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

INTRODUCTION: We 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. METHODS: Growth 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. RESULTS: The 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, p<0.001), and lean mass index (0.50, 95% CI 0.16, 0.83, p = 0.004), but not skinfold thicknesses. The SAT was associated with unit increases in the mental processing index and child socioemotional score. The caregiver questionnaire identified high levels of adversity and food insecurity. CONCLUSIONS: The 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

A systematic approach for reviewing research capacity within Zimbabwe’s national blood service

Background Blood services need to undertake research to improve their strategic goals, operational effectiveness and promote evidence-based policies. NBSZ has along history of active research and undertook a systematic review of its research capacity to guide its new research strategy. In the absence of a published approach for research capacity assessment for national blood services, a frame-work to assess research capacity in African universities was used. Methods Semi-structured interviews were conducted with 85 NBSZ internal and external stakeholders. The interview topics were based on eight areas covered by the framework used to assess universities’ research systems. Information was ver-ified through triangulation, and recommended actions emerging from the review were validated at a national stakeholder workshop. The appropriateness of the framework for use in the setting of blood services was also evaluated. Results Synthesis of information from the multi perspective interviews high-lighted key areas of NBSZ’s research capacity for improvement, in particular better dissemination of NBSZ’s research priorities and closer ties with academics and their institutions for preparing research proposals and jointly undertaking research projects. With minor adaptations, the framework was found to be applicable to NBSZ, and no aspects of research capacity were identified which were not covered by the framework. Discussion Our results indicate that it is feasible and useful to apply a structured process to review the research capacity of blood services. However, the frame-work needs to be tested in blood services and other non-university setting to assess its usefulness and transferability

A feasibility study using time-driven activity-based costing as a management tool for provider cost estimation: lessons from the national TB control program in Zimbabwe in 2018.

BACKGROUND: Insufficient cost data and limited capacity constrains the understanding of the actual resources required for effective TB control. This study used process maps and time-driven activity-based costing to document TB service delivery processes. The analysis identified the resources required to sustain TB services in Zimbabwe, as well as several opportunities for more effective and efficient use of available resources. METHODS: A multi-disciplinary team applied time-driven activity-based costing (TDABC) to develop process maps and measure the cost of clinical pathways used for Drug Susceptible TB (DS-TB) at urban polyclinics, rural district and provincial hospitals, and community based targeted screening for TB (Tas4TB). The team performed interviews and observations to collect data on the time taken by health care worker-patient pairs at every stage of the treatment pathway. The personnel's practical capacity and capacity cost rates were calculated on five cost domains. An MS Excel model calculated diagnostic and treatment costs. FINDINGS: Twenty-five stages were identified in the TB care pathway across all health facilities except for community targeted screening for TB. Considerable variations were observed among the facilities in how health care professionals performed client registration, taking of vital signs, treatment follow-up, dispensing medicines and processing samples. The average cost per patient for the entire DS-TB care was USD324 with diagnosis costing USD69 and treatment costing USD255. The average cost for diagnosis and treatment was higher in clinics than in hospitals (USD392 versus USD256). Nurses in clinics were 1.6 time more expensive than in hospitals. The main cost components were personnel (USD130) and laboratory (USD119). Diagnostic cost in Tas4TB was twice that of health facility setting (USD153 vs USD69), with major cost drivers being demand creation (USD89) and sputum specimen transportation (USD5 vs USD3). CONCLUSION: TDABC is a feasible and effective costing and management tool in low-resource settings. The TDABC process maps and treatment costs revealed several opportunities for innovative improvements in the NTP under public health programme settings. Re-engineering laboratory testing processes and synchronising TB treatment follow-up with antiretroviral treatments could produce better and more uniform TB treatments at significantly lower cost in Zimbabwe

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)

Comparison of blood services and clinical transfusion practices in Zimbabwe and the Netherlands: What are the key lessons?

IntroductionTracking blood safety status of member states by World Health Organisation is now a routine activity through Global Database for Blood Safety. To understand further the differences between high income and low-income countries a detailed review may be warranted. In this review, the blood services of Netherlands and Zimbabwe were compared.MethodologyA study visit to Netherlands was undertaken and the key findings from this visit were compared with equivalent data from Zimbabwe. Key thematic points were summarised from the review of the reports as well as the outcomes from key observations and informant discussions. Lessons learnt and recommendations were drawn for each thematic area considered.Key FindingsThe difference in geographical land sizes (Zimbabwe 10 times larger) and population demographics (Zimbabwe predominately youths) poses different challenges to Netherlands and Zimbabwe. The organisation and management structures of the Services are similar and both rely on 100% voluntary non-remunerated blood donors. Despite the high transfusion transmission infections (TTI) rates in the general population in Zimbabwe the testing technology is low as compared to Netherlands. However, Zimbabwe through other strategies has managed to maintain low TTI prevalence in donated blood. There are comparable efforts in blood process, testing and distribution activities. The support services such as haemovigilance, research and development activities are greatly comparable though the outputs magnitude will differ depending of the level of investment.ConclusionOur findings seems to suggest that despite the differing income status of countries, given the proper strategies blood services in low resources settings can make comparable achievement

Challenges of using HIV as a primary risk indicator: Need for integrated blood donor risk management model

Background: The use of risk modelling in blood safety is increasing getting momentum. NBSZ initiated blood donor risk profiling based on donation frequency (r-coding) since 1994 and in 2006 a generic risk classification model was developed (include age and donation venue) which was mainly based on HIV risk considerations. The blood safety implications of this model, which include all the four routinely tested transfusion transmission infections (TTI) has not been studied. We aim to assess whether the use of HIV as a primary risk indicator is sufficient in Zimbabwe and the possible blood safety concerns for this. Methods: Blood donor data on HIV, HBV, HCV and Syphilis from 2002 to 2011 was analysed. The NBSZ blood donor risk model developed in 2006, which has four levels [RC I (lower) - RC IV (higher)] of blood safety, was evaluated based on the TTIs seroprevalence results. The TTIs relative risk (RR) for usable (RC I and II) and unusable (RC III and IV) were determined and 95% CI determined. Sub-group analysis by gender was also done to aid in explaining the results. Results: A total of 627,072 donations were analysed. The overall TTIs seroprevalence by donor risk category are shown in Table 1. NBSZ donor risk classification seems to be performing well for all TTIs except for HBV, which has highest seroprevalence in RC II. The overall relative risk (RR) for TTIs in risk categories for unusable units over usable units is 3.5 (95% CI, 3.3-3.8), 1.3 (1.2-1.3), 1.3 (1.1-1.5) and 2.1 (1.9-2.4) for HIV, HBV, HCV and Syphilis respectively. The average RR in all risk categories for males being TTI positive compared to females is 0.70, 1.95, 1.6 and 1.2 for HIV, HBV, HCV and Syphilis respectively. [TABLE PRESENTED] Discussion and conclusions: The results for HIV, HCV and Syphilis indicate increasing safety concerns from low (RC I) to high (RC II) as we expect the model to perform. However, the high HBV seroprevalence in RC II is of concern to blood safety as these are usable blood units. Further analysis also noted that in risk category II, which is mainly composed of new donors in schools, the HBV risk is 68% higher when compared with other combined risk categories. Males are 95%, 60% and 20% more likely to be positive for HBV, HCV and Syphilis than females. However, they are 30% less likely to be HIV positive when compared to female donors. In conclusion, our results points to blood safety concerns for HBV in Zimbabwe and hence there is need to review the current NBSZ blood donor risk classification model taking into consideration other TTIs and cost-effectiveness analysis