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)

Adaptation of the Kaufman Assessment Battery for Children—2nd edition (KABC-II) to assess school-age neurodevelopment in rural Zimbabwe

There remains an urgent need for neurodevelopment assessment tools that can be applied in low-resource settings, where over 250 million children remain at risk of poor cognitive development. Most available tools were developed in high-income settings and may lack cross-cultural validity when applied to low-resource contexts. This section hosts the raw data and extended data for the process of adapting two subtests (pattern reasoning and story completion) within the Kaufman Assessment Battery for Children--2nd edition (KABC-II) for use in rural Zimbabwean children aged 7 years, both within the planning domain

Adaptation of the Kaufman Assessment Battery for Children—2nd edition (KABC-II) to assess school-age neurodevelopment in rural Zimbabwe

There remains an urgent need for neurodevelopment assessment tools that can be applied in low-resource settings, where over 250 million children remain at risk of poor cognitive development. This project describes the adaptation of two subtests (pattern reasoning and story completion) within the Kaufman Assessment Battery for Children--2nd edition (KABC-II) for use in rural Zimbabwean children aged 7 years, both within the planning domain

Characterising school-age health and function in rural Zimbabwe using the SAHARAN toolbox

IntroductionWe developed the School-Age Health, Activity, Resilience, Anthropometry and Neurocognitive (SAHARAN) toolbox to address the shortage of school-age assessment tools that combine growth, physical and cognitive function. Here we present i) development, acceptability and feasibility of the SAHARAN toolbox; ii) characteristics of a pilot cohort; and iii) associations between the domains measured in the cohort.MethodsGrowth was measured with anthropometry, knee-heel length and skinfold thicknesses. Bioimpedance analysis measured lean mass index and phase angle. Cognition was assessed using the mental processing index, derived from the Kaufman Assessment Battery for Children version 2, a fine motor finger-tapping task, and School Achievement Test (SAT). Physical function combined grip strength, broad jump and the 20m shuttle-run test to produce a total physical score. A caregiver questionnaire was performed in parallel.ResultsThe SAHARAN toolbox was feasible to implement in rural Zimbabwe, and highly acceptable to children and caregivers following some minor modifications. Eighty children with mean (SD) age 7.6 (0.2) years had mean height-for-age (HAZ) and weight-for-age Z-scores (WAZ) of -0.63 (0.81) and -0.55 (0.85), respectively. Lean mass index and total skinfold thicknesses were related to WAZ and BMI Z-score, but not to HAZ. Total physical score was associated with unit rises in HAZ (1.29, 95% CI 0.75, 1.82, pConclusionsThe SAHARAN toolbox provided a feasible and acceptable holistic assessment of child growth and function in mid-childhood. We found clear associations between growth, height-adjusted lean mass and physical function, but not cognitive function. The SAHARAN toolbox could be deployed to characterise school-age growth, development and function elsewhere in sub-Saharan Africa

Piloting the adaptation of the Kaufman Assessment Battery for Children—2nd edition (KABC-II) to assess school-age neurodevelopment in rural Zimbabwe

Background: Neurodevelopment assessment tools for low-resource settings are urgently needed. However, most available tools were developed in high-income settings and may lack cross-cultural validity. Methods: We piloted and adapted two subtests (pattern reasoning and story completion) within the Kaufman Assessment Battery for Children-2nd edition (KABC-II) for use in rural Zimbabwean children aged 7 years old, both within the planning domain. After initial assessments of face validity, we substituted and added items in the test battery through a co-design process with fieldworkers and child development experts. To assess how successful the changes were, T-tests adjusting for unequal variances were used to compare scores between the original and adapted versions of the same subtest. ANOVA and pairwise analysis was performed to compare the performance of KABC-II subtests across domains. Intraclass correlation coefficient was calculated to explore the variability between domains. Results: Initial test scores on the planning domain were significantly lower than the other three domains of learning, sequential memory and simultaneous reasoning (P&lt;0.001) in 50 children. Modified subtests were administered to another 20 children, who showed story completion scores that were 0.7 marks higher (95% CI 0.0, 1.4; P=0.05) and pattern reasoning scores 1.8 marks higher (95% CI 0.5, 3.2; P=0.01). Overall, the planning domain mean score increased from 8.1 (SD 2.9) to 10.6 (SD 3.4). The intra class correlation coefficient between all four KABC-II domains was initially 0.43 (95% CI 0.13, 0.64) and after modification was 0.69 (95% CI 0.37, 0.87), suggesting an increase in the construct validity. Conclusions: The KABC-II planning domain was successfully adapted to improve cross-cultural validity. Construct validity was enhanced, based on increased inter-correlations among scales. This pilot has since been applied to the SHINE follow-up study. The process of co-design to modify tests for new settings may be beneficial for other commonly used neurodevelopmental tools.</ns3:p

The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial: Protocol for school-age follow-up

Background: There is a need for follow-up of early-life stunting intervention trials into childhood to determine their long-term impact. A holistic school-age assessment of health, growth, physical and cognitive function will help to comprehensively characterise the sustained effects of early-life interventions. Methods: : The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial in rural Zimbabwe assessed the effects of improved infant and young child feeding (IYCF) and/or improved water, sanitation and hygiene (WASH) on stunting and anaemia at 18 months. Among children enrolled to SHINE, 1,275 have been followed up at 7-8 years of age (1,000 children who have not been exposed to HIV, 268 exposed to HIV antenatally who remain HIV negative and 7 HIV positive children). Children were assessed using the School-Age Health, Activity, Resilience, Anthropometry and Neurocognitive (SAHARAN) toolbox, to measure their growth, body composition, cognitive and physical function. In parallel, a caregiver questionnaire assessed household demographics, socioeconomic status, adversity, nurturing, caregiver support, food and water insecurity. A monthly morbidity questionnaire is currently being administered by community health workers to evaluate school-age rates of infection and healthcare-seeking. The impact of the SHINE IYCF and WASH interventions, the early-life ‘exposome’, maternal HIV, and contemporary exposures on each school-age outcome will be assessed. We will also undertake an exploratory factor analysis to generate new, simpler metrics for assessment of cognition (COG-SAHARAN), growth (GROW-SAHARAN) and combined growth, cognitive and physical function (SUB-SAHARAN). The SUB-SAHARAN toolbox will be used to conduct annual assessments within the SHINE cohort from ages 8-12 years. Ethics and dissemination: Approval was obtained from Medical Research Council of Zimbabwe (08/02/21) and registered with Pan-African Clinical Trials Registry ( PACTR202201828512110 , 24/01/22). Primary caregivers provided written informed consent and children written assent. Findings will be disseminated through community sensitisation, peer-reviewed journals and stakeholders including the Zimbabwean Ministry of Health and Child Care