This partnership brings together researchers from the Arts and Humanities - history, historical and medical anthropology, linguistics and theatre studies - with medical and public health specialists, to address a key global health development challenge: extremely high Maternal Mortality Ratios (MMRs). It will focus on western Kenya, but seek to influence policy and practice across East Africa. While Kenya's crude death rate is now on a par with Europe, its MMR was 510/100,000 livebirths in 2015, 43 times higher than high-income regions. On current trajectories, Kenya, like most African countries, will not come close to the Sustainable Development Goal (SDG) MMR target of 70/100,000 by 2030. Our partnership seeks to develop new approaches to maternal health through interdisciplinary research and networking. Drawing on and further developing established relationships between East African and European arts and humanities and medical researchers, this medical humanities partnership will be based on the principles of international collaboration and co-production, motivated by the goal of reducing excessive maternal mortality. Our broader aim is to establish a regional consensus that socio-cultural research can effectively address major health problems. That high MMRs are a particularly important, intractable health problem has been acknowledged both within the UK government, which has made working 'to end preventable child and maternal deaths' one its seven aid priorities, and in Kenya's national plan (Kenya Vision 2030), which identified MMRs as one of two key areas 'where Kenya is lagging'. Kenyan partners in government, medical institutions and key NGOs recognise high MMRs as a national priority, acknowledge that risk factors remain poorly understood, have informed the definition of problems which this partnership seeks to addressed, and are prepared to engage in research, policy development, and implementation. This partnership's approach has developed from medical researchers' recognition that high MMRs result not only from physiological problems and infrastructural deficit, but also relate to patients' experience of biomedical maternity services, domestic decision-making, social norms and collective understandings of motherhood, health and illness. Arts and Humanities researchers will work with medical practitioners, policymakers and teaching staff to consider in particular how, in both domestic and clinical settings, risk is evaluated, information is communicated, and resources are allocated. Research will focus on the western Kenyan region around Kisumu, investigating why recent interventions, such as free maternity services and building referral hospitals, have had less impact in Kenya than anticipated. The partnership will consider why some interventions, effective in other countries, have proven problematic within the Kenyan context, and also compare Kenya's past successes in maternal healthcare with the relative stagnation of recent decades. Researchers will utilize a range of methodologies, including archival research, interviews, linguistic analysis and participatory theatre. They aim to better understand the tensions and miscommunication which often characterise clinicians' relationships with pregnant women, and the unintended consequences of policy changes. They will also investigate the gender and generational factors which shape health-related decisionmaking within the household, peer-groups, and extended family. Throughout, our partnership will be shaped by co-production with African academics, practitioners and institutions, building capacity in north the Global North and South. This will assist communication of findings to government, hospital administrations, citizens and NGOs such as INDEPTH, WHO, and Unicef. Outcomes will be shared with policymakers across the East African region, and a range of tools, music, radio and theatre will be used to communicate key messages across the Kisumu region.

In 2009, there were 42,000 newborn deaths and they accounted for 40% of all deaths among children under 5 Kenya. This high neonatal mortality is a major reason why Kenya is not succeeding in its battle to reduce child deaths in line with stated targets. Recognising this, the Ministry of Health has started to focus on improving newborn (and maternal) health with strategies aimed at communities and small clinics. However, sick or vulnerable newborns will often require inpatient care in referral facilities from skilled workers with access to basic technologies. Interventions typically delivered at this level include, for example, fluids or feeds for those unable to suck or oxygen for respiratory support. Such interventions require carers to perform the same, time-consuming tasks multiple times per day for many days. Shortage of skilled health workers often means these services are inadequately delivered, potentially delaying or preventing recovery. We are planning research that will establish: the potential burden of severe neonatal illness; what existing infrastructure and human resource capacity is available supporting access for this population; utilisation of these services; and the quality of existing nursing care services. We will do this focusing on Nairobi's population of 5 million, many of whom are very poor. With a focus on universal coverage and neonatal care meeting agreed standards, this work will provide the basis for estimating the gap between available and needed services (Gap 1) and the quality gap between existing and desired services (Gap 2). In partnership with important stakeholders, we will explore how a low-income country might best tackle health workforce challenges to close these gaps and improve provision of essential nursing care to all sick newborn babies in an affordable and efficient way. This ultimate aim of research is driven by the fact that salary costs are a major proportion of total health care costs. One option will therefore be to explore alternatives to employing professional nurses if necessary interventions can be effectively provided by other groups under the supervision of professionals - an approach known as task-shifting. Although task-shifting sounds a simple solution, it may not always be. Failure to consider national regulations, the opinions of important professionals, managers or parents may lead to the approach being rejected or failing. Taking account of the local situation may be particularly important when those being cared for are sick, newborn babies and when day to day care has traditionally been given by professional, even specialist nurses. First, therefore, we will define with the major groups what forms of care should be available to all, learn what regulations exist on providing care, and consider the concerns of major groups with respect to task-shifting. We will examine carefully all the things that nurses have to do in a range of different facilities, explore with experts which tasks may be simple enough for others to do, and examine whether there is time to do all the essential care tasks. We will estimate how much need there is for neonatal nursing care in Nairobi and the gap between what is available and what is needed. Using all these data we will explore how many new staff might be needed to improve the delivery of essential care for all newborns in need. We will also undertake preliminary work to explore the costs of meeting this need using extra professional nurses or if tasks were shifted to other, lower cost staff. Possible roles for lower cost staff will be informed by work examining what tasks to shift and how they might fit within existing patterns of providing care. All this work will be conducted with the major decision makers in health, health professionals and parents to develop options sensitive to local conditions. Based on this body of work we aim to develop a task-shifting approach that can be tested in Kenya in the future.

Globally, more than a quarter of children under the age of five years are stunted (undernourished). Stunted children experience lifelong problems with their health and are more likely to die early. The time at which an infant transitions from receiving only breastmilk to needing additional foods (complementary feeding) has been shown to be associated with increasing problems with stunting. Currently only 22% of Kenyan and 8% of Malawian children aged 6-23 months receive the minimum acceptable diet, down from 39% (Kenya) and 19% (Malawi) between 2008 and 2014. It is estimated that interventions which promote optimal infant and young child feeding (IYCF) practices could prevent 20% of deaths in under-fives in countries with high levels of child deaths. Approximately one-third of urban residents in low and middle income countries live in slums, with an additional 100,000 moving in daily. Children living in slums are more likely to suffer from under-nutrition than other urban children. Nevertheless the literature tells us that there is a lack of evidence regarding nutrition interventions in slum environments, and almost no evidence regarding the potential for 'nutrition-sensitive' interventions that target the drivers of poor nutrition such as poverty, cultural and social practices, and poor physical environments. Successful design of these types of intervention requires a well-integrated interdisciplinary approach. In addition to nutrition expertise, contributions from other disciplines are needed to understand the cultural, social, physical and economic environments that influence IYCF practices. We therefore propose an interdisciplinary network with the aim to produce evidence to drive future research and inform policies to improve the nutritional status of IYC living in poverty in sub-Saharan African countries (SSA) experiencing rapid urbanisation. The network is led by Loughborough University with Kenyan partners at the African Population and Health Research Centre and Malawian partners at the University of Malawi and The Lilongwe University of Agriculture and Natural Resources as well as UK partners at The Universities of Sheffield and Southampton. The specific network objectives will be to: 1) Prepare a rapid review of evidence documenting interventions for the urban poor to improve the nutrition of IYC in SSA; 2) Convene the first network workshop (to include stakeholders) to firstly guide analysis of existing data sources on this topic, to secondly consider the current evidence base and policies identified in the rapid review and finally to ask key stakeholders to identify highest-ranking evidence/research gaps for improving IYC feeding programmes and policies; 3) Undertake analyses of existing data from demographic and health surveys in sub-Saharan Africa and pre-existing data from slums in Nairobi to explore how the various drivers of IYCF practices are influenced by urbanisation and to consider whether those drivers vary for the urban poor compared to other urban populations; and finally 4) Facilitate end-of-project workshops to develop research proposals informed by evidence from the first three objectives and to present findings of the secondary analysis and discuss these with stakeholders (including Ministries of Health, NGOs, communities) and policy-makers. The network will also foster the development of skills in data analysis and evidence synthesis in early career researchers in the UK, Malawi and Kenya, thus helping to ensure a sustainable group with potential for evolving future leadership. In the longer term we will develop a UK-Africa interdisciplinary network with expertise to support interventions to promote optimal IYCF practices in rapidly urbanising environments. It is envisaged that such interventions will improve the human capital of developing countries by reducing under nutrition, thus promoting optimal cognitive and physical development, and thereby increasing prospects for economic prosperity.

Background: Globally 15 million babies are born preterm or "born too soon" each year. Nearly two-thirds of such births happen in sub-Saharan Africa and Asia. Premature birth is the cause for a third of all deaths in the first month of life. In Kenya, over 200,000 babies are "born too soon" and despite recent reductions, deaths in the first month of life remain high at 20 per 1000; 7 times higher than in the UK. Kenya suffer from a shortage of resources including lack of trained neonatal doctors and nurses. Poor record keeping in hospital causes delays in recognising poorly babies, in providing treatment and leads to poor outcomes. Early warning scores (EWS) are a streamlined way to monitor patients and prompt treatment to prevent deterioration that could lead to death. The "Newborn Early Warning Track and Trigger" (NEWTT) used in the UK uses a simple paper-based form, which has a "traffic-light system" to easily plot infants' vital signs (temperature, heart rate and respiratory rate). This promptly alerts healthcare professionals to take actions if signs are in the red or amber zones. Closer monitoring of preterm infants with a system that more easily identifies sicker infants could help resource-limited staff to reduce deaths and illness in this very vulnerable group. Previous work: To understand how doctors and nurses care for preterm and low birth weight (LBW) infants in Kenya, we recently completed a study at a large hospital in Nairobi, Kenya. We collected data on 294 babies over 8 weeks and recorded vital signs on the NEWTT. We also spoke to 19 mothers and 20 stakeholders to explore their views of newborn care. The data were presented at a large meeting in Nairobi in July 2019 attended by around 80 people involved in care of preterm infants. The idea of implementing a EWS for preterm infants in Kenya was discussed and feedback was positive. They liked the simplicity of documentation using a traffic-light system for quick identification of high risk infants. Some barriers were discussed such as a recognition of need for training and resources such as nursing time and colour printed charts. Current study: This study aims to test how feasible and acceptable it is to implement an EWS in neonatal units in Kenya. We will implement the paper-based EWS in three neonatal units and ask staff to complete this for all preterm or LBW infants over a 4-week period. When a vital sign is entered onto one red or two amber trigger zones, they will alert a more senior member of staff to assess the infant and advise further action. The EWS will temporarily replace the current documents to avoid duplication of work. We will also conduct interviews a range of healthcare professionals involved in caring for preterm infants. In order to include a range of opinions, we will aim to include 2-3 interviews with each type of staff, resulting in around 24-30 interviews. Skills development: We will develop capacity to conduct research and increase the skills of our Kenyan partners. Three researchers, one from each hospital in Kenya, will visit the UK They will attend the well established Nottingham Fundamentals of Clinical Trials course (https://www.nottingham.ac.uk/nctu/short-courses/fundamentals-of-clinical-trials.aspx). Here they will learn basic skills in the design and conduct of clinical trials via a mixture of classroom style teaching and workshops and network with other course attendees. They will also spend time at Nottingham Clinical Trials Unit and the Liverpool School of Tropical Medicine to gain hands-on experience of clinical trials and discuss future opportunities. Future work: The current study is a step in a longer-term programme of work to establish a practical and useful EWS for reducing death among preterm infants in resource-limited hospitals. If shown to be feasible and acceptable, we will undertake an appropriately designed clinical trial to test if using such an EWS will help save lives of those "born too soon".

Food security is one of the "big four" agenda initiatives championed by the Kenyan Government. More than 80% of Kenya's population is dependent upon agriculture for employment, income, or food security needs (FAO) and a large proportion of the population are food insecure, for example 26% of children under 5 years of age suffer from malnutrition (UNICEF). The food security challenge is intensified by: reducing size of land parcels as a result of population growth; farmers being pushed into dryer lower quality land areas vulnerable to drought; conflicts resulting from competition for land; and people dropping out of nomadic life to move to settled communities dependent upon food aid (FAO). To address this, increases in agricultural productivity are needed. An important way to improve crop yield relates to better soil fertility. Optimising fertiliser strategies for soil can be summed up as: Right Source, Right Rate, Right Place, Right Time. For the greatest impact, this requires in-field measurement tools that can be used by farmers to understand the spatial changes in nutrient concentration within a field, and how these vary over time. No technology currently exists that allows this to be carried out at very low cost. The alternative to in-field testing is the use of soil laboratories in Nairobi, but these are expensive to use, far away from the farm and provide a single measurement which is not representative of the whole area farmed. In consequence, most smallholders are in the dark about the nutrition status of their soil and how it changes in response to different soil amendment approaches. This project will help address the measurement challenge by developing a new kind of sensor that can be used by farmers at very low cost to regularly test for two key soil macro-nutrients, called nitrate and phosphate. The project will take inspiration from ancient art and design based printing processes, combined with locally available natural materials (e.g. chimney soot, egg, newspaper and enzymes from plants and bacteria available within Kenya) to make extremely low cost soil sensors. By adopting a "co-creation" based philosophy, the University of Strathclyde in Glasgow, Kenyatta University in Nairobi and Glasgow School of Art in Glasgow will build a collaboration to deliver a step change in sensing technology for smallholder farmers in Kenya. This will be achieved by initially developing the sensor in the UK, employing a researcher from Kenya. Once a proof of concept has been created, the researcher will return to Kenya with the knowledge and understanding to recreate the sensor and test performance in greenhouse trials. The project will also involve a series of workshops where we will engage communities, industry and policy makers to ensure that we create user led solutions to address food security within Kenya. In the long term, this could be delivered to farmers either as a "factory in a box" containing the tools needed for sensor manufacture, or simply as an information pack that shows how to gather the resources required and print sensors. The project could also influence the wider region: 20 million people across Kenya, Ethiopia and Somalia are food insecure (Worldbank, 2022), and face similar challenges. Parallel benefits also exist for UK innovation, where knowledge and learning from this project could support the manufacture of nature based and zero waste sensors to support UK agriculture and the transition to net zero.