Revitalising Informal Settlements and their Environments (RISE): Assessing health, social, and environmental outcomes following water-sensitive revitalisation of informal settlements in Indonesia and Fiji

INTERVENTION: Twenty‐four informal settlements will participate in the trial (12 located in Makassar, Indonesia; 12 located in Suva, Fiji). Twelve settlements will be intervention sites while the remaining sites will be control sites. Intervention and control sites will be equally distributed between the two main study locations. Prior to the start of the trial, a baseline survey will be conducted to collect baseline demographics and health data in all settlements. The intervention arm will involve delivery and construction of water‐sensitive revitalisation infrastructure. These interventions will include the installation of latrines and septic tanks, use of subsurface wetlands for sewage treatment, use of biofilters, building‐scale rainwater harvesting, and installing street‐scale drainage and storm water treatment facilities. Design and architectural teams from Monash University will personalize all infrastructure to each settlement site. Construction of infrastructure will be carried out and monitored by respective government bodies at each site (City Government of Makassar in Indonesia and Department of Housing, under the Ministry of Local Government, Housing and the Environment in Fiji). The first two years of the study will consist of protocol and intervention design, site selection, community and individual enrollment, community engagement, and community co‐design of intervention. Construction at intervention sites will commence towards the end of the second year of the study and be completed by the end of year 3; leaving a monitoring period post‐construction of 2 years (for a total study length of 5 years). After the trial concludes, the twelve control settlements will receive the above water‐sensitive infrastructure. All settlement sites will receive a basic sanitation focused educational intervention. This will include posters relating to hand hygiene and safe water storage delivered to community centers and homes and trained field workers will provide house‐by‐house education on hygiene practices. Once enrolled, and for the full duration of the trial, all communities will be visited by field workers every 3 months (this includes before and during the build of the intervention as well as after the installation of the intervention is completed). At that time, a range of health and wellbeing data will be collected using questionnaires. Field workers will collect fecal samples from children under 5 every 3 months and blood samples from children under 5 every 6 months. CONDITION: Diarrhoea Environmental enteropathy PRIMARY OUTCOME: Concentration of intestinal inflammation markers representing environmental enteropathy (Alpha‐1‐antitrypsin, neopterin, myeloperoxidase) in children less than 5 years of age Presence of bacterial and parasitic gastrointestinal pathogens in children less than 5 years of age (composite primary outcome) Presence of drug‐resistance in GI flora of children less than 5 years of age (composite primary outcome, assessed using metagenomic approach) SECONDARY OUTCOME: C‐reactive protein inflammatory marker in children under 5 years ; Caregiver reported diarrhoea (in the 7 days prior to field worker visit) in children under 5 years of age ; Caregiver reported respiratory infection (in the 7 days prior to field worker visit) in children under 5 years of age ; Ecological biodiversity at study sites and vertebrate and invertebrate population levels around settlement sites ; Fecal contamination of the environment ; Weight measures in children under 5 using an electronic scale. White blood cell count in children under 5 INCLUSION CRITERIA: ‐ Settlements located in the urban areas of Makassar, Indonesia and Suva, Fiji ‐ Settlements which are suitable building sites for architectural intervention ; Healthcare visits to local health clinics and hospitals in children under 5 Height measures in children under 5. Length measured using an infant measuring board for children who cannot stand unassisted and height measured using a portable height rod in children who can stand unassisted. Hemoglobin level in children under 5 Iron studies in children under 5 Self‐reported / Caregiver reported wellbeing of adults and children ‐ Community receptiveness to intervention installations and commitment to ongoing study participation over five years ‐ All enrolled individuals must be a resident in a settlement area enrolled in the trial