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

Nutritional status of school-age children (5-19 years) in South Asia: A scoping review

Information on malnutrition for school-age children and adolescents (5-19 years) in South Asia is fragmented and inconsistent, which limits the prioritization of nutrition policies, programmes and research for this age group. This scoping review aimed to synthesize existing evidence on the burden of malnutrition for children and adolescents aged 5-19 years in South Asia, and on interventions to improve their nutritional status. Cochrane Library, EMBASE, Medline and Google Scholar were systematically searched for articles published between January 2016 and November 2022. Eligible studies reported the prevalence of undernutrition, overweight/obesity, micronutrient deficiencies and unhealthy dietary intakes, and interventions that aimed to address these in South Asia. In total, 296 articles met our inclusion criteria. Evidence revealed widespread, yet heterogeneous, prevalence of undernutrition among South Asian children and adolescents: thinness (1.9%-88.8%), wasting (3%-48%), underweight (9.5%-84.4%) and stunting (3.7%-71.7%). A triple burden of malnutrition was evident: the prevalence of overweight and obesity ranged from 0.2% to 73% and 0% to 38% (with rapidly rising trends), respectively, alongside persistent micronutrient deficiencies. Diets often failed to meet nutritional requirements and high levels of fast-food consumption were reported. Education, fortification, supplementation and school feeding programmes demonstrated beneficial effects on nutritional status. Comprehensive and regular monitoring of all forms of malnutrition among children and adolescents, across all countries in South Asia is required. Further, more large-scale intervention research is needed to ensure policy and programmes effectively target and address malnutrition among children and adolescents in South Asia.

Water, sanitation and hygiene (WASH) practices and deworming improve nutritional status and anemia of unmarried adolescent girls in rural Bangladesh

BACKGROUND

In Bangladesh, undernutrition and anemia are more occurrent among adolescent girls. BRAC, the largest non-governmental organization (NGO), has been implementing a community-based nutrition education service package targeting adolescent girls for reducing their undernutrition and anemia.

OBJECTIVE

We aimed to explore the underlying factors associated with nutritional status and anemia among adolescent girls under the BRAC nutrition program areas to improve their existing intervention package.

METHODOLOGY

We conducted a cross-sectional and comparative study in 2016, in 24 upazilas of Bogra, Barguna, Comilla, Dinajpur, Feni, Jessore, and Meherpur districts where the BRAC nutrition program was implemented while the remaining 27 upazilas of those districts were selected as comparison area. We followed a multistage cluster random sampling for selecting 1620 unmarried adolescent girls aged 10-19 years for interviewing in the intervention and comparison areas. Data were collected on socio-demographic information, dietary intake, morbidity, water, sanitation, and hygiene (WASH) practice, anthropometry, and serum hemoglobin (Hb) level by using a pre-structured questionnaire. The nutritional status of the adolescent girls was expressed as height-for-age Z (HAZ) and body mass index-for-age Z (BMIZ) score, while anemia referred to the serum Hb at the level of below 12 g/dl for adolescent girls. All statistical analyses were done in STATA version 17 (Chicago Inc.).

FINDINGS

The prevalence of stunting (22.9% vs. 22.5%), thinness (12% vs. 14%), and anemia (34.5% vs. 37.3%) exhibited similarities between the intervention and comparison regions. Stunting and thinness were predictors for each other for this population group. Our findings indicated that adolescent girls who were not washing hands with soap after defecation were likely to be stunted [AOR 1.51 (95% CI 1.12-2.04)], and who did not utilize sanitary latrines had an increased likelihood of being thin [AOR 2.38 (95% CI 1.11-5.08)]. Conversely, those who did not watch television [AOR 1.69 (95% CI 1.12-2.56)] and did not have deworming tablets [AOR 1.33 (95% CI 1.07-1.64)] in the 6 months leading up to the interview had a 69% and 33% higher probability of being anemic, respectively.

CONCLUSION

For sustainable improvement in the undernutrition and anemia of adolescent girls, integration of WASH, consistent administration of deworming tablets and broadcasting awareness programs through television are urgent to scale up the nutrition intervention programs in similar settings like Bangladesh.

Health Issues Among Nepalese Youth: A Literature Review

Nepal is one of the world's least-developed countries. Nepalese children are often vulnerable to a lack of resources which leads to suboptimal levels of health in turn. This review article aims to identify health issues and inequities faced by school-aged children greater than five years old in Nepal. A comprehensive search of the literature was conducted in PubMed and Global Health databases to gather relevant studies. Inclusion and exclusion criteria were applied to select appropriate articles, and 35 full-length articles were reviewed in-depth. The literature supports the association between inadequate resource distribution among Nepalese children and poorer health outcomes compared to youth in developed countries. The key health issues of Nepalese youth identified in the literature consist of diarrheal illness, stunted growth, dental caries, visual impairment, poor mental health, and low health literacy. This review article aims to identify key health issues affecting Nepalese youth as well as propose interventions that can lead to an enhanced quality of life in this population.

Effect of an Integrated School Garden and Home Garden Intervention on Anemia Among School-Aged Children in Nepal: Evidence From a Cluster Randomised Controlled Trial

BACKGROUND

Integrated school and home garden interventions can improve health outcomes in low-income countries, but rigorous evidence remains scarce, particularly for school-aged children and to reduce anemia.

OBJECTIVE

We test if an integrated school and home garden intervention, implemented at pilot stage, improves hemoglobin levels among school children (aged 9-13 years) in a rural district in the mid-hills of Nepal.

METHODS

We use a cluster randomized controlled trial with 15 schools each in the control and treatment groups (n = 680 school children). To test if nutritional improvements translate into a reduction of anemia prevalence, hemoglobin data were collected 6 months after intervention support had ended. Using structural equation modeling, we estimate the direct and indirect effects of the treatment through several pathways, including nutritional knowledge, good food and hygiene practices, and dietary diversity.

RESULTS

The integrated school and home garden intervention did not lead to a direct significant reduction in anemia. Causal positive changes of the treatment on nutritional outcomes, although significant, are not strong enough to impact hemoglobin levels. The program improved hemoglobin levels indirectly for children below 12 by increasing the use of good food and hygiene practices at home. These practices are associated with higher hemoglobin levels, particularly for girls, young children, and in households where caregivers are literate.

CONCLUSIONS

Even integrated school and home garden interventions are not sufficient to reduce anemia among school children. Incorporating behavioral change components around food and hygiene practices into integrated garden interventions is important to unlocking their health impacts.

Analysis of dynamic change of nutrition status in primary school children of Furong District of Changsha City from 2019 to 2020

OBJECTIVE

To analyze the nutritional status of primary school children in Furong District of Changsha from 2019 to 2020.

METHODS

The physical examination data of students from 35 primary schools (grade 1-6) in Furong District of Changsha in Hunan Provincial People's Hospital from September 2019 to October 2020 were analyzed retrospectively. General information of all children was collected for statistical analysis of malnutrition among children of different gender and age groups.

RESULT

The overnutrition rate was 32.73% in 2020. This was 7.42% higher than 25.31% in 2019. The undernourishment rate was 4.70% in 2020. This was 3.94% lower than 8.64% in 2019. In 2019 and 2022, the obesity and overweight rates of boys were higher than those of girls (both P < 0.05). The rates of growth retardation (0.36%, 0.37%) for boys were higher than those for girls (0.27%, 0.24%). The rates of mild wasting (4.31%, 2.36%) were lower than those for girls (4.00%, 2.39%) in 2020 and 2019. The rates of moderate and severe wasting (4.06%, 1.98%) were higher than those for girls (2.75%, 1.47%). In 2020, the undernourishment rate for boys decreased by 4.02% compared to 2019. The undernourishment rate for girls decreased by 2.91% compared to 2019. The growth retardation rate for boys increased by 0.01% compared to 2019. The growth retardation rate for girls decreased by 0.03% compared to 2019. The mild wasting rate for boys decreased by 1.95% as compared to 2019. The mild wasting rate for girls decreased by 1.61% as compared to 2019. The moderate to severe emaciation rate in boys was 2.08% lower in 2020 than in 2019 and 1.28% lower in girls than in 2019. The malnutrition rates of children aged 6-11 decreased by 4.20%, 4.85%, 3.83%, 9.45%, 6.65%, and 6.45% in 2020 compared with that of 2019.

CONCLUSION

Compared to 2019, the primary school students in Furong District had abnormal nutritional status in 2020. It is necessary to strengthen the management of children's health care to ensure the healthy growth of children.

Water, sanitation, hygiene practices, health and nutritional status among children before and during the COVID-19 pandemic: longitudinal evidence from remote areas of Dailekh and Achham districts in Nepal

Background

The COVID-19 pandemic drew hygiene to the center of disease prevention. The provision of adequate water, sanitation, and hygiene (WASH) services is crucial to protect public health during a pandemic. Yet, access to levels of water supply that support adequate hygiene measures are deficient in many areas in Nepal. We examined WASH practices and their impact on child health and nutritional status in two districts before and during the COVID-19 pandemic.

Methods

A longitudinal and mixed method study was conducted in March–May 2018 and November–December 2021. In total, 715 children aged 0–10 years were surveyed at baseline. Of these, 490 children were assessed at endline. Data collection methods included observations, a questionnaire, stool analysis, anthropometric measurements, water quality analysis, and an assessment of clinical signs of nutritional deficiencies. We conducted 10 in-depth interviews to understand major problems related to COVID-19.

Results

Most respondents (94.2%) had heard about COVID-19; however, they did not wear face masks or comply with any social distancing protocols. Almost 94.2% of the households self-reported handwashing with soap 5–10 times per day at endline, especially after defecation, compared to 19.6% at baseline. Water quality was better at endline than at baseline with median 12 to 29 CFU Escherichia coli/100 mL (interquartile range at baseline [IQR] = 4–101) at the point of collection and 34 to 51.5 CFU Escherichia coli/100 mL (IQR = 8–194) at the point of consumption. Fever (41.1–16.8%; p = 0.01), respiratory illness (14.3–4.3%; p = 0.002), diarrhea (19.6–9.5%; p = 0.01), and Giardia lamblia infections (34.2–6.5%, p = 0.01) decreased at endline. In contrast, nutritional deficiencies such as bitot’s spots (26.7–40.2%; p = 0.01), pale conjunctiva (47.0–63.3%; p = 0.01), and dermatitis (64.8–81.4%; p = 0.01) increased at endline. The inadequacy of the harvest and the lack of household income to meet households’ nutritional needs increased drastically (35.0–94.2%; p = 0.01).

Conclusion

We found that improved water quality and handwashing practices were associated with a decrease in infectious diseases. However, food security also decreased resulting in a high prevalence of nutritional deficiencies. Our findings underline that disaster preparedness should consider access to adequate WASH, nutrition, and health supplies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14346-8.

School water, sanitation, and hygiene (WaSH) intervention to improve malnutrition, dehydration, health literacy, and handwashing: a cluster-randomised controlled trial in Metro Manila, Philippines

BACKGROUND

The impacts of multicomponent school water, sanitation, and hygiene (WaSH) interventions on children's health are unclear. We conducted a cluster-randomized controlled trial to test the effects of a school WaSH intervention on children's malnutrition, dehydration, health literacy (HL), and handwashing (HW) in Metro Manila, Philippines.

METHODS

The trial lasted from June 2017 to March 2018 and included children, in grades 5, 6, 7, and 10, from 15 schools. At baseline 756 children were enrolled. Seventy-eight children in two clusters were purposively assigned to the control group (CG); 13 clusters were randomly assigned to one of three intervention groups: low-intensity health education (LIHE; two schools, n = 116 children), medium-intensity health education (MIHE; seven schools, n = 356 children), and high-intensity health education (HIHE; four schools, n = 206 children). The intervention consisted of health education (HE), WaSH policy workshops, provision of hygiene supplies, and WaSH facilities repairs. Outcomes were: height-for-age and body mass index-for-age Z scores (HAZ, BAZ); stunting, undernutrition, overnutrition, dehydration prevalence; HL and HW scores. We used anthropometry to measure children's physical growth, urine test strips to measure dehydration, questionnaires to measure HL, and observation to measure HW practice. The same measurements were used during baseline and endline. We used multilevel mixed-effects logistic and linear regression models to assess intervention effects.

RESULTS

None of the interventions reduced undernutrition prevalence or improved HAZ, BAZ, or overall HL scores. Low-intensity HE reduced stunting (adjusted odds ratio [aOR] 0.95; 95% CI 0.93 to 0.96), while low- (aOR 0.57; 95% CI 0.34 to 0.96) and high-intensity HE (aOR 0.63; 95% CI 0.42 to 0.93) reduced overnutrition. Medium- (adjusted incidence rate ratio [aIRR] 0.02; 95% CI 0.01 to 0.04) and high-intensity HE (aIRR 0.01; 95% CI 0.00 to 0.16) reduced severe dehydration. Medium- (aOR 3.18; 95% CI 1.34 to 7.55) and high-intensity HE (aOR 3.89; 95% CI 3.74 to 4.05) increased observed HW after using the toilet/urinal.

CONCLUSION

Increasing the intensity of HE reduced prevalence of stunting, overnutrition, and severe dehydration and increased prevalence of observed HW. Data may be relevant for school WaSH interventions in the Global South. Interventions may have been more effective if adherence was higher, exposure to interventions longer, parents/caregivers were more involved, or household WaSH was addressed.

TRIAL REGISTRATION NUMBER

DRKS00021623.

Interventions for Neglected Tropical Diseases Among Children and Adolescents: A Meta-analysis

BACKGROUND

Neglected tropical diseases (NTDs) are a group of communicable diseases affecting the poorest populations around the world.

OBJECTIVE

To assess the effectiveness of interventions, including mass drug administration (MDA), water, sanitation, and hygiene (WASH), vector control, health education, and micronutrients supplementation, for NTDs among children and adolescents.

METHODS

We conducted a literature search on the Cochrane Controlled Trials Register, Medline, and other databases until December 2020. We included randomized controlled trials and quasi-experimental studies conducted among children and adolescents. Two authors independently screened studies for relevance. Two authors independently extracted data, assessed the risk of bias, performed metaanalysis, and rated the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation.

RESULTS

We included 155 studies (231 articles) involving 262 299 participants. For soil-transmitted helminthiasis, MDA may reduce the prevalence of Ascaris, Trichuris, and hookworm by 58%, 36%, and 57%, respectively. We are uncertain of the effect of health education, WASH, and iron supplementation on soil-transmitted helminthiasis prevalence. For Schistosomiasis, health education probably reduces the intensity and prevalence of S. mansoni, whereas micronutrient supplementation may reduce anemia prevalence and the infection intensity of S. hematobium compared with no supplementation. We are uncertain of the effect of MDA and vector control on Schistosomiasis outcomes. For trachoma, health education probably reduces the prevalence of active Trachoma, whereas we are uncertain of the effect of MDA, WASH, and vector control on Trachoma outcomes. There is limited data on the effectiveness of interventions for NTDs targeting children and adolescents.

CONCLUSION

Future studies are needed to evaluate the relative effectiveness and cost-effectiveness of various interventions specifically targeting children and adolescents.

Nature and Children's Health: A Systematic Review

CONTEXT

Daily outdoor play is encouraged by the American Academy of Pediatrics. Existing evidence is unclear on the independent effect of nature exposures on child health.

OBJECTIVE

We systematically evaluated evidence regarding the relationship between nature contact and children's health.

DATA SOURCES

The database search was conducted by using PubMed, Cumulative Index to Nursing and Allied Health Literature, PsychInfo, ERIC, Scopus, and Web of Science in February 2021.

STUDY SELECTION

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In all searches, the first element included nature terms; the second included child health outcome terms.

DATA EXTRACTION

Of the 10 940 studies identified, 296 were included. Study quality and risk of bias were assessed.

RESULTS

The strongest evidence for type of nature exposure was residential green space studies (n = 147, 50%). The strongest evidence for the beneficial health effects of nature was for physical activity (n = 108, 32%) and cognitive, behavioral, or mental health (n = 85, 25%). Physical activity was objectively measured in 55% of studies, and 41% of the cognitive, behavioral, or mental health studies were experimental in design.

LIMITATIONS

Types of nature exposures and health outcomes and behaviors were heterogenous. Risk of selection bias was moderate to high for all studies. Most studies were cross-sectional (n = 204, 69%), limiting our ability to assess causality.

CONCLUSIONS

Current literature supports a positive relationship between nature contact and children's health, especially for physical activity and mental health, both public health priorities. The evidence supports pediatricians in advocating for equitable nature contact for children in places where they live, play, and learn.

Integrated Approach in Addressing Undernutrition in Developing Countries: A Scoping Review of Integrated Water Access, Sanitation, and Hygiene (WASH) + Nutrition Interventions

A scoping review of integrated water access, sanitation, and hygiene (WASH) plus nutrition interventions was conducted mainly to describe different components of intervention and examine their effectiveness in improving nutritional outcomes among children. Of the 8 small- to large-scale interventions, 6 were conducted in sub-Saharan Africa and the remaining 2 in South Asia. All the interventions were done in rural settings; the majority involved sanitation and hygiene deliverables along with the nutrition strategies, such as distribution of nutrition supplements. In assessing effectiveness, no significant improvements were seen in growth indicators; reduction in diarrheal rate among children was also not universal across interventions. Further strengthening of WASH, especially an improvement in "W", or water access, is warranted to ensure uptake of sanitation and hygiene behaviors and prevent the fecal-oral route among children. Improved water access will also enhance the effectiveness of nutrition initiatives, such as promoting vegetable gardening and utilization of child nutrient supplements.

Attributes of drinking water, sanitation, and hygiene associated with microbiological water quality of stored drinking water in rural schools in Mozambique and Uganda

Contaminated drinking water causes morbidity and mortality worldwide, especially in low- and middle-income countries. Drinking water quality has been studied extensively in household settings, but little research is available on drinking water quality in schools. School settings are of particular importance, because children are more susceptible than adults to a variety of diseases from contaminated drinking water. Many school water, sanitation and hygiene (WaSH) interventions have been studied for their efficacy to reduce diarrheal disease incidence, but few have evaluated drinking water quality, which reflects an important exposure pathway between WaSH services and health outcomes. Using school surveys developed from internationally established WaSH indicators and field microbiological water quality tests, we studied 374 rural schools in Mozambique and Uganda to understand the association between specific WaSH services and drinking water microbiological contamination, specifically testing most probable number (MPN) of Escherichia coli, an indicator of fecal contamination, per 100 mL. In Mozambique and Uganda, 71% and 83% respectively of rural schools had low risk drinking water quality (<1 E. coli/100 mL); thirteen percent and seven percent had very high-risk water quality (≥100 E. coli/100 mL). When accounting for all WaSH services studied, schools that used an improved-type water source had 0.22 times less E. coli in stored drinking water in Mozambique (95% CI: 0.07, 0.65) and 0.12 times less E. coli in Uganda (95% CI: 0.02, 0.80). In Mozambique, use of a water source within 30 minutes for travel and collection and the presence of water and soap/ash for handwashing were also significantly associated with less E. coli in drinking water. The findings of this study provide public health practitioners with implementable WaSH services to improve school drinking water quality, which has implications for the health, learning environment, and cognitive development of school children in rural Mozambique and Uganda.

Nudging children toward healthier food choices: An experiment combining school and home gardens

School gardens have become a widely used approach to influence children's food knowledge, preferences and choices in low- and high-income countries alike. However, evidence indicates that such programs are more effective at influencing food knowledge and preferences than actual food choices. Such finding may occur because school gardens insufficiently influence the food behavior of parents and because healthy food items are not always available in children's homes. We tested this hypothesis using a one-year cluster randomized controlled trial in Nepal with 15 treatment and 15 control schools and a matched sample of 779 schoolchildren (aged 8-12) and their caregivers. Data were collected before and after the intervention during the 2018-2019 school year. In addition, children's food consumption was monitored using a monthly food logbook. Average treatment effects were quantified with a double-difference estimator. For caregivers, the intervention led to a 26% increase in their food and nutrition knowledge (p < 0.001), a 5% increase in their agricultural knowledge (p = 0.022), a 10% increase in their liking for vegetables (p < 0.001), and a 15% increase in home garden productivity (p = 0.073). For children, the intervention had no discernible effect on food and nutrition knowledge (p = 0.666) but led to a 6% increase in their liking for vegetables (p = 0.070), healthy food practices (p < 0.001), and vegetable consumption (October-December +15%; p = 0.084; January-March +26%; p = 0.017; April-June +26%; p = 0.088). The results therefore indicate both schools and parents matter for nudging children toward healthier food choices.