Children's intestinal parasite and nutritional patterns in face of integrated school garden, nutrition, water, sanitation and hygiene interventions in central Burkina Faso

Summary Background: Undernutrition is a global public health problem, with over 159 million children under the age of 5 years affected in low- and middle-income countries (LMICs). The determinants of children’s nutritional status are multifactorial. The direct causes of undernutrition in children are insufficient energy and nutrient intake, and recurrent infectious diseases, such as intestinal parasitic infection. Underlying determinants of children’s nutritional status include food insecurity, inadequate child care, weak health systems, and a lack of access to clean water, improved sanitation and adequate hygiene (WASH). To address these challenges, international development organisations are increasingly paying attention to enhancing synergies between agriculture, nutrition and health through multi-sectoral collaboration. Yet, there is a lack of evidence to support the effect of agricultural and health interventions on improving children’s nutritional status, particularly for school-aged children. To fill this gap, a project entitled “Vegetables go to School: Improving Nutrition through Agricultural Diversification” (VgtS) was developed to address schoolchildren’s nutrition in a multi-pronged approach, through introducing school vegetable gardens and other school-based health, nutritional and environmental interventions. The VgtS project is funded by the Swiss Agency for Development and Cooperation (SDC) and was implemented in five countries, including Burkina Faso, with the overall goal of improving schoolchildren’s nutritional status. This PhD thesis was embedded in the VgtS project in Burkina Faso as operational research study to improve the evidence-base of the interlinked approach as well as to influence the design and implementation of the interventions. In Burkina Faso, undernutrition, anaemia and diarrhoeal diseases are the leading causes of morbidity in under-5-year-old children. Whilst Demographic and Health Surveys (DHS) and national nutrition surveillance systems have been measuring the height and weight of children under the age of 5 years, there is a paucity of anthropometric data for school-aged children (8-14 years). Likewise, the global burden of disease from polyparasitism of intestinal parasitic infections caused by helminths and intestinal protozoa has not yet been estimated for school-aged children or for the population of any other age group. Goal and objectives: The overarching goal of this PhD thesis was to assess undernutrition and intestinal parasitic infections among children in rural schools in two regions of Burkina Faso, and to generate evidence on the effects of complementary school garden, nutrition and WASH interventions on schoolchildren’s nutrition and health status. Three specific objectives were pursued: (i) to deepen our understanding on undernutrition and associated risk factors among schoolchildren (8-14 years) at a baseline cross-sectional survey before implementing complementary school garden, nutrition and WASH interventions in the two VgtS project regions; (ii) to investigate intestinal parasites and its associations with household- and school-level WASH conditions at baseline of the implementation of complementary school garden, nutrition and WASH interventions in the two VgtS project regions; and (iii) to assess whether complementary school garden, nutrition and WASH interventions reduce the prevalence of intestinal parasitic infections and improve schoolchildren’s nutritional status. Methods: This study was designed as a cluster-randomised controlled trial, with an equal number of schools randomly allocated to an intervention and to a control group. The intervention group benefited from complementary nutrition and WASH interventions linked to the school garden programme. A baseline cross-sectional survey was conducted between February and March 2015 among 385 children aged 8-14 years in eight randomly selected schools situated in the Plateau Central and Centre-Ouest regions of Burkina Faso. An end-line survey was conducted in the same cohort of children one year after the baseline survey, between February and March 2016. In both surveys, the same field and laboratory procedures were employed. Schoolchildren’s nutritional status was determined by anthropometric measurements. Children were asked to provide single stool and urine samples over two consecutive days, which were examined for infection with helminths and intestinal protozoa. The Kato-Katz method was used to diagnose soil-transmitted helminths (Ascaris lumbricoides, hookworm and Trichuris trichiura), Hymenolepis nana and Schistosoma mansoni. The formalin-ether concentration method was employed to detect both, helminths and intestinal protozoa. Urine samples were examined with a urine filtration technique to identify Schistosoma haematobium eggs. Prevalence of anaemia was determined by measuring haemoglobin levels in finger-prick blood samples. All children found anaemic or infected with intestinal parasites received treatments according to national guidelines. Questionnaires were administered to children to determine their knowledge of nutrition and health and their related attitudes and practices (KAP). Children’s caregivers/parents were administered a questionnaire to assess basic household sociodemographic and economic characteristics, health KAP and WASH conditions. Water samples from community sources, children’s households and children’s drinking water cups were analysed for contamination with coliform bacteria and faecal streptococci using a membrane filtration technique. Results: More than a third (35%) of the children surveyed in the two study regions were undernourished at baseline. The prevalence of undernutrition was higher among children aged 12-14 years compared to their younger peers (8-11 years). Intestinal protozoa were highly prevalent (85%), while faecal-oral transmitted helminths and schistosomiasis showed low prevalence (7% and 4%, respectively) and were mainly of light intensity. Intestinal protozoa were significantly associated with household sociodemographic characteristics. Children from households with freely roaming domestic animals, particularly dogs, showed higher odds of Giardia intestinalis infection. Water quality, household drinking water source and storage did not emerge as significant risk factors for intestinal parasitic infections in children. We further observed that undernutrition, anaemia and parasitic infections were strongly associated. Between the baseline and end-line surveys, the prevalence of intestinal parasitic infections decreased in children from both the intervention and control groups (from 90% to 62%, and from 82% to 72%, respectively) with a significantly stronger decrease in children from the intervention group. Furthermore, adequate handwashing practices before eating and after using latrines at schools increased significantly more among children from the intervention group. Indices of undernutrition and anaemia did not decrease at end-line in the intervention group and water quality remained poor without significant changes. Conclusions: Undernutrition and intestinal parasitic infections, particularly intestinal protozoa infections, are an important public health concern among schoolchildren in the Plateau Central and Centre-Ouest regions of Burkina Faso. In view of our findings and of the multifactorial aetiology of undernutrition, concerted efforts are needed to concurrently address undernutrition, intestinal parasitic infections and access to WASH among schoolchildren. By conducting repeated cross-sectional surveys in a cohort of children, this study showed that a combination of nutritional and WASH-based interventions linked to a school garden programme and delivered through a school platform, holds promise for improving schoolchildren’s health and nutritional status. Our findings call for sustaining the achievements made and for increased public health measures tailored to school-aged children, through multi-sectoral school-, household- and community-based programmes

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)

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)

Health in the 2030 Agenda for Sustainable Development : from framework to action, transforming challenges into opportunities

The critically important role of health for development was underlined in the 16th World Development Report entitled “Investing in health”, published in 1993 [1]. Put forth by the World Bank and enhanced with input from the World Health Organization (WHO), the report examined the interplay between human health, health policy, and economic development. In the period 2000-2015, health for development was strongly emphasized in the Millennium Development Goals (MDGs). Indeed, three of the eight MDGs explicitly featured health [2]. Meanwhile, major achievements have been made in population health. For instance, average global life expectancy has increased by more than 20 years between 1950 and 2010 [3]. Yet, there are areas of unfinished business, such as reducing child mortality and improving maternal health [4]. Key vulnerable groups, such as the poorest and most isolated populations, have been left excluded and marginalized [4,5]. In addition, there are new challenges, as for instance non-communicable diseases have surpassed infectious diseases in terms of global burden [6], novel infectious threats from zoonoses [7] and anti-microbial resistance [8] have emerged, there are toxic mixtures of chemicals compromising human, animal, and ecosystem health, while climate change, urbanization, and migration have amplified health problems and vulnerabilities [9]. Taken together, there are multifactorial stresses that ask for innovative, multi-partner, integrated approaches.ISSN:2047-298

Complementary school garden, nutrition, water, sanitation and hygiene interventions to improve children's nutrition and health status in Burkina Faso and Nepal : a study protocol

Malnutrition and intestinal parasitic infections are common among children in Burkina Faso and Nepal. However, specific health-related data in school-aged children in these two countries are scarce. In the frame of a larger multi-stakeholder project entitled "Vegetables go to School: Improving Nutrition through Agricultural Diversification" (VgtS), a study has been designed with the objectives to: (i) describe schoolchildren's health status in Burkina Faso and Nepal; and to (ii) provide an evidence-base for programme decisions on the relevance of complementary school garden, nutrition, water, sanitation and hygiene (WASH) interventions.; The studies will be conducted in the Centre Ouest and the Plateau Central regions of Burkina Faso and the Dolakha and Ramechhap districts of Nepal. Data will be collected and combined at the level of schools, children and their households. A range of indicators will be used to examine nutritional status, intestinal parasitic infections and WASH conditions in 24 schools among 1144 children aged 8-14 years at baseline and a 1-year follow-up. The studies are designed as cluster randomised trials and the schools will be assigned to two core study arms: (i) the 'complementary school garden, nutrition and WASH intervention' arm; and the (ii) 'control' arm with no interventions. Children will be subjected to parasitological examinations using stool and urine samples and to quality-controlled anthropometric and haemoglobin measurements. Drinking water will be assessed for contamination with coliform bacteria and faecal streptococci. A questionnaire survey on nutritional and health knowledge, attitudes and practices (KAP) will be administered to children and their caregivers, also assessing socioeconomic, food-security and WASH conditions at household level. Focus group and key-informant interviews on children's nutrition and hygiene perceptions and behaviours will be conducted with their caregivers and school personnel.; The studies will contribute to fill a data gap on school-aged children in Burkina Faso and Nepal. The data collected will also serve to inform the design of school-based interventions and will contribute to deepen the understanding of potential effects of these interventions to improve schoolchildren's health in resource-constrained settings. Key findings will be used to provide guidance for the implementation of health policies at the school level in Burkina Faso and Nepal.; ISRCTN30840 (date assigned: 17 July 2015)

Addressing fragility through community-based health programmes: insights from two qualitative case study evaluations in South Sudan and Haiti

Abstract Background Fragility can have a negative effect on health systems and people’s health, and poses considerable challenges for actors implementing health programmes. However, how such programmes, in turn, affect the overall fragility of a context is rarely considered. The Swiss Red Cross has been active in South Sudan and Haiti since 2008 and 2011, respectively, and commissioned a scoping study to shed new light on this issue within the frame of a learning process launched in 2015. Methods The study consisted of a document review, qualitative field research undertaken between June and August 2015 in South Sudan and Haiti, and two data triangulation/validation workshops. Semi-structured key informant interviews and focus group discussions included 49 purposively sampled participants who helped build a deeper understanding of what constitutes and drives fragility in the respective countries. Moreover, interviews and focus group discussions served to grasp positive and negative effects that the Swiss Red Cross’s activities may have had on the overall state of fragility in the given contexts. Results Qualitative data from the two case studies suggest that the community-based health programmes implemented in South Sudan and Haiti may have influenced certain drivers of fragility. While impacts cannot be measured or quantified in the absence of a baseline (the projects were not originally designed to mitigate overall fragility), the study nevertheless reveals entry points for designing programmes that are responsive to the overall fragility context and contain more specific elements for navigating a more sustainable pathway out of fragility. There are, however, multiple challenges, especially considering the complexity of fragile and conflict-affected contexts where a multitude of local and international actors with different goals and strategies interfere in a rapidly changing setting. Conclusions Health programmes may not only reach their health objectives but might potentially also contribute towards mitigating overall fragility. However, considerable hurdles remain for aid agencies, especially where scope for action is limited for a single actor and where engagement with state structures is difficult. Thus, cooperation and exchange with other aid and development actors across the spectrum has to be strengthened to increase the coherence of aid policies and interventions of actors both within and across the different aid communities