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)

Nursing and midwifery students’ experiences and perception of their clinical learning environment in Malawi: A mixed method study

The clinical learning environment is an important part of the nursing and midwifery training as it helps students to integrate theory into clinical practice. However, not all clinical learning environments foster positive learning. This study aimed to assess the student nurses and midwives’ experiences and perception of the clinical learning environment in Malawi. Methods: A concurrent triangulation mixed methods research design was used to collect data from nursing and midwifery students. Quantitative data were collected using a Clinical Learning Environment Inventory, while qualitative data were collected using focus group discussions. The Clinical Learning Environment Inventory has six subscales of satisfaction, involvement, individualisation, innovation, task orientation and personalisation. The focus group interview guide had questions about clinical learning, supervision, assessment, communication and resources. Quantitative data were analysed by independent t-test and multivariate linear regression and qualitative data were thematically analysed. Results: A total of 126 participants completed the questionnaire and 30 students participated in three focus group discussions. Satisfaction subscale had the highest mean score (M = 26.93, SD = 4.82) while individualisation had the lowest mean score (M = 18.01, SD =3.50). Multiple linear regression analysis showed a statistically significant association between satisfaction with clinical learning environment and personalization (β = 0.50, p = < 0.001), and task orientation (β =0.16 p = < 0.05). Teaching and learning resources, hostile environment, poor relationship with a qualified staff, absence of clinical supervisors, and lack of resources were some of the challenges faced by students in their clinical learning environment. Conclusion: Although satisfaction with clinical learning environment subscale had the highest mean score, nursing and midwifery students encountered multifaceted challenges such as lack of resources, poor relationship with staff and a lack of support from clinical teachers that negatively impacted on their clinical learning experiences. Training institutions and hospitals need to work together to find means of addressing the challenges by among others providing resources to students during clinical placemen

Nursing and midwifery students’ experiences and perception of their clinical learning environment in Malawi: a mixedmethod study

Background: The clinical learning environment is an important part of the nursing and midwifery training as it helps students to integrate theory into clinical practice. However, not all clinical learning environments foster positive learning. This study aimed to assess the student nurses and midwives’ experiences and perception of the clinical learning environment in Malawi. Methods: A concurrent triangulation mixed methods research design was used to collect data from nursing and midwifery students. Quantitative data were collected using a Clinical Learning Environment Inventory, while qualitative data were collected using focus group discussions. The Clinical Learning Environment Inventory has six subscales of satisfaction, involvement, individualisation, innovation, task orientation and personalisation. The focus group interview guide had questions about clinical learning, supervision, assessment, communication and resources. Quantitative data were analysed by independent t-test and multivariate linear regression and qualitative data were thematically analysed. Results: A total of 126 participants completed the questionnaire and 30 students participated in three focus group discussions. Satisfaction subscale had the highest mean score (M = 26.93, SD = 4.82) while individualisation had the lowest mean score (M = 18.01, SD =3.50). Multiple linear regression analysis showed a statistically significant association between satisfaction with clinical learning environment and personalization (β = 0.50, p = < 0.001), and task orientation (β =0.16 p = < 0.05). Teaching and learning resources, hostile environment, poor relationship with a qualified staff, absence of clinical supervisors, and lack of resources were some of the challenges faced by students in their clinical learning environment. Conclusion: Although satisfaction with clinical learning environment subscale had the highest mean score, nursing and midwifery students encountered multifaceted challenges such as lack of resources, poor relationship with staff and a lack of support from clinical teachers that negatively impacted on their clinical learning experiences. Training institutions and hospitals need to work together to find means of addressing the challenges by among others providing resources to students during clinical placement

Nursing and midwifery students’ experiences and perception of their clinical learning environment in Malawi: a mixedmethod study

Background: The clinical learning environment is an important part of the nursing and midwifery training as it helps students to integrate theory into clinical practice. However, not all clinical learning environments foster positive learning. This study aimed to assess the student nurses and midwives’ experiences and perception of the clinical learning environment in Malawi. Methods: A concurrent triangulation mixed methods research design was used to collect data from nursing and midwifery students. Quantitative data were collected using a Clinical Learning Environment Inventory, while qualitative data were collected using focus group discussions. The Clinical Learning Environment Inventory has six subscales of satisfaction, involvement, individualisation, innovation, task orientation and personalisation. The focus group interview guide had questions about clinical learning, supervision, assessment, communication and resources. Quantitative data were analysed by independent t-test and multivariate linear regression and qualitative data were thematically analysed. Results: A total of 126 participants completed the questionnaire and 30 students participated in three focus group discussions. Satisfaction subscale had the highest mean score (M = 26.93, SD = 4.82) while individualisation had the lowest mean score (M = 18.01, SD =3.50). Multiple linear regression analysis showed a statistically significant association between satisfaction with clinical learning environment and personalization (β = 0.50, p = < 0.001), and task orientation (β =0.16 p = < 0.05). Teaching and learning resources, hostile environment, poor relationship with a qualified staff, absence of clinical supervisors, and lack of resources were some of the challenges faced by students in their clinical learning environment. Conclusion: Although satisfaction with clinical learning environment subscale had the highest mean score, nursing and midwifery students encountered multifaceted challenges such as lack of resources, poor relationship with staff and a lack of support from clinical teachers that negatively impacted on their clinical learning experiences. Training institutions and hospitals need to work together to find means of addressing the challenges by among others providing resources to students during clinical placement.publishedVersio