Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial.

BACKGROUND: Child stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe. METHODS: We did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940. FINDINGS: Between Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08-0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28-2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported. INTERPRETATION: Household-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone. FUNDING: Bill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.The SHINE trial is funded by the Bill & Melinda Gates Foundation (OPP1021542 and OPP113707); UK Department for International Development; Wellcome Trust, UK (093768/Z/10/Z, 108065/Z/15/Z and 203905/Z/16/Z); Swiss Agency for Development and Cooperation; US National Institutes of Health (2R01HD060338-06); and UNICEF (PCA-2017-0002)

Probiotic Potential, Iron and Zinc Bioaccessibility, and Sensory Quality of Uapaca kirkiana Fruit Jam Fermented with Lactobacillus rhamnosus Yoba

Uapaca kirkiana is an underutilised indigenous fruit tree (IFT) found in the miombo ecological zone in sub-Saharan Africa. Furthermore, sub-Saharan Africa is home to many nutritionally insecure people who suffer from micronutrient deficiency. The incorporation of probiotic strains in jams as a possible way of enhancing mineral accessibility, food quality, and health is limited in Africa. This study monitored the probiotic potential, bioaccessible iron and zinc, and organoleptic properties of U. kirkiana fruit jam fermented with L. rhamnosus yoba. U. kirkiana fruits were collected from semiarid rural areas of Zimbabwe. The L. rhamnosus yoba strain was obtained from the Yoba for Life Foundation, Netherlands. Mineral and biochemical properties of the probiotic jam were analysed using AOAC standard methods. The U. kirkiana fruit tree was ranked first as a food resource by most rural populations in Zimbabwe. The probiotic jam formulation had 55% (wt/vol) U. kirkiana fruit pulp, 43% (wt/vol) sugar, 1.25% (wt/vol) pectin, 0.5% (wt/vol) citric acid, and 0.25% (wt/vol) L. rhamnosus yoba strain. The probiotic jam had 6.2±0.2 log CFU/mL viable L. rhamnosus yoba cells. Iron and zinc content (mg/100 g w.b.) was 4.13±0.22 and 0.68±0.02 with pH 3.45±0.11, respectively. Nutrient content was g/100 g w.b., carbohydrate 66±4.1, fat 0.1±0.01, crude protein 0.2±0.01, ash 0.7±0.02, and crude fiber 0.3±0.01. Bioaccessible iron and zinc were 6.55±0.36% and 16.1±0.50% and increased by 4% and 2% in the probiotic jam, respectively. Mineral bioaccessibility and nutrient content were significantly different (p<0.05) in jam with 0.25% L. rhamnosus yoba. Jam acceptance rating was 83%. The probiotic jam can be used as a sustainable food containing probiotic with potential nutritional and health benefits

Investigating the accessibility factors that influence antenatal care services utilisation in Mangwe district, Zimbabwe

Background: Maternal and infant mortality remains a huge public health problem in developing countries. One of the strategies to minimise the risks of both maternal and infant mortality is access to and utilisation of antenatal care (ANC) services. Aim: This study aimed to investigate the accessibility factors that influence the use of ANC services in Mangwe district. Methods: A qualitative approach using explorative design was adopted to target women who have babies under 1 year of age. The study was conducted in Mangwe district, Matabeleland South province, Zimbabwe. Data were collected through semi-structured interviews and observations. Data saturation was reached after 15 women who were conveniently sampled were interviewed. Field notes were analysed thematically using Tech’s steps. Lincoln and Guba’s criteria ensured trustworthiness of the study findings. Results: Accessibility factors such as lack of transport, high transport costs and long distances to health care facilities, health care workers’ attitudes, type and quality of services as well as delays in receiving care influence women’s utilisation of ANC services in Mangwe district, Zimbabwe. Conclusion: The study concluded that women were still facing problems of unavailability of nearby clinics; therefore, it was recommended that the government should avail resources for women to use. Recommendations: Mangwe District Health Department should provide mobile clinics rendering ANC services in distant rural areas