SummaryBackgroundChild 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.MethodsWe 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.FindingsBetween 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.InterpretationHousehold-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not r...

Child stunting and anemia are intractable public health problems in developing countries and have profound short- and long-term consequences. The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial is motivated by the premise that environmental enteric dysfunction (EED) is a major underlying cause of both stunting and anemia, that chronic inflammation is the central characteristic of EED mediating these adverse effects, and that EED is primarily caused by high fecal ingestion due to living in conditions of poor water, sanitation, and hygiene (WASH). SHINE is a proof-of-concept, 2 × 2 factorial, cluster-randomized, community-based trial in 2 rural districts of Zimbabwe that will test the independent and combined effects of protecting babies from fecal ingestion (factor 1, operationalized through a WASH intervention) and optimizing nutritional adequacy of infant diet (factor 2, operationalized through an infant and young child feeding [IYCF] intervention) on length and hemoglobin at 18 months of age. Within SHINE we will measure 2 causal pathways. The program impact pathway comprises the series of processes and behaviors linking implementation of the interventions with the 2 child health primary outcomes; it will be modeled using measures of fidelity of intervention delivery and household uptake of promoted behaviors and practices. We will also measure a range of household and individual characteristics, social interactions, and maternal capabilities for childcare, which we hypothesize will explain heterogeneity along these pathways. The biomedical pathway comprises the infant biologic responses to the WASH and IYCF interventions that ultimately result in attained stature and hemoglobin concentration at 18 months of age; it will be elucidated by measuring biomarkers of intestinal structure and function (inflammation, regeneration, absorption, and permeability); microbial translocation; systemic inflammation; and hormonal determinants of growth and anemia among a subgroup of infants enrolled in an EED substudy. This article describes the rationale, design, and methods underlying the SHINE trial.Clinical Trials Registration. NCT01824940.

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Background: Healthcare workers and students on training who are directly involved in treating and nursing patients face a great risk of acquiring blood-borne infections from the workplace. Needle prick injuries (NPI) are the commonest route by which such infections are transmitted from patients to healthcare providers. Nursing students on training are no exception, as they get exposed to accidental needle pricks and contamination during their hospital activities. Lack of appropriate resources, knowledge and skills, coupled with the unavailability of the universal standard precautionary procedures and compliance thereof, constitute high risks for needle prick injuries. Adequate knowledge and adherence to safety practices could prevent the occurrence of NPI and the related consequences. A survey was conducted among nursing students at a specific university in Gauteng to assess their knowledge of NPI, to identify and describe factors that contribute to the occurrence of NPI, and to discover the circumstances of needle prick accidents among the targeted group of students. Methods: A cross-sectional quantitative survey was conducted among nursing students from the second to the fourth year of study registered at the specific university for the 2007 academic year. Questionnaires were hand delivered to a convenient sample of nursing students attending mandatory nursing classes. Those who consented signed a consent form. Participants completed and handed back the questionnaires to the researchers on the same day that they were delivered. Data collected included factors contributing to NPI and high-risk procedures leading to NPI, as perceived by these students. A knowledge assessment of NPI guidelines, policies and protocols and prevalence of NPI among these students was also done. Results: A response rate of 96 (74%) was achieved. The average age of the respondents was 23 years, with a minimum age of 18 and a maximum age of 35. The sample consisted of more females than males. The majority of respondents were in the second year of study. The majority (56%) rated needle recapping, disposing used needles (28.1%) and cleaning sharp instruments (56.3%) as extremely high-risk procedures. Furthermore, 30.2% of the respondents thought suturing and blood taking (33.3%) were high-risk procedures for NPI, while 25% rated administering injections, 35.5% rated blood transfusion and 74.8% rated the lack of adequate containers for sharps disposal to be highly associated with the risk of NPI. A significant proportion of the respondents rated the lack of knowledge about NPI (policies and protocols) at institutions of clinical training as an extremely high risk, followed by the lack of accompaniment and in-service training. Only 16.0% of the respondents had suffered NPI and only 8.3% had reported the incident. Conclusion: Procedures rated as high risk were considered to be most likely associated with the occurrence of NPI. Appropriate guidelines, adequate knowledge and the enforcement of compliance with standard precautionary measures cou...

Access to water and sanitation are important determinants of behavioral responses to hygiene and sanitation interventions. We estimated cluster-specific water access and sanitation coverage to inform a constrained randomization technique in the SHINE trial. Technicians and engineers inspected all public access water sources to ascertain seasonality, function, and geospatial coordinates. Households and water sources were mapped using open-source geospatial software. The distance from each household to the nearest perennial, functional, protected water source was calculated, and for each cluster, the median distance and the proportion of households within <500 m and >1500 m of such a water source. Cluster-specific sanitation coverage was ascertained using a random sample of 13 households per cluster. These parameters were included as covariates in randomization to optimize balance in water and sanitation access across treatment arms at the start of the trial. The observed high variability between clusters in both parameters suggests that constraining on these factors was needed to reduce risk of bias.