Integrated school garden, nutrition, water, sanitation and hygiene interventions for improving nutritional and health status of schoolchildren in Nepal

Background: Malnutrition occurs at all stages of the lifecycle. However, there is little information on malnutrition during school age. The concentration of malnutrition in Asia is greater than anywhere else on Earth. It is reported that 156 million children are stunted, 50 million children are wasted and more than 50% of the 146 million underweight children in the world are living in the South Asia. Malnutrition is a major underlying cause of child mortality within Nepal and anaemia among infants and children is high. In Nepal, 41% percent of children were suffering from chronic malnutrition in 2011. Similarly, iron-deficiency anaemia is one of the top ten leading causes of years of life with disability among all age groups. The dietary risks, malnutrition, unsafe water, sanitation and hygiene (WASH) are among the top ten causes of disability-adjusted life years (DALYs). Intestinal parasitic infections are among common public health problems of children in Nepal and the infection rate has primarily been attributed to the appalling unhygienic environmental conditions. The intestinal parasitic infection and amoebic dysentery stand second among the top ten causes of hospital visits within the country. According to the Global Burden of Diesease Study (GBD) and the World Health Organisation (WHO)/United Nations Chidren’s Fund (UNICEF) “Joint Monitoring Programme for Water Supply and Sanitation”, 8% of deaths in children aged 8-14 years in Nepal, were caused by diarrhoeal diseases and attributed to inadequate WASH condition as a primary risk factor. Nutrition as a cross-cutting theme is closely interlinked with multifactorial determinants. Malnutrition is an outcome of poor nourishment (i.e. inadequate, unbalanced or excessive nourishment), while other factors, such as illness and poor sanitation also contribute to malnutrition. Three interacting groups of underlying factors contribute, in turn, to inadequate dietary intake and infectious diseases: household food insecurity; inadequate maternal and child care; and poor health and environmental services. Hence to address these challenges, the more recent strategic frameworks call for a combination of nutrition-sensitive and nutrition-specific interventions, including synergies between agriculture, nutrition and WASH. However, there is lack of evidence about the contribution of integrated agriculture, nutrition and WASH interventions in minimising malnutrition and anaemia. A project entitled “Vegetables go to School: improving nutrition through agricultural diversification” (VgtS) has been developed to improve schoolchildren’s nutrition, through introducing school vegetable gardens and additional complementary school-based health interventions. The VgtS project is funded by the Swiss Agency for Development and Cooperation (SDC) and was implemented in five countries (i.e. Burkina Faso, Bhutan, Indonesia, Nepal and the Philippines). This PhD thesis was embedded in the VgtS project in Nepal as an operational research study to contribute to the outcome 3 of the project; generating increased knowledge on how school vegetable gardens contribute to improved nutrition and health of schoolchildren, as well as the interaction with WASH. Goal and objectives: This PhD thesis aims at assessing the effects of complementary school garden, nutrition and WASH interventions on nutrition and health status of schoolchildren in Nepal. In order to achieve this aim, the following four specific objectives were pursued: (i) to investigate the WASH conditions at the unit of selected schools, households and community in the districts of Dolakha and Ramechhap in Nepal; (ii) to determine the local epidemiology of malnutrition and intestinal parasitic infection among schoolchildren; (iii) to assess the knowledge, attitude and practices (KAP) of schoolchildren and caregivers regarding nutrition and WASH conditions; and (iv) to evaluate the effects of supplemented complementary school gardens, nutrition and WASH interventions on children nutritional and health status. Methods: The study was designed as a cluster-randomised controlled trial (RCT). The trial included 12 schools randomised into three arms: arm 1 implementing a school garden (SG); arm 2 with additional WASH and nutrition complementary interventions (SG+WASH); and arm 3 without any interventions (control) in the districts of Dolakha and Ramechhap of Nepal. The baseline cross-sectional survey was conducted between March and May 2015 among 705 children aged 8-16 years. The pack of complementary interventions to the school garden has been implemented after the baseline survey. A follow-up survey was conducted within the same cohort of children one year after the baseline survey, in June 2016. In both surveys, questionnaires were administered to evaluate WASH conditions at the level of schools, households and communities. Dietary intake was assessed using a food frequency questionnaire and 24-hours (24-h) recall. Haemoglobin (Hb) levels were measured using a HaemoCue digital photometer. Stool samples were subjected to wet-mount, Kato-Katz and formalin-ether concentration methods for the diagnosis of intestinal parasitic infections. Water quality was assessed using the Delagua testing kit and flame atomic absorption method. Results: A total of 75% of school drinking water source samples and 77% point-of-use samples at schools, 40% water source samples in the community, and 27% point-of-use samples at household levels were contaminated with thermo-tolerant coliforms (TTC). The values of water samples for pH (6.8–7.6), free and total residual chlorine (0.1–0.5 mg/L), mean lead concentration (0.01 mg/L), and mean arsenic concentration (0.05 mg/L) were within national drinking water quality standards. The presence of domestic animals roaming inside schoolchildren’s homes was significantly associated with drinking water contamination (adjusted odds ratio (aOR): 1.64; 95% confidence interval (CI): 1.08–2.50; p=0.02). Overall, 27.0% of the participating children were stunted and 11.3% were wasted. We observed a significant difference of stunting and wasting between boys and girls (stunting: 31.6% for boys versus 22.8% for girls, p=0.01; wasting: 15.9% for boys versus 7.1% for girls, p=0.01). We also found a significant difference in stunting between the two districts where Dolakha had a higher stunting rate than Ramechhap (30.1% in Dolakha versus 15.7% in Ramechhap; p=0.01). The overall prevalence of anaemia was 23.9% at baseline. The lack of meals prepared in the households (aOR=2.36, 95% CI: 1.14-4.92; p=0.01) and not having supper (aOR=3.46, 95% CI: 1.09-11.03; p=0.04) were significantly associated with anaemia. The dietary diversity scores were lower among anaemic compared to non-anaemic children. Consumption of vitamin A-rich fruits and vegetables were negatively associated with anaemia, but not significantly so. More than half (55.0%) of the children had at least one sign (e.g., loss of hair pigment) of nutritional deficiency. The overall prevalence of intestinal parasite infections was 39.7%. Trichuris trichiura and Giardia intestinalis were the predominant helminth and intestinal protozoa species, with a prevalence of 31.0% each. Children from households lacking soap for hand washing were at higher odds of intestinal parasite infections (aOR=1.81; 95% CI: 1.13-2.89; p=0.01), while children from households without freely roaming domestic animals showed lower odds of G. intestinalis compared to those households with such animals (aOR 0.52; 95% CI: 0.33-0.83; p=0.01). We found considerable morbidity among the surveyed children, including fever (31%) and watery diarrhoea (22%). Water contamination with TTC did not emerge as significant risk factor for intestinal parasitic infections. This study shows that the diet of surveyed schoolchildren mainly comprised of starchy staples and legumes. The mean consumption of animal product per week was low (1.96 for poultry, 1.18 for red meat, 0.81 for fish and 0.91 for milk products). Five dietary patterns were derived: mixed food, vegetables and lentils, milk products, salty snacks, and processed food pattern scores. The vegetables and lentils pattern scores were negatively associated with stunting (aOR 0.84; 95% CI: 0.66-1.08, p=0.17) after adjusting for regional differences, demographic and behaviour risk factors, however not significant. At the follow-up, stunting was slightly reduced in complementary intervention arm (SG+WASH) (20% to 18%; p=0.92, compared to control) contrary to a slight increase in the school garden arm (SG) (18% to 20%; p=0.54, compared to control) and control (20% to 19%). Anaemia slightly decreased in SG+WASH (33% to 32%; p<0.01, compared to control) and markedly increased in the control arm (23% to 42%) and the SG (21% to 44%; p=0.56, compared to control). Handwashing with soap (i) before eating and (ii) after defecation strongly increased in SG+WASH arm (i) 74% to 97%; p=0.01 compared to control with 78% to 84%; (ii) 77% to 99%; p=0.36 compared to control with 78% to 92%. While the prevalence of parasite infections significantly declined in SG+WASH arm (37% to 9%; p<0.01, compared to control) and a minor decline in SG (34% to 27%; p=0.42, compared to control) and stable in the control arm (44% to 42%). Conclusions: Malnutrition, anaemia and intestinal parasitic infections, particularly soil-transmitted helminths, are of an important public health concern among schoolchildren in the districts of Dolakha and Ramechhap, Nepal. Our complementary interventions implemented in schools and households, increased children’s awareness on fruits and vegetables intake, reduced anaemia, stunting and intestinal parasitic infections among schoolchildren within one year. Hence, this study showed that a combination of agricultural, nutritional and WASH-based interventions, readily delivered through the school platform, could improve schoolchildren’s health and nutritional status. Our findings call for a sustained joint national effort for integrating agriculture, nutrition and WASH interventions at schools, households and communities levels

Water carrying in hills of Nepal-associations with women's musculoskeletal disorders, uterine prolapse, and spontaneous abortions.

More than a third of women in Nepal have to carry water from source to home to satisfy their families' daily needs. A cross-sectional study was carried out in a hilly area in Nepal to assess water-carrying practices and their association with women's health. Quantitative interviews were conducted with 1001 women of reproductive age and were complemented with health surveys carried out by health professionals and structured observations of water carrying. Multivariate mixed logistic regression models were used to assess the associations between water-carrying-related risk factors and health issues for women. Around 46% of women faced considerably increased to excessive physical stress due to water carrying during the dry season. Women suffered from a disproportionately high prevalence of back pain (61%), with about 18% of this pain being horrible to excruciating; pain in the knees (34%); uterine prolapse (11.3%); and at least one spontaneous abortion (9%). The risk category of water carrying was significantly associated with uterine prolapse (OR = 1.44, 95%CI = 1.12-1.85, p = 0.031) and pain in the hips (OR = 1.69, 95%CI = 1.27-2.26, p<0.001). Receiving help with water carrying during pregnancy and during the first three months after delivery was associated with reduced odds ratios for uterine prolapse (OR = 0.10, 95% CI = 0.01-0.87, p = 0.037), and strong back pain (OR = 0.32, 95% CI = 0.12-0.87, p = 0.026). Improvements to water supply infrastructure and the promotion of social support for carrying water during pregnancy and after delivery are recommended to reduce water-carrying-related health risks

Understanding safe water‐carrying practices during pregnancy and postpartum: A mixed‐methods study in Nepal

Daily carrying of heavy loads of domestic water, especially during pregnancy and postpartum, bears a threat to maternal health in low-income countries. Using an extended health action process approach (HAPA), we examined women's reasons for and psychosocial determinants of safe water-carrying during pregnancy and postpartum. In a mixed-methods study, trained local interviewers conducted 1001 quantitative interviews with women of reproductive age (n = 921 analyzed) and 21 qualitative interviews with women of reproductive age, in-laws, and spouses in rural Nepal. We analyzed the quantitative data with generalized estimating equations to model the HAPA-based psychosocial determinants of avoiding water-carrying during pregnancy and postpartum. Subjective perspectives were investigated with thematic analysis. Outcome expectancies (B = 0.24), self-efficacy (B = 0.20), and injunctive norms (B = 0.23) were significantly associated with the intention to avoid water-carrying. Self-efficacy (B = 0.36) and instrumental support (B = 0.05) are related to behavior (all p < 0.05). Women explained water-carrying during pregnancy by a lack of family support, a shift of health decision-making power to in-laws, and low behavioral control. Overall, the necessity of water, family decision-making structures, and low support make it difficult for women to discontinue water-carrying. Additionally to infrastructural improvements, behavioral interventions may increase women's self-efficacy for safe water-carrying (e.g. reducing weight) and social support

Nutritional and health status of children 15 months after integrated school garden, nutrition, and water, sanitation and hygiene interventions: a cluster-randomised controlled trial in Nepal

It has been suggested that specific interventions delivered through the education sector in low- and middle-income countries might improve children's health and wellbeing. This cluster-randomised controlled trial aimed to evaluate the effects of a school garden programme and complementary nutrition, and water, sanitation and hygiene (WASH) interventions on children's health and nutritional status in two districts of Nepal.; The trial included 682 children aged 8-17 years from 12 schools. The schools were randomly allocated to one of three interventions: (a) school garden programme (SG; 4 schools, n = 172 children); (b) school garden programme with complementary WASH, health and nutrition interventions (SG+; 4 schools, n = 197 children); and (c) no specific intervention (control; 4 schools, n = 313 children). The same field and laboratory procedures were employed at the baseline (March 2015) and end-line (June 2016) surveys. Questionnaires were administered to evaluate WASH conditions at schools and households. Water quality was assessed using a Delagua kit. Dietary intake was determined using food frequency and 24-h recall questionnaire. Haemoglobin levels were measured using HemoCue digital device and used as a proxy for anaemia. Stool samples were subjected to a suite of copro-microscopic diagnostic methods for detection of intestinal protozoa and helminths. The changes in key indicators between the baseline and end-line surveys were analysed by mixed logistic and linear regression models.; Stunting was slightly lowered in SG+ (19.9 to 18.3%; p = 0.92) and in the control (19.7 to 18.9%). Anaemia slightly decreased in SG+ (33.0 to 32.0%; p < 0.01) and markedly increased in the control (22.7 to 41.3%; p < 0.01), a minor decline was found in the control (43.9 to 42.4%). Handwashing with soap before eating strongly increased in SG+ (from 74.1 to 96.9%; p = 0.01, compared to control where only a slight increase was observed from 78.0 to 84.0%). A similar observation was made for handwashing after defecation (increase from 77.2 to 99.0% in SG+ versus 78.0 to 91.9% in control, p = 0.15).; An integrated intervention consisting of school garden, WASH, nutrition and health components (SG+) increased children's fruit and vegetable consumption, decreased intestinal parasitic infections and improved hygiene behaviours.; ISRCTN17968589 (date assigned: 17 July 2015)

Amniotic Band Syndrome with CTEV and Meningocele: A Rare Case Report

Amniotic band syndrome (ABS) is a group of rare congenital abnormalities caused by wrapping of parts of the foetus by fibrous amniotic bands during intrauterine life. It can be seen in infants without any known genetic mutations. Band formation most frequently affects the distal segments, including the hand. Here, we report a case of a neonate who presented with multiple congenital abnormalities and clinical features that suggest the Amniotic Band Syndrome. It was delivered by a 17-year-old female patient at 28 weeks period of gestation, who had a medical abortion

Prevalence and risk factors of undernutrition among schoolchildren in the Plateau Central and Centre-Ouest regions of Burkina Faso

Multiple factors determine children's nutritional status, including energy and nutrient intake, recurrent infectious diseases, access (or lack thereof) to clean water and improved sanitation, and hygiene practices, among others. The "Vegetables go to School: improving nutrition through agricultural diversification" (VgtS) project implements an integrated school garden programme in five countries, including Burkina Faso. The aim of this study was to determine the prevalence of undernutrition and its risk factors among schoolchildren in Burkina Faso before the start of the project.; In February 2015, a cross-sectional survey was carried out among 455 randomly selected children, aged 8-14 years, in eight schools in the Plateau Central and Centre-Ouest regions of Burkina Faso. Nutritional status was determined by anthropometric assessment. Helminth and intestinal protozoa infections were assessed using the Kato-Katz and a formalin-ether concentration method. A urine filtration technique was used to identify Schistosoma haematobium eggs. Prevalence of anaemia was determined by measuring haemoglobin levels in finger-prick blood samples. Questionnaires were administered to children to determine their knowledge of nutrition and health and their related attitudes and practices (KAP). Questionnaires were also administered to the children's caregivers to identify basic household socio-demographic and economic characteristics, and water, sanitation and hygiene (WASH) conditions. To determine the factors associated with schoolchildren's nutritional status, mixed logistic regression models were used. Differences and associations were considered statistically significant if P-values were below 0.05.; Complete datasets were available for 385 children. The prevalence of undernutrition, stunting and thinness were 35.1%, 29.4% and 11.2%, respectively. The multivariable analysis revealed that undernutrition was associated with older age (i.e. 12-14 years compared to &lt;12 years; adjusted odds ratio (aOR) = 3.45, 95% confidence interval (CI) 2.12-5.62, P &lt; 0.001), multiple pathogenic parasitic infections (aOR = 1.87, 95% CI 1.02-3.43, P = 0.044) and with moderate and severe anaemia in children (aOR = 2.52, 95% CI 1.25-5.08, P = 0.010).; We found high prevalence of undernutrition among the children surveyed in the two study regions of Burkina Faso. We further observed that undernutrition, anaemia and parasitic infections were strongly associated. In view of these findings, concerted efforts are needed to address undernutrition and associated risk factors among school-aged children. As part of the VgtS project, WASH, health education and nutritional interventions will be implemented with the goal to improve children's health.; ISRCTN17968589 (date assigned: 17 July 2015)

Prevalence of intestinal parasitic infections and associated risk factors among schoolchildren in the Plateau Central and Centre-Ouest regions of Burkina Faso

BACKGROUND: Unsafe drinking water, unimproved sanitation and lack of hygiene pose health risks, particularly to children in low- and middle-income countries. This study aimed to assess the prevalence and risk factors of intestinal parasitic infections in school-aged children in two regions of Burkina Faso. METHODS: A cross-sectional survey was carried out in February 2015 with 385 children aged 8-14 years from eight randomly selected schools in the Plateau Central and Centre-Ouest regions of Burkina Faso. Stool samples were subjected to the Kato-Katz and a formalin-ether concentration method for the diagnosis of helminths and intestinal protozoa infections. Urine samples were examined with a urine filtration technique for Schistosoma haematobium eggs. Water samples from community sources (n = 37), children's households (n = 95) and children's drinking water cups (n = 113) were analysed for contamination with coliform bacteria and faecal streptococci. Data on individual and family-level risk factors were obtained using a questionnaire. Mixed logistic regression models were employed to determine factors associated with intestinal parasitic infections in schoolchildren. RESULTS: Intestinal parasitic infections were highly prevalent; 84.7 % of the children harboured intestinal protozoa, while helminth infections were diagnosed in 10.7 % of the children. We found significantly lower odds of pathogenic intestinal protozoa infection (Entamoeba histolytica/E. dispar and Giardia intestinalis) among children from the Plateau Central, compared to the Centre-Ouest region (P < 0.001). Children from households with "freely roaming domestic animals" (P = 0.008), particularly dogs (P = 0.016) showed higher odds of G. intestinalis, and children reporting exposure to freshwater sources through domestic chores had higher odds of S. haematobium infection compared to children without this water contact activity (P = 0.035). Water quality, household drinking water source and storage did not emerge as significant risk factors for intestinal parasitic infections in children. CONCLUSIONS: Intestinal protozoa but not helminths were highly prevalent among schoolchildren in randomly selected schools in two regions of Burkina Faso. Our findings call for specific public health measures tailored to school-aged children and rural communities in this part of Burkina Faso. It will be interesting to assess the effect of water, sanitation and hygiene interventions on the transmission of intestinal parasitic infections

Intestinal parasite infections and associated risk factors among schoolchildren in Dolakha and Ramechhap districts, Nepal: a cross-sectional study

Infections with soil-transmitted helminths and pathogenic intestinal protozoa pose a considerable public health burden, particularly in low- and middle-income countries, including Nepal. We assessed the extent of intestinal parasite infections among schoolchildren in two districts of Nepal and determined underlying risk factors.; A cross-sectional survey was conducted between March and May 2015 in the districts of Dolakha and Ramechhap, Nepal. A total of 708 children, aged 8-16 years from 16 purposively selected schools, were enrolled. Each child provided a single stool sample that was subjected to a suite of copro-microscopic diagnoses for intestinal protozoa and helminths. Drinking water samples from different sources at schools (n = 29), community places (n = 43) and households (n = 562) were analysed for contamination with thermotolerant coliforms (TTC). A questionnaire was administered to determine individual- and household-level risk factors of intestinal parasite infections. Self-reported symptoms were assessed and a clinical examination was undertaken by a physician. Haemoglobin was measured and used as a proxy for anaemia. Mixed logistic regression models were applied to investigate associations.; The overall prevalence of intestinal parasite infections was 39.7%. Trichuris trichiura (30.9%), Giardia intestinalis (30.5%) and hookworm (30.2%) were the predominant intestinal parasite infections. Children from households lacking soap for handwashing were at higher odds of intestinal parasite infections than children who had soap [adjusted odds ratio (aOR) 1.81; 95% confidence interval (CI): 1.13-2.89; P = 0.01]. Children from households without freely roaming domestic animals showed lower odds of G. intestinalis compared to children from households with freely roaming animals (aOR 0.52; 95% CI: 0.33-0.83; P = 0.01). One out of three (31.0%) children suffered from fever and 22.4% had watery diarrhoea within a two-week recall period. Anaemia was diagnosed in 23.6% of the children. Water contamination with TTC showed no clear association with intestinal parasite infection.; Intestinal parasites are common among schoolchildren in the two surveyed districts of Nepal. An important risk factor was lack of soap for handwashing. Our findings call for efforts to control intestinal parasite infection and emphasis should be placed on improvements in water, sanitation and hygiene interventions.; ISRCTN17968589 (date assigned: 17 July 2015)

Risk profiling of soil-transmitted helminth infection and estimated number of infected people in South Asia : a systematic review and Bayesian geostatistical analysis

In South Asia, hundreds of millions of people are infected with soil-transmitted helminths (Ascaris lumbricoides, hookworm, and Trichuris trichiura). However, high-resolution risk profiles and the estimated number of people infected have yet to be determined. In turn, such information will assist control programs to identify priority areas for allocation of scarce resource for the control of soil-transmitted helminth infection.; We pursued a systematic review to identify prevalence surveys pertaining to soil-transmitted helminth infections in four mainland countries (i.e., Bangladesh, India, Nepal, and Pakistan) of South Asia. PubMed and ISI Web of Science were searched from inception to April 25, 2019, without restriction of language, study design, and survey date. We utilized Bayesian geostatistical models to identify environmental and socioeconomic predictors, and to estimate infection risk at high spatial resolution across the study region.; A total of 536, 490, and 410 georeferenced surveys were identified for A. lumbricoides, hookworm, and T. trichiura, respectively. We estimate that 361 million people (95% Bayesian credible interval (BCI) 331-395 million), approximately one-quarter of the South Asia population, was infected with at least one soil-transmitted helminth species in 2015. A. lumbricoides was the predominant species. Moderate to high prevalence (&gt;20%) of any soil-transmitted helminth infection was predicted in the northeastern part and some northern areas of the study region, as well as the southern coastal areas of India. The annual treatment needs for the school-age population requiring preventive chemotherapy was estimated at 165 million doses (95% BCI: 146-185 million).; Our risk maps provide an overview of the geographic distribution of soil-transmitted helminth infection in four mainland countries of South Asia and highlight the need for up-to-date surveys to accurately evaluate the disease burden in the region