing on the findings of former studies from institutions in Bangladesh, Mali, Nepal and Pakistan), and in another trial in Kenya, which evaluated a community programme to improve breastfeeding and CF content. Given the influence of good nutrition, and safe and hygienic play environments for reducing diarrhoea and improving optimal growth among this population, our present intervention combined components of hygienic play and nutrition.
This project draws on the growing strengths of the Institute of Applied Health Research in health informatics research (including policy evaluation using routine electronic healthcare data), biostatistics and qualitative approaches to the study of maternal and child health. The project is led by the University of Birmingham, and the University of Science, Techniques and Technology Bamako, Bamako, Mali with strong collaboration with Malian Governmental and Academic organizations, as well as international organizations such as the WHO, UNICEF, ICDDR,B, and WaterAid; and other British academic partners.
Developing or testing the efficacy of a low-cost, scalable and adaptable community intervention to reduce diarrhoea and improve the growth of young children in urban and rural Mali. Assessing the effects in both settings, to inform replication and scaling of the intervention, because the dynamics of community life vary in each.
Adapting the intervention with communities to the socio-cultural context of the local communities, our intervention seeks to empower local families to implement behaviour change. This includes campaign-like activities such as culturally relevant dramatic arts (drama, songs, and stories), public meetings, certifications, and home visits. Delivery is from a small team over a total of 4 days of community campaign visits dispersed over 40 days, and includes home visits by trained female volunteers, plus a reminder campaign day after 9-12 months. 60 urban and rural sites in Mali are randomly chosen (allocated by chance) to receive the intervention, and an equal amount chosen where the intervention is not delivered (120 in total). After 15 months we will then assess 27 households in each site. This study is designed to explore whether the interventions work differently in rural and urban contexts, and to examine whether and how other societal influences (e.g. household poverty, women's work, and education, etc) affect the outcomes. Using observations, interviews, discussion groups, surveys and laboratory tests we will compare the implementation of the intervention across urban and rural settings in order to evaluate it’s potential for reducing the incidence of diarrhoea among children under five and enhacing child growth and development...