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

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