Intestinal helminth infections and dietary diversity score predict nutritional status of urban schoolchildren from southern Ethiopia

BACKGROUND: Undernutrition is a major public health problem in developing countries like Ethiopia where schoolchildren are among the vulnerable groups. However, limited attention has been given for the nutritional status of schoolchildren including the lack of available evidence on the magnitude and modifiable risk factors in different parts of the country. Thus, we aimed at determining the magnitude and predictors of undernutrition among schoolchildren in Arba Minch town, southern Ethiopia. METHODS: A school-based cross-sectional study was conducted in March and April, 2014 involving 532 schoolchildren aged 7 to 14 years. A two-stage probability sampling procedure was applied to select study schools and subjects. Anthropometry measurements were taken using standardized techniques and calibrated equipment. Intestinal parasite infections were determined from stool samples using direct saline method and formal ether concentration technique; whereas data on demographic and relevant risk factors were gathered through structured interview of caretakers. Bivariate and multivariable logistic regressions were used to identify predictors of stunting and wasting in the study population. RESULTS: The prevalence of stunting and wasting were 26.0% (95% CI: 22.3, 30.1%) and 11.7% (95% CI: 9.1, 14.9%), respectively. In multivariable model, poor household wealth [AOR (95% CI) = 3.2 (1.2, 8.5)], living in large family [AOR (95% CI) = 2.3 (1.0, 5.1)], lack of maternal formal education [AOR (95% CI) = 4.1 (1.8, 9.4)], low Dietary Diversity Score [AOR (95% CI) = 2.3 (1.2, 4.7)], A. lumbricoides [AOR (95% CI) = 5.0 (2.7, 9.4)], hookworm [AOR (95% CI) = 8.0 (4.0, 15.8)] and T. trichuria [AOR (95% CI) = 6.3 (2.8, 14.1)] infections were associated with stunting. Wasting status was independently associated with not living with both parents [AOR (95% CI) = 2.0 (1.0, 4.1)], poor household wealth [AOR (95% CI) = 8.9 (2.0, 39.2)], and recent illnesses [AOR (95% CI) = 6.3 (3.1, 12.6)]. CONCLUSIONS: Both acute and chronic malnutrition are prevalent among schoolchildren in the study area where intestinal parasite infections, poor dietary quality and common illnesses are important modifiable risk factors. A comprehensive school-based health and nutrition intervention involving parents may help to alleviate the problem including regular deworming and promotion of personal hygiene and balanced diet

Drivers of the trend in child stunting and the role of omega-3 long-chain polyunsaturated fatty acids in relation to child growth and development in rural Ethiopia

Despite the significant progress the world has made over the past few decades, millions of children in low- and middle-income countries still suffer from poor growth and development. Growth faltering during the critical window period of the first 1,000 days after conception is associated with multiple adverse consequences limiting human potential and economic growth. Recognizing the magnitude of the problem and its severe consequences, the World Health Assembly in 2012 endorsed a Comprehensive Implementation Plan on Maternal, Infant, and Young Child Nutrition with six global targets, chief among which is the target to reduce the number of stunted children by 40% in 2025. Identifying priority areas of action in high nutrition-burden countries is the first step to accelerate current progress and achieve the global nutrition targets. For the purpose of facilitating evidence-based decision-making, the first part of this Ph.D. thesis explores nutrition-specific and -sensitive factors that can contribute to a reduction in chronic child undernutrition in low- and middle-income countries. We pooled data from 50 Demographic and Health Surveys conducted in 14 low- and middle-income countries to explain the trend in under-five stunting prevalence over the past two decades. A four-level mixed-effects linear probability model, accounting for clustering of data by sampling clusters, survey-rounds, and countries, was fitted to estimate the association between the change in a range of distal to proximal determinants at a country-level and stunting risk for an individual child while adjusting for time trend and child-level covariates. Furthermore, innovative approaches that maximize the impact of existing nutrition interventions are highly required to assist the progress in low- and middle-income countries. Complementary feeding interventions in low-income settings to date have been focused on the energy and micronutrient content of diets and yielded only small to moderate effects on growth and development. Increasing evidence support the hypothesis that environmental enteric dysfunction, chronic gut inflammation with morphological and functional derangements, and systemic inflammation occurring at a high prevalence in children living in poor settings, could be an important missing link that mediates and reduces the expected benefits from interventions. There is evidence that omega-3 long-chain polyunsaturated fatty acids (n-3 LCPs) may improve gut integrity, reduce inflammation and enhance maturation of the immune system, which could lead to amelioration of this condition and the associated growth impairment. Additionally, some studies in high-income populations showed that n-3 LCPs may have benefits for infant neurocognitive development. However, there is limited evidence from studies testing these potential benefits in infants and young children in a low-income setting. Therefore, in the second part of the PhD thesis, we hypothesized that an increased intake of n-3 LCPs would result in reduced morbidity and inflammation, and improved growth and development of children aged 6-24 months in a low-income setting. To test these proposed hypotheses, we conducted the OME3JIM project involving a 2 x 2 factorial randomized controlled trial of n-3 LCPs-rich fish-oil supplementation (500 mg/day n-3-LCPs) through lactation (MI), complementary feeding (CI), or a combination of both (MCI). We enrolled 360 pairs of lactating mothers and their infants 6-12 months old from three rural communities in Jimma district, southwest Ethiopia. The primary study outcomes were child linear growth, i.e., monthly changes in length-for-age z score (LAZ) over the 12 months intervention follow-up, and the evolution of developmental performance from baseline through 6 and 12 months of the intervention, using the Denver II and the Ages and Stages Questionnaire: Social Emotional tools. Secondary outcomes included LCP concentrations in maternal milk and child blood, anthropometry measurements of weight-for-length z score (WLZ), head-circumference and mid-upper arm circumference (MUAC), nutritional status (stunting, wasting and anemia), common childhood morbidities, and inflammation using C-reactive protein. Chapter 3 presents results of the study on the trend in child stunting. Stunting followed a declining trend in all the 14 countries studied at an average annual reduction rate of 1.04 percentage points (pp). Among the distal factors assessed, a decrease in the Gini coefficient, an improvement in women’s decision-making, and an increase in urbanization over time within a country were significantly associated with a lower risk of stunting. Improvements in households’ access to improved sanitation facilities and drinking water sources, and children’s access to basic vaccinations were the important intermediate service-related drivers of stunting risk identified, whereas an improvement in early initiation of breastfeeding and a decrease in the prevalence of low birthweight were the important proximal drivers. Our findings indicate that although there has been progress in reducing stunting, the rate of reduction in the studied countries was below the average 3.9 pp annual reduction rate required to meet the global target set for 2025. Furthermore, our findings reinforce the need for a combination of nutrition-specific and -sensitive interventions on top of economic development to tackle the problem of chronic childhood undernutrition. The identified drivers will help to guide global efforts to further accelerate stunting reduction and monitor progress against chronic child undernutrition. Results of the OME3JIM study are presented and discussed in Chapters 4-6. From the total of 360 mother-infant pairs enrolled, 87% completed all the 12 months study follow-ups and the mean (SD) duration of supplementation was 11.0 (2.9) months. Compliance rate for the child and the maternal interventions were ~80% and ~70%, with no difference between study arms. All statistical analyses were conducted following the intention-to-treat principle. In Chapter 4, we present the efficacy of fishoil supplementation of lactating mothers on human milk LCP concentrations using a random sub-sample of 154 study participants. Fish-oil supplementation during lactation increased maternal milk concentrations of docosahexaenoic acid (DHA) by 39.0% (P < 0.001) and eicosapentaenoic acid (EPA) by 36.2% (P < 0.001), whereas the ratio of arachidonic acid (AA)/(DHA + EPA) decreased by 53.5% (P < 0.001), compared to the control. However, the maternal milk DHA concentration still remained lower than international norms after the intervention. The results demonstrate that fish-oil supplementation during lactation improves n-3 LCPs status of the maternal milk. In these mothers with a very low baseline breastmilk DHA status, which further declines over the course of lactation, a higher dose of supplementation may be required to attain optimal breastmilk DHA levels. Chapter 5 presents the independent and combined effects of the fish-oil intervention through lactation and complementary food on child n-3 LCPs status, health and growth. Fish-oil supplementation significantly increased child blood n-3 LCPs concentrations (P < 0.01) and decreased the AA/(DHA + EPA) ratio (P < 0.001) in all the MI, CI and MCI intervention arms as compared to the control. Fish-oil intervention also resulted in a better ponderal growth of children, as indicated by the small, but statistically significant, positive effects on monthly WLZ changes in the CI (effect size: 0.022/month; 95% CI: 0.005, 0.039/month; P = 0.012) and MCI arms (effect size: 0.018/month; 95% CI: 0.001, 0.034/month; P = 0.041). We also noted a non-significant trend towards larger monthly MUAC increments in the CI and MCI arms compared to the control. No further effects were detected on the primary study outcome linear growth or on the other secondary outcomes of growth, nutritional status, morbidity, and inflammation. Chapter 6 presents the effects of the same intervention on child development performance. There was no difference between study arms on the evolution of overall and social-emotional developmental performance over time (intervention by time interaction: F = 1.09; P = 0.35, and F = 0.61; P = 0.61, respectively). Overall, the findings from the OME3JIM trial did not support our primary study hypotheses that dietary n-3 LCPs supplementation through lactation and/or complementary feeding improves linear growth and development of infants and young children from a rural setting in Ethiopia. n-3 LCP supplementation given directly to children or in combination with maternal supplementation was found to modestly increase relative weight gain. In conclusion, this PhD research provides evidence on a set of potentially important proximal to distal factors that can contribute to reduction in chronic childhood undernutrition in low- and middle-income countries. It also contributes to the limited literature on the effects of n-3 LCP supplementation in infants and young children in a rural sub-Saharan African setting. In Chapter 7 the implications of the study findings are discussed and recommendations for future research and policy are provided. It is underlined that economic development and nutrition-sensitive interventions, on top of nutrition-specific programs, could play an important role in further reduction of the high stunting burden in low- and middle-income countries. Future follow-up of the OME3JIM cohort is also recommended to determine whether there are long-term effects of the fish-oil intervention

Infant and young child feeding practices and child linear growth in Nepal : regression-decomposition analysis of national survey data, 1996–2016

Suboptimal infant and young child feeding (IYCF) practices have profound implications on child survival, health, growth, and development. First, our study analysed trends in 18 IYCF indicators and height-for-age z-score (HAZ) and stunting prevalence across Nepal's Family Health Survey 1996 and four rounds of Nepal Demographic and Health Surveys from 2001-2016. Second, we constructed multivariable regression models and decomposed the contribution of optimal IYCF practices on HAZ and stunting prevalence over the 1996-2016 period. Our findings indicate that most age-appropriate IYCF practices and child linear growth outcomes improved over the past two decades. At present, according to the World Health Organization's tool for national assessment of IYCF practices, duration of breastfeeding is rated very good, early initiation of breastfeeding and exclusive breastfeeding (EBF) are rated good, whereas minimal bottle-feeding and introduction of solid, semi-solid or soft foods are rated fair. Our study also reports that a paucity of age-appropriate IYCF practices-in particular complementary feeding-are significantly associated with increased HAZ and decreased probability of stunting (p < .05). Moreover, age-appropriate IYCF practices-in isolation-made modest statistical contributions to the rapid and sustained reduction in age-specific child linear growth faltering from 1996-2016. Nevertheless, our findings indicate that comprehensive multisectoral nutrition strategies-integrating and advocating optimal IYCF-are critical to further accelerate the progress against child linear growth faltering. Furthermore, specific focus is needed to improve IYCF practices that have shown no significant development over the past two decades in Nepal: EBF, minimum acceptable diet, and minimal bottle-feeding

Drivers of under-five stunting trend in 14 low- and middle-income countries since the turn of the millennium : a multilevel pooled analysis of 50 demographic and health surveys

Background: Understanding the drivers contributing to the decreasing trend in stunting is paramount to meeting the World Health Assembly's global target of 40% stunting reduction by 2025. Methods: We pooled data from 50 Demographic and Health Surveys since 2000 in 14 countries to examine the relationships between the stunting trend and potential factors at distal, intermediate, and proximal levels. A multilevel pooled trend analysis was used to estimate the association between the change in potential drivers at a country level and stunting probability for an individual child while adjusting for time trends and child-level covariates. A four-level mixed-effects linear probability regression model was fitted, accounting for the clustering of data by sampling clusters, survey-rounds, and countries. Results: Stunting followed a decreasing trend in all countries at an average annual rate of 1.04 percentage points. Among the distal factors assessed, a decrease in the Gini coefficient, an improvement in women's decision-making, and an increase in urbanization were significantly associated with a lower probability of stunting within a country. Improvements in households' access to improved sanitation facilities and drinking water sources, and children's access to basic vaccinations were the important intermediate service-related drivers, whereas improvements in early initiation of breastfeeding and a decrease in the prevalence of low birthweight were the important proximal drivers. Conclusions: The results reinforce the need for a combination of nutrition-sensitive and -specific interventions to tackle the problem of stunting. The identified drivers help to guide global efforts to further accelerate stunting reduction and monitor progress against chronic childhood undernutrition

Usefulness of applying research reporting guidelines as Writing Aid software : a crossover randomised controlled trial

Objectives: To assess the intention of using a Writing Aid software, which integrates four research reporting guidelines (Consolidated Standards of Reporting Trials, Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Strengthening the Reporting of Observational Studies in Epidemiology and STrengthening the Reporting of Observational Studies in Epidemiology-nutritional epidemiology) and their Elaboration & Explanation (E&E) documents during the write-up of research in Microsoft Word compared with current practices. Design: Two-arms crossover randomised controlled trial with no blinding and no washout period. Setting: Face-to-face or online sessions. Participants: 54 (28 in arm 1 and 26 in arm 2) doctoral arid postdoctoral researchers. Interventions: Reporting guidelines and their E&E document were randomly administered as Writing Aid or as Word documents in a single 30 min to 1 hour session, with a short break before crossing over to the other study intervention. Primary and secondary outcomes: Using the Technology Acceptance Model, we assessed the primary outcome: the difference in the mean of intention of use; and secondary outcomes: the difference in mean perceived ease of use and perceived usefulness. The three outcomes were measured using questions with a 7-point Likert-scale. Secondary analysis using structural equation modelling (SEM) was applied to explore the relationships between the outcomes. Results: No significant difference in reported intention of use (mean difference and 95% CI 0.25 (-0.05 to 0.55), p=0.10), and perceived usefulness (mean difference and 95% CI 0.19 (-0.04 to 0.41), p=0.10). The Writing Aid performed significantly better than the word document on researchers' perceived ease of use (mean difference and 95% CI 0.59 (0.29 to 0.89), p<0.001). In the SEM analysis, participants' intention of using the tools was indirectly affected by perceived ease of use (beta 0.53 p=0.002). Conclusions: Despite no significant difference in the intention of use between the tools, administering reporting guidelines as Writing Aid is perceived as easier to use, offering a possibility to further explore its applicability to enhance reporting adherence

Maternal nutritional status mediates the association between maternal age and birth outcomes

Young maternal age during pregnancy is linked with adverse birth outcomes. This study examined the role of maternal nutritional status in the association between maternal age and small for gestational age (SGA) delivery and birth length. We used data from a birth cohort study in Ethiopia, involving women who were 15-24 years of age and their newborns. A mediation analysis was fitted in a sample of 1,422 mother infant dyads for whom data on birth length were available, and 777 dyads for whom gestational age and birth weight was measured. We used commands, medeff for the mediation analysis and medsens for sensitivity analysis in STATA 14. Maternal nutritional status, measured by mid-upper arm circumference, mediated 21% of the association between maternal age and birth length and 14% of the association with SGA delivery. The average direct effect (ADE) of maternal age on birth length was (beta = 0.45, 95% CI [0.17, 0.99]) and the average causal mediated effect (ACME) was (beta = 0.12, 95% CI [0.02, 0.15]). We also found an ADE (beta = 0.31, 95% CI [0.09, 0.47]) and an ACME of (beta = 0.05, 95% CI [0.003, 0.205]) of maternal age on SGA delivery. The sensitivity analysis suggests an unmeasured confounder with a positive correlation of 0.15 and 0.20 between the mediator and the outcome could explain the observed ACME for birth length and SGA, respectively. We cannot make strong causal assertions as the findings suggest the mediator partly explained the total effect of maternal age on both outcomes

Freeze desalination as point-of-use water defluoridation technique

Freeze desalination, i.e., desalination of water by freezing it, may be an option to treat polluted water at individual household level. Taking into account the widespread fluoride contamination of Ethiopian water resources and with the reason that most households in semi-urban and urban areas do have easier accessibility of refrigerators, this study aimed to investigate the defluoridation capacity of freeze desalination and its energy consumption for different water sources. For this purpose, synthetic solutions that emulate the major ion compositions of natural waters (hereafter called simulated water), tap water, and double-distilled water to which variable concentrations of fluoride ions were added were evaluated using home-use insulated refrigerator (BEKO, RRN 2650). The effects of conditions such as initial fluoride concentration, multi-ion existence, fraction of ice frozen, volume of the container, and freezing duration were evaluated in relation to the produced ice quality. It was found that nearly 48% and 62% removal of fluoride were achieved from tap water spiked with 10mg/L F- and 10mg/L F- aqueous solutions, respectively, with a total water recovery of 85 to 90%. The energy consumption predicted to produce the ice from tap water spiked with 10mg/L F- and double-distilled water alone was found to be 93.9 and 91.8kJ/L, respectively. The results showed that freeze desalination can be a potential technique for fluoride removal from water to be used as drinking water at household level in semi-urban and urban areas as well as in colder regions

Elucidating the sustained decline in under‐three child linear growth faltering in Nepal, 1996-2016

Childhood linear growth faltering remains a major public health concern in Nepal. Nevertheless, over the past 20 years, Nepal sustained one of the most rapid reductions in the prevalence of stunting worldwide. First, our study analysed the trends in height-for-age z-score (HAZ), stunting prevalence, and available nutrition-sensitive and nutrition-specific determinants of linear growth faltering in under-three children across Nepal's Family Health Survey 1996 and Nepal's Demographic and Health Surveys 2001, 2006, 2001, and 2016. Second, we constructed pooled multivariable linear regression models and decomposed the contributions of our time-variant determinants on the predicted changes in HAZ and stunting over the past two decades. Our findings indicate substantial improvements in HAZ (38.5%) and reductions in stunting (-42.6%) and severe stunting prevalence (-63.9%) in Nepalese children aged 0-35 months. We also report that the increment in HAZ, across the 1996-2016 period, was significantly associated (confounder-adjustedp< .05) with household asset index, maternal and paternal years of education, maternal body mass index and height, basic child vaccinations, preceding birth interval, childbirth in a medical facility, and prenatal doctor visits. Furthermore, our quantitative decomposition of HAZ identified advances in utilisation of health care and related services (31.7% of predicted change), household wealth accumulation (25%), parental education (21.7%), and maternal nutrition (8.3%) as key drivers of the long-term and sustained progress against child linear growth deficits. Our research reiterates the multifactorial nature of chronic child undernutrition and the need for coherent multisectoral nutrition-sensitive and nutrition-specific strategies at national scale to further improve linear growth in Nepal

Solar disinfection: an approach for low-cost household water treatment technology in Southwestern Ethiopia

Disinfection of contaminated water using solar radiation (SODIS) is known to inactivate bacteria. Its inactivation efficiency depends on local conditions where the disinfection is made. This study was aiming to test the efficiency of solar disinfection using different water parameters as low-cost household water treatment technology. Inactivation of microbes was tested using fecal coliform as test organism. The SODIS experiment was carried out at turbidity 2NTU, pH 7, and various water temperature (38.1°C, 41.8°C, 45.6°Cand 51.1°C) and solar intensities, using clear and black plastic bottles filled to different depths. The results show that the rate of microbial inactivation in relation to depth of water, turbidity, container type, intensity of light and color of container was statistically significant (p < 0.05). However, bottle placement, exposure and water pH were unrelated to microbial inactivation. Bacterial re-growth was not observed after solar disinfection. By adjusting the parameters, complete and irreversible fecal coliform inactivation was achieved within an exposure time of less than four hours in the areas where the solar irradiance is about 3.99 kW/m(2) and above. Our results indicate that application of SODIS could play a significant role in the provision of safe water in rural communities of developing countries where there is ample sunshine, specifically in sub-Saharan African countries

Household food insecurity and its association with school absenteeism among primary school adolescents in Jimma zone, Ethiopia

Abstract Background Household food insecurity and lack of education are two of the most remarkable deprivations which developing countries are currently experiencing. Evidences from different studies showed that health and nutrition problems are major barriers to educational access and achievement in low-income countries which poses a serious challenge on effort towards the achieving Sustainable Development Goals. Evidence on the link between food security and school attendance is very important to address this challenge. This study aimed to assess to what extent food insecurity affects school absenteeism among primary school adolescents. Methods A school based cross-sectional study was conducted among primary school adolescents in Jimma zone from October-November, 2013. Structured questionnaire was used to collect data on the household food security and socio-demographic variables. Data were analyzed using SPSS for windows version 16.0 after checking for missing values and outliers. Multivariable logistic regression analyses were used to determine the association of school absenteeism and food insecurity with independent variables using odds ratio and 95 % of confidence intervals. Variables with p ≤ 0.25 in the bivariate analyses were entered into a multivariable regression analysis to control for associations among the independent variables. Results The frequency of adolescent school absenteeism was significantly high (50.20 %) among food insecure households (P < 0.001) compared to their peers whose households were food secure (37.89 %). Findings of multivariable logistic regression analysis also showed that household food insecurity [AOR = 2.81 (1.70, 4.76)] was positively associated with poor school attendance while female-headed household [AOR = 0.23 (0.07, 0.72)], urban residence [AOR = 0.52 (0.36, 0.81)] and male-gender [AOR = 0.64 (0.54, 0.74)] were inversely associated with school absenteeism. Household food insecurity was positively associated with lack of maternal education [AOR = 2.26 (0.57, 8.93)] and poor household economic status [AOR = 1.39 (1.18, 2.83)]. However, livestock ownership [AOR = 0.17 (0.06, 0.51)] was negatively associated with household food insecurity. Conclusions Findings of this study showed that household food insecurity has strong linkage with adolescent school absenteeism. Maternal education and household economic status were significantly associated with household food security status. Therefore, national policies and programs need to stress on how to improve family income earning capacity and socioeconomic status to handle household food insecurity which is a key contributor of adolescent school absenteeism