Hand-washing and its impact on child health in Kathmandu, Nepal

Gut damage, resulting in maldigestion or malabsorption of food and stimulation of the immune system, has been linked to growth faltering in young children in the developing world. Gut damage occurs along a spectrum, with only the more severe damage resulting in visible symptoms such as diarrhoea; most gut damage in young children is sub-clinical but chronic, and over time it can have a significant impact on a child’s growth rate. Hand-washing with soap has been found to reduce the risk of diarrhoea by 42-47%. Would this simple intervention also reduce the sub-clinical yet chronic form of gut damage associated with childhood growth faltering? Framed within the bio-cultural research paradigm, and theoretically informed by insights from Critical Medical Anthropology, this study used a mixed-method, longitudinal approach in order to investigate this question. Eighty-eight children aged 3-12 months were recruited from eight slum communities in Kathmandu, Nepal. Each community was allocated to a control or intervention group (n=43 and 45 children, respectively). In intervention areas, a community-based hand-washing with soap programme was devised and implemented for six months; in control areas, mothers continued their normal practices. The intervention was evaluated by comparing five outcomes: rates of maternal hand-washing, levels of child morbidity, gut damage, immune stimulation and growth faltering in the two groups. Hand-washing rates increased amongst intervention mothers: by the end of the intervention, mothers living in hand-washing areas were more likely to report hand-washing with soap after cleaning the baby’s bottom and before cooking, eating or feeding the child (for all, P<.01). As a result, children in the intervention areas experienced a decrease in both the number of diarrhoeal episodes (3.0 vs. 4.3 episodes, P=.049) and the number of days with diarrhoeal symptoms over the period of study (9.67 vs. 16.33 days, P=.023). Yet, despite reducing diarrhoeal morbidity, hand-washing had no impact on the biochemical or growth status of the children: there was no significant reduction in levels of gut damage or immune stimulation in children from intervention areas over the period of the study. Consequently there was no improvement in growth rates for these children, as measured by height-for-age, weight-for-age and weight-for-height z-scores. This study concludes that when children live in highly contaminated, over-crowded environments, with poor access to clean water and sanitation, selective interventions focusing on one small behavioural change are unlikely to have an impact. In such highly contaminated environments, faecal contamination of hands is just one of the many pathways by which these children are exposed to pathogenic organisms. The biggest threat to the health of these children is not poor hygiene behaviour, but life in the slum. Comprehensive strategies to provide basic services and raise general standards of living in the slums are the best way in which to have a significant impact: piecemeal interventions focusing on single issues risk being ineffective both in terms of health impact and cost-effectiveness. This point is situated within the literature on effective and sustainable health interventions and the wider social and political debates surrounding global public health policy and practice in the 21st Century

What do young people think about their school-based sex and relationship education?:A qualitative synthesis of young people’s views and experiences

OBJECTIVES: Although sex and relationship education (SRE) represents a key strand in policies to safeguard young people and improve their sexual health, it currently lacks statutory status, government guidance is outdated and a third of UK schools has poor-quality SRE. We aimed to investigate whether current provision meets young people's needs. DESIGN: Synthesis of qualitative studies of young people's views of their school-based SRE. SETTING: Eligible studies originated from the UK, Ireland, the USA, Australia, New Zealand, Canada, Japan, Iran, Brazil and Sweden. PARTICIPANTS: Studies of students aged 4–19 in full-time education, young adults ≤19 (not necessarily in full-time education) or adults ≤25 if recalling their experiences of school-based SRE. RESULTS: –69 publications were identified, with 55 remaining after quality appraisal (representing 48 studies). The synthesis found that although sex is a potent and potentially embarrassing topic, schools appear reluctant to acknowledge this and attempt to teach SRE in the same way as other subjects. Young people report feeling vulnerable in SRE, with young men anxious to conceal sexual ignorance and young women risking sexual harassment if they participate. Schools appear to have difficulty accepting that some young people are sexually active, leading to SRE that is out of touch with many young people's lives. Young people report that SRE can be negative, gendered and heterosexist. They expressed dislike of their own teachers delivering SRE due to blurred boundaries, lack of anonymity, embarrassment and poor training. CONCLUSIONS: SRE should be ‘sex-positive’ and delivered by experts who maintain clear boundaries with students. Schools should acknowledge that sex is a special subject with unique challenges, as well as the fact and range of young people's sexual activity, otherwise young people will continue to disengage from SRE and opportunities for safeguarding and improving their sexual health will be reduced

The World Health Organization’s Health Promoting Schools framework: a Cochrane systematic review and meta-analysis

BACKGROUND: Healthy children achieve better educational outcomes which, in turn, are associated with improved health later in life. The World Health Organization's Health Promoting Schools (HPS) framework is a holistic approach to promoting health and educational attainment in school. The effectiveness of this approach has not yet been rigorously reviewed. METHODS: We searched 20 health, education and social science databases, and trials registries and relevant websites in 2011 and 2013. We included cluster randomised controlled trials. Participants were children and young people aged four to 18 years attending schools/colleges. HPS interventions had to include the following three elements: input into the curriculum; changes to the school's ethos or environment; and engagement with families and/or local communities. Two reviewers identified relevant trials, extracted data and assessed risk of bias. We grouped studies according to the health topic(s) targeted. Where data permitted, we performed random-effects meta-analyses. RESULTS: We identified 67 eligible trials tackling a range of health issues. Few studies included any academic/attendance outcomes. We found positive average intervention effects for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small. On average across studies, we found little evidence of effectiveness for zBMI (BMI, standardized for age and gender), and no evidence for fat intake, alcohol use, drug use, mental health, violence and bullying others. It was not possible to meta-analyse data on other health outcomes due to lack of data. Methodological limitations were identified including reliance on self-reported data, lack of long-term follow-up, and high attrition rates. CONCLUSION: This Cochrane review has found the WHO HPS framework is effective at improving some aspects of student health. The effects are small but potentially important at a population level

The Health Promoting Schools Framework: Known Unknowns and an Agenda for Future Research.

The World Health Organization's Health Promoting Schools (HPS) framework is a whole-school approach to promoting health that recognizes the intrinsic relationship between health and education. Our recent Cochrane systematic review found HPS interventions produced improvements in a number of student health outcomes. Here we reflect on what this review was not able to tell us: in other words, what evidence is missing with regard to the HPS approach. Few HPS interventions engage with schools' "core business" by examining impacts on educational outcomes. Current evidence is dominated by obesity interventions, with most studies conducted with children rather than adolescents. Evidence is lacking for outcomes such as mental or sexual health, substance use, and violence. Activities to engage families and communities are currently weak and unlikely to prompt behavioral change. The HPS approach is largely absent in low-income settings, despite its potential in meeting children's basic health needs. Intervention theories are insufficiently complex, often ignoring upstream determinants of health. Few studies provide evidence on intervention sustainability or cost-effectiveness, nor in-depth contextual or process data. We set out an agenda for future school health promotion research, considering implications for key stakeholders, namely, national governments, research funders, academics, and schools

Pilot trial and process evaluation of a multilevel smoking prevention intervention in further education settings

Background: Preventing smoking uptake among young people is a public health priority. Further education (FE) settings provide access to the majority of 16- to 18-year-olds, but few evaluations of smoking prevention interventions have been reported in this context to date. Objectives: To evaluate the feasibility and acceptability of implementing and trialling a new multilevel smoking prevention intervention in FE settings. Design: Pilot cluster randomised controlled trial and process evaluation. Setting: Six UK FE institutions. Participants: FE students aged 16–18 years. Intervention: ‘The Filter FE’ intervention. Staff working on Action on Smoking and Health Wales’ ‘The Filter’ youth project applied existing staff training, social media and youth work resources in three intervention settings, compared with three control sites with usual practice. The intervention aimed to prevent smoking uptake by restricting the sale of tobacco to under-18s in local shops, implementing tobacco-free campus policies, training FE staff to deliver smoke-free messages, publicising The Filter youth project’s online advice and support services, and providing educational youth work activities. Main outcome measures: (1) The primary outcome assessed was the feasibility and acceptability of delivering and trialling the intervention. (2) Qualitative process data were analysed to explore student, staff and intervention team experiences of implementing and trialling the intervention. (3) Primary, secondary and intermediate (process) outcomes and economic evaluation methods were piloted. Data sources: New students at participating FE settings were surveyed in September 2014 and followed up in September 2015. Qualitative process data were collected via interviews with FE college managers (n = 5) and the intervention team (n = 6); focus groups with students (n = 11) and staff (n = 5); and observations of intervention settings. Other data sources were semistructured observations of intervention delivery, intervention team records, ‘mystery shopper’ audits of local shops and college policy documents. Results: The intervention was not delivered as planned at any of the three intervention settings, with no implementation of some community- and college-level components, and low fidelity of the social media component across sites. Staff training reached 28 staff and youth work activities were attended by 190 students across the three sites (< 10% of all eligible staff and students), with low levels of acceptability reported. Implementation was limited by various factors, such as uncertainty about the value of smoking prevention activities in FE colleges, intervention management weaknesses and high turnover of intervention staff. It was feasible to recruit, randomise and retain FE settings. Prevalence of weekly smoking at baseline was 20.6% and was 17.2% at follow-up, with low levels of missing data for all pilot outcomes. Limitations: Only 17% of eligible students participated in baseline and follow-up surveys; the representativeness of student and staff focus groups is uncertain. Conclusions: In this study, FE settings were not a supportive environment for smoking prevention activities because of their non-interventionist institutional cultures promoting personal responsibility. Weaknesses in intervention management and staff turnover also limited implementation. Managers accept randomisation but methodological work is required to improve student recruitment and retention rates if trials are to be conducted in FE settings. Trial registration: Current Controlled Trials ISRCTN19563136. Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 5, No. 8. See the NIHR Journals Library website for further project information. It was also funded by the Big Lottery Fund

A qualitative study of parental strategies to enable pre-school children’s outdoor and nature experiences during COVID-19 restrictions

Outdoor and nature experiences including play have been shown to be beneficial for children's physical, cognitive, social and emotional development. Parents/carers play an important role in encouraging or impeding their child's access to the outdoor environment and participation in outdoor play. The COVID-19 pandemic and associated restrictions on free movement and social interactions placed an unprecedented pressure on families to manage the drastic change in their daily routines. This paper reports findings from two combined data sets generated in 2020 during the COVID-19 pandemic and provides a deeper understanding of the interconnected nature of how contextual factors influence parenting processes and outcomes relating to young children's outdoor and nature experiences and subsequent child health. Findings have the potential to inform the messaging of existing outdoor play policies and the content of new interventions aiming to promote the exposure of children to the natural outdoor environment

Improving chronological control for environmental sequences from the last glacial period

Recognition of palaeoclimatic instability in the Greenland ice cores has spurred researchers to identify corresponding evidence in other terrestrial records from the last glacial stage. Such evidence is critical for establishing how much environmental stress precipitated Neanderthal and Late Pleistocene megafaunal extinctions, although a need for improved chronology has been consistently highlighted. In formerly glaciated and periglaciated areas of northern Europe, palaeoenvironmental sequences are frequently discontinuous. These often yield high-resolution proxy-based quantitative palaeotemperature estimates but can be hard to date, due to difficulties in removing contamination from biological samples at the limits of the radiocarbon technique (c.30-50kya). Here we demonstrate, for the first time using samples with independent age control, that different radiocarbon pretreatments can generate different age data and that gentler, less effective treatments applied to avoid sample loss may not yield reliable age-estimates. We advocate alternative harsher pretreatment using a strong acid-base-acid protocol. This provides an acceptable balance between contamination removal and excessive sample loss and generates more accurate ages, significantly enhancing our ability to detect and understand the impacts of palaeoclimatic instability in the terrestrial record of the last glacial

Demystifying academics to enhance university-business collaborations in environmental science

In countries globally there is intense political interest in fostering effective university-business collaborations, but there has been scant attention devoted to exactly how an individual scientist's workload (i.e. specified tasks) and incentive structures (i.e. assessment criteria) may act as a key barrier to this. To investigate this an original, empirical dataset is derived from UK job specifications and promotion criteria, which distil universities' varied drivers into requirements upon academics. This work reveals the nature of the severe challenge posed by a heavily time-constrained culture; specifically, tension exists between opportunities presented by working with business and non-optional duties (e.g. administration and teaching). Thus, to justify the time to work with business, such work must inspire curiosity and facilitate future novel science in order to mitigate its conflict with the overriding imperative for academics to publish. It must also provide evidence of real-world changes (i.e. impact), and ideally other reportable outcomes (e.g. official status as a business' advisor), to feed back into the scientist's performance appraisals. Indicatively, amid 20-50 key duties, typical full-time scientists may be able to free up to 0.5 day per week for work with business. Thus specific, pragmatic actions, including short-term and time-efficient steps, are proposed in a "user guide"to help initiate and nurture a long-term collaboration between an early- to mid-career environmental scientist and a practitioner in the insurance sector. These actions are mapped back to a tailored typology of impact and a newly created representative set of appraisal criteria to explain how they may be effective, mutually beneficial and overcome barriers. Throughout, the focus is on environmental science, with illustrative detail provided through the example of natural hazard risk modelling in the insurance sector. However, a new conceptual model of academics' behaviour is developed, fusing perspectives from literature on academics' motivations and performance assessment, which we propose is internationally applicable and transferable between sectors. Sector-specific details (e.g. list of relevant impacts and user guide) may serve as templates for how people may act differently to work more effectively together