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)

Care requirements for clients who present after rape and clients who presented after consensual sex as a minor at a clinic in Harare, Zimbabwe, from 2011 to 2014.

To describe the differences between clients presenting after rape and clients who have consented to sex as a minor to an SGBV clinic in Harare, Zimbabwe, and how these differences affect their care requirements.Adolescents and adults presenting at the specialized Sexual and Gender Based Violence clinic in Harare are offered a standardised package of free medical and psychosocial care. Zimbabwe has an HIV prevalence of 14%, so prevention of HIV infection using PEP for those that present within 72 hours is a key part of the response. STI treatment, emergency contraceptive pills, referral for termination of pregnancy, psychological, social and legal support is also provided.This is a retrospective descriptive study of routine programmatic data collected at the Edith Opperman polyclinic in Mbare SGBV clinic from 2011 to 2014. Chi-square tests and logistic regression were used to describe the different experiences and the differences in uptake of care between clients presenting for rape compared to those who consented to sex as a minor.During the study period a total of 3617 clients presented to the clinic. 2242 (62%) sought care after rape, 602 (17%) for having consented to sex as a minor and 395 (11%) for suspected sexual abuse. 1615 (45%) of people presenting were 12-15 year olds. Minors who consented to sex compared to survivors of rape were less likely to report within 72 hours- 156 (26%) vs 894 (40%) p<0.001; less likely to report that they delayed due to fear- 68 (17%) vs 472 (40%) p<0.001, less likely to have experienced accompanying violence- 9 (1%) vs 176 (8%) p<0.001 or physical trauma-34 (6%) vs 427 (19%) p<0.001; and less likely to display psychological symptoms at presentation 51 (8%) vs 411 (18%) p<0.001. Minors who consented to sex compared to those who were raped were less likely to start PEP if eligible-123 (80%) vs 751 (93%) p<0.001, less likely to take emergency contraceptives if eligible-125 (81%) vs 598 (88%) p<0.001, more likely to be pregnant- 132 (23%) vs 241 (15%) p<0.001; less likely to request a termination of pregnancy if pregnant-10 (8%) vs 74 (31%) p<0.001; and less likely to come for at least one follow up 281 (47%) vs 1304 (58%) p<0.001.The experiences of those who consent to sex as a minor and those that have experienced forced sex were very different. The standardised SGBV medical response does not fully meet the needs to protect minors who have consented to sex from HIV or unwanted pregnancies. Clients who present for having consented to sex as a minor might benefit more from being offered long-term family planning or being assessed as a sero-discordant couple rather than simply PEP and ECP as is relevant for clients who have been raped. More provision of health care is needed for minors to ensure they have access to enough information and protection from HIV, other STIs and unwanted pregnancy, before they decide to engage in sexual intercourse, rather than as an emergency at an SGBV clinic

Incident characteristics, Mbare SGBV clinic (09/2011–12/2014).

<p>Incident characteristics, Mbare SGBV clinic (09/2011–12/2014).</p

Number new SGBV clients per quarter by reason for visit, Mbare SGBV clinic (09/2011–12/2014).

<p>Number new SGBV clients per quarter by reason for visit, Mbare SGBV clinic (09/2011–12/2014).</p

Medical-legal management Mbare SGBV clinic (09/11–12/2014).

<p>Medical-legal management Mbare SGBV clinic (09/11–12/2014).</p

Factors associated with presentation within 72 hours after an incident of sexual violence, Mbare SGBV clinic (09/11–12/2014).

<p>Factors associated with presentation within 72 hours after an incident of sexual violence, Mbare SGBV clinic (09/11–12/2014).</p

Time to presentation and follow-up, Mbare SGBV clinic (09/11–12/2014).

<p>Time to presentation and follow-up, Mbare SGBV clinic (09/11–12/2014).</p