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)

Kivunhoidon ohjaus syöpää sairastavan potilaan ja hänen läheisensä kuvaamana palliatiivisessa hoidossa:integroitu kirjallisuuskatsaus

Abstract Aim: The purpose of this integrative review was to describe patients and their caregivers’ views of pain counseling to patients who are terminally ill and suffer from cancer pain. Data and methods: The data was collected from studies included in scientific databases at systematic search, focusing on studies published in Finnish or in English between the years 2000 and 2018. A quality assessment of these studies was carried out and after that nine peer reviewed studies were accepted for this review. The data was analyzed by content analysis. Results: Based on results, patients and their caregivers were satisfied with counseling they have received, but they need more information of pain, painkillers, side effects of medicine and non-pharmacological interventions in pain relief. Pain counseling should be organized and congruent, regardless who provides the counseling. Patients and caregivers have experienced that interaction during counseling as good, because it increases the possibilities to meet the individual counseling needs. Due to counseling, the use of pain management methods increased among patients and caregivers and additionally, counseling reduced patients and their caregivers’ fears against to painkillers. Discussion: Pain management counseling improves the patient’s quality of life. In the future, it would be important to solve the question of how to integrate palliative care and pain management counseling as a part of the holistic care of the patient and family caregivers already earlier than now.Tiivistelmä Tutkimuksen tarkoitus: Integroidun kirjallisuuskatsauksen tarkoituksena oli kuvata kivunhoidon ohjausta palliatiivisessa hoidossa olevan, syöpää sairastavan potilaan ja hänen läheisensä näkökulmasta. Aineisto ja menetelmät: Tiedonhaut tehtiin tieteellisiin viitetietokantoihin systemaattisella haulla. Haut kohdistettiin vuosina 2000–2018 julkaistuihin vertaisarvioituihin suomen- tai englanninkielisiin artikkeleihin. Aineistoksi valikoitui yhdeksän sisäänotto- ja laadunarviointikriteerit täyttävää artikkelia. Aineisto analysoitiin sisällönanalyysillä. Tulokset: Tutkimusten mukaan potilaat ja läheiset olivat tyytyväisiä saamaansa ohjaukseen, mutta toivoivat saavansa lisää tietoa kivusta, kipulääkityksestä, lääkityksen sivuvaikutuksista sekä lääkkeettömistä kivunlievitysmenetelmistä. Esille tuli myös, että kivunhoidon ohjauksen tulee olla suunniteltua ja yhdenmukaista, riippumatta siitä kuka ohjausta toteuttaa. Potilaat ja läheiset ovat kokeneet vuorovaikutuksellisen ohjauksen hyväksi, sillä se mahdollisti yksilöllisten ohjaustarpeiden huomioimisen. Potilaat ja läheiset ovat kokeneet kivunhoidon ohjauksen monipuolistaneen kivunhoitomenetelmien käyttöä ja vähentäneen heidän ennakkoluulojaan kipulääkitystä kohtaan. Päätelmät: Kivunhoidon ohjauksen on todettu parantavan potilaan elämänlaatua. Jatkossa olisi hyvä tutkia palliatiivisen hoidon ja laadukkaan kivunhoidon ohjauksen integroimista osaksi potilaan ja läheisen kokonaisvaltaista hoitotyötä entistä varhaisemmassa vaiheessa