'Fit for school' - a school-based water, sanitation and hygiene programme to improve child health: Results from a longitudinal study in Cambodia, Indonesia and Lao PDR

Impact of a school-based water and hygiene intervention on child health and school attendance in Addis Ababa, Ethiopia: a cluster-randomised controlled trial

BACKGROUND

School-based water, sanitation and hygiene (WASH) may improve the health and attendance of schoolchildren, particularly post-menarcheal girls, but existing evidence is mixed. We examined the impact of an urban school-based WASH programme (Project WISE) on child health and attendance.

METHODS

The WISE cluster-randomised trial, conducted in 60 public primary schools in Addis Ababa, Ethiopia over one academic year, enrolled 2-4 randomly selected classes per school (~ 100 pupils) from grades 2 to 8 (aged 7-16) in an 'open cohort'. Schools were assigned 1:1 by stratified randomisation to receive the intervention during the 2021/2022 or the 2022/2023 academic year (waitlist control). The intervention included improvements to drinking water storage, filtration and access, handwashing stations and behaviour change promotion. Planned sanitation improvements were not realised. At four unannounced classroom visits post-intervention (March-June 2022), enumerators recorded primary outcomes of roll-call absence, and pupil-reported respiratory illness and diarrhoea in the past 7 days among pupils present. Analysis was by intention-to-treat.

RESULTS

Of 83 eligible schools, 60 were randomly selected and assigned. In total, 6229 eligible pupils were enrolled (median per school 101.5; IQR 94-112), 5987 enrolled at study initiation (23rd November-22nd December 2021) and the remaining 242 during follow-up. Data were available on roll-call absence for 6166 pupils (99.0%), and pupil-reported illness for 6145 pupils (98.6%). We observed a 16% relative reduction in odds of pupil-reported respiratory illness in the past 7 days during follow-up in intervention vs. control schools (aOR 0.84; 95% CI 0.71-1.00; p = 0.046). There was no evidence of effect on pupil-reported diarrhoea in the past 7 days (aOR 1.15; 95% CI 0.84-1.59; p = 0.39) nor roll-call absence (aOR 1.07; 95% 0.83-1.38; p = 0.59). There was a small increase in menstrual care self-efficacy (aMD 3.32 on 0-100 scale; 95% CI 0.05-6.59), and no evidence of effects on other secondary outcomes.

CONCLUSIONS

This large-scale intervention to improve school WASH conditions city-wide had a borderline impact on pupil-reported respiratory illness but no effect on diarrhoeal disease nor pupil absence. Future research should establish relationships between WASH-related illness, absence and other educational outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, number NCT05024890.

Global trends in incidence of caries in permanent teeth of children aged 5 through 14 years, 1990 through 2019

BACKGROUND

School-aged children are in the stage of permanent tooth eruption to replace primary teeth and this can be reached at a life stage when their health habits are being formed due to a large amount of time in school. However, data on the global trend in incidence of caries in permanent teeth in school-aged children are sparse. This study aimed to assess the trends in incidence of caries in permanent teeth in children aged 5 through 14 years from 1990 through 2019 at the global, regional, and national levels.

METHODS

The authors collected data on incidence of caries in permanent teeth in children aged 5 through 14 years from 1990 through 2019 from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to assess trends at the global, regional, and national levels.

RESULTS

Globally, incident cases of caries in permanent teeth in children aged 5 through 14 years increased by 15.25% from 1990 through 2019, and the incidence rate remained stable during this period, with incidence rates of 34.04% in 1990 and 33.93% in 2019. The incidence rate increased at an average annual percentage change of 0.08% (95% CI, 0.06% to 0.10%) and 0.07% (95% CI, 0.05% to 0.09%) from 1990 through 2019 in low and low-middle sociodemographic index regions, respectively. An increasing trend also was observed in nearly one-half of GBD regions and more than one-half of the world's countries from 1990 through 2019 (P < .05).

CONCLUSIONS

Global incidence of caries in permanent teeth remained stable at a high level in children aged 5 through 14 years, but there was a trend toward increasing rates in nearly one-half of sociodemographic index or GBD regions and more than one-half of the world's countries and territories from 1990 through 2019. These findings suggest that caries in permanent teeth is a priority health issue in school-aged children worldwide.

PRACTICAL IMPLICATIONS

Reducing free sugar intake and implementing school-based effective caries prevention programs, such as school water fluoridation, provision of fluoride tablets at school, and school dental sealant programs, are needed for school-aged children.

A scoping review of the links between early childhood caries and clean water and sanitation: the Sustainable Development Goal 6

INTRODUCTION

The United Nation's Sustainable Development Goal (SDG) 6 calls for universal access to clean water, sanitation and hygiene (WASH), which are crucial elements of health and well-being and fundamental for a life in dignity. Early childhood caries (ECC) is a preventable disease affecting health and quality of life of millions of young children worldwide. This scoping review aims to explore the connection between ECC and access to clean water and sanitation.

METHODS

This scoping review, registered on the Open Science Framework and following PRISMA-ScR guidelines, conducted a thorough search in databases (PubMed, Web of Science, Embase, Google Scholar, SciELO) and websites (via Google) in November 2023. The search, without date limitations, targeted studies in English and Spanish linking ECC to SDG6. Exclusions were made for studies solely focusing on ECC without a direct connection to clean water and sanitation. Descriptive statistics summarized the retrieved papers.

RESULTS

The initial search yielded 303 articles. After removing duplicates, 264 articles remained for title and abstract screening after which 244 were excluded and one report was added through citation searching. The 21 remaining articles underwent full text review. There were no studies on a direct association between access to clean water and sanitation and the prevalence of ECC. There were nine studies that showed indirect associations between ECC and access to clean water and sanitation through the links of: water and sanitation access as a marker for poverty (n = 1), water consumption as a feeding practice (n = 4), and the effectiveness of water fluoridation (n = 4). These were used to develop a conceptual model.

CONCLUSIONS

While it is conceivable that a direct link exists between ECC and access to clean water and sanitation, the available body of research only offers evidence of indirect associations. The exploration of potential pathways connecting water access to ECC warrants further investigation in future research.

Acceptability and perceived feasibility of the KaziKidz health promotion intervention among educators and caregivers in schools from South Africa: a qualitative descriptive study

BACKGROUND

Despite the uncontested benefits of physical activity, its promotion lags behind in the public health agenda of low- and middle-income countries (LMICs). School-based interventions are promising strategies to foster health during childhood, but evidence of their effectiveness is limited and inconclusive for LMICs. Thus, further investigation is needed on contextual factors associated with intervention implementation in low-resource settings. We studied the acceptability and feasibility of the KaziKidz health promotion intervention and its implementation and make recommendations to improve future adoption and sustainability.

METHODS

KaziKidz was implemented in four primary schools from low-income communities in South Africa in 2019. Semi-structured interviews with four school principals, three focus group interviews with 16 educators, and another three with 16 caregivers were conducted between October and November 2021. Participants were purposively recruited. Interview transcripts were analyzed via thematic analysis using a deductive and reflexive approach.

RESULTS

Three main themes influencing intervention implementation and adoption were identified: (1) prioritizing teachers' needs (2), integrating the program into the school structure, and (3) creating opportunities in the community. Supporting recommendations included: (theme 1) adopting intervention approaches that are inclusive of educators' health and providing them with capacity development and external support; (theme 2) fostering a feeling of ownership and belonging among school stakeholders to adapt interventions to specific resources and needs; and (theme 3) raising community awareness to encourage individuals to claim power over and actively engage with the program.

CONCLUSIONS

Comprehensive interventions comprising health support, adequate training, and ongoing assistance for educators combined with school-wide and community outreach actions seeking to strengthen program ownership, accountability, and engagement can enhance uptake of school-based interventions and long-term maintenance.

TRIAL REGISTRATION

ISRCTN15648510, registered on 17/04/2020.

Oral health promotion through health-promoting schools in developing countries: A scoping review

OBJECTIVES

To explore and assess what is known about oral health promotion through health-promoting primary schools in developing countries.

METHODS

A scoping review was conducted using the Arksey & O'Malley framework. Web of Science, PubMed, Scopus and Cochrane Library were searched, followed by the reference lists of the resulting studies. The UN classification of developing countries was used to define the countries included and the search was between 1986 and 2021. Quality assessment was carried out using Joanna Briggs Institute's quality appraisal tools.

RESULTS

The search resulted in 33 studies of which almost half were randomized controlled trials. The oral health promotion strategies were oral health education (n = 16) delivered by teachers, parents or peers, or multicomponent involving both toothbrushing (n = 15) and dietary components (n = 2). Most of the included studies were conducted in Asia (n = 25/33).

CONCLUSIONS

Findings suggested that comprehensive, multicomponent theory-based oral health promotion showed improvements in oral health outcomes of schoolchildren, particularly if delivered using a whole-school approach. However, further research on feasibility and implementation of oral health promotion through health-promoting primary schools in developing countries should be considered.

Strategies to integrate oral health into primary care: a systematic review

OBJECTIVES

Integration of oral health into primary care has been proposed as a primary healthcare approach for efficient and sustainable delivery of oral health services, and the effective management of oral diseases. This paper aimed to synthesise evidence on the effectiveness of strategies to integrate oral health into primary care.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, CINAHL, Embase, Scopus, ProQuest, Cochrane and Google Scholar were searched without date limits until the third week of June 2022. Reference lists of eligible studies were also searched. Experts in the field and existing professional networks were consulted.

ELIGIBILITY CRITERIA

Only studies that evaluated integration strategies were included in the review. Eligibility was restricted to English language studies published in academic peer-reviewed journals.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data and performed the risk of bias assessments. A narrative synthesis approach was used to report review findings. Heterogeneity among included studies precluded a meta-analysis.

RESULTS

The search identified 8731 unique articles, of which 49 were included in the review. Majority of the studies explored provision of oral healthcare by primary care professionals in primary care settings, where integration was primarily via training/education and/or policy changes. Most studies reported results favouring the integration strategy, such as improvements in referral pathways, documentation processes, operating efficiencies, number of available health staff, number of visits to non-dental primary care professionals for oral health issues, proportion of children receiving fluoride varnish applications/other preventive treatment, proportion of visits to an oral health professional and dental caries estimates.

CONCLUSION

The findings from this review demonstrate that the majority of identified strategies were associated with improved outcomes and can be used to inform decision-making on strategy selection. However, more research and evaluation are required to identify best practice models of service integration.

PROSPERO REGISTRATION NUMBER

CRD42020203111.

Effectiveness of school-based strategies to prevent tooth decay in Filipino children: A cluster-randomized trial

OBJECTIVES

Evidence for affordable and pragmatic programmes to address the burden of untreated tooth decay in children in low- and middle-income settings is limited. This study aimed to (1) assess the effect of a government-run, school-based daily group toothbrushing programme compared to standard school-based oral health education on the incidence of dental caries and odontogenic infections in Filipino children over a period of 3 years; and (2) assess the additional preventive effect of on-demand oral urgent treatment (OUT) and weekly fluoride gel application.

METHODS

A cluster-randomized trial was conducted in Camiguin, Philippines. Schools in three regions were randomly assigned to one of three intervention groups: The Essential Health Care Programme (EHCP), which includes daily toothbrushing with fluoride toothpaste; EHCP plus twice-yearly access to on-demand urgent oral treatment (EHCP + OUT) and EHCP plus weekly application of high-concentrated fluoride gel (EHCP + Fluoride). Schools in a nearby province with a similar child population were selected as external concurrent control group. Clinical oral examinations were performed by calibrated dentists from a random sample of 682 seven-year-old students who were examined at baseline and over the following 3 years. Outcome variables were the number of decayed primary teeth, the number of decayed, missing and filled permanent teeth (DMFT) and surfaces (DMFS), and the number of permanent teeth with pulpal involvement, ulcerations, fistula or abscess (PUFA). Data were analysed using multilevel mixed-effects negative binomial regression.

RESULTS

Three years after implementation, increments in dental caries and odontogenic infections in permanent teeth did not significantly differ between the EHCP and control group, yet the incidence of DMFT was lower by 22% in children receiving EHCP. Compared to controls, children receiving EHCP + Fluoride had a significantly lower increment of DMFT, DMFS and PUFA by 40%, 40% and 47%, respectively. Children receiving EHCP + OUT had lower incidence rates of DMFT and DMFS than control children by 23% and 28%, respectively. A lower incidence rate was also found for PUFA, but the effect was not statistically significant.

CONCLUSIONS

Findings suggest that the weekly application of fluoride gel and urgent oral treatment, in addition to daily school-based toothbrushing with fluoride toothpaste, are realistic and effective strategies to lower the burden of dental caries in Filipino children. Implementation challenges may explain why no substantial caries-preventive benefits were demonstrated for school-based toothbrushing only. Intervention compliance should be considered in future programme implementation and evaluation research.

Caries Incidence Is Associated with Wasting among Cambodian Children

Evidence suggests that dental caries is associated with chronic and acute malnutrition, manifested as stunting and wasting in children. However, studies have not always appropriately accounted for confounding factors or for the temporal ordering between exposure and outcome. This study examined relationships between the development of caries lesions with subsequent stunting and wasting outcomes using data from a population-based cohort in Cambodia. Caries incidence was assessed based on the presence of a new cavitated carious lesion or a new pulpally involved lesion across a 6-mo observation period. Anthropometric measurements were taken at regular intervals. Effects of carious lesions on stunting and wasting were assessed using inverse probability treatment weighting, adjusting for potential confounders, using z scores for height-for-age (HAZ) and weight-for-height (WHZ) as outcomes. In total, 894 children (mean age 20 mo at baseline) were followed over 2 y. At baseline, 350 (39.1%) were identified as having stunting malnutrition. At follow-up, 58 (6.5%) had a new pulpally involved lesion. There was no association between incidence of cavitated or pulpally involved carious lesions at follow-up and stunting (relative risk [RR] = 1.06; 95% confidence interval [CI]: 0.75, 1.50). The incidence of pulpally involved carious lesions had an effect on wasting prevalence (WHZ <-2; RR = 1.35; 95% CI: 0.70, 2.62) and WHZ scores (average treatment effect = -0.294; 95% CI: -0.538, -0.050). This study offers evidence that the development of pulpally involved carious lesions has an effect on WHZ scores. Oral health promotion and clinical prevention and management of dental caries should be explored as interventions to promote normal growth and development among preschool children, particularly in low-income settings.

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.

Improving Toilet Usability and Cleanliness in Public Schools in the Philippines Using a Packaged Operation and Maintenance Intervention

This study evaluated the impact of packaged interventions for operation and maintenance (O&M) on the usability and cleanliness of toilets in public schools in the Philippines. In this cluster-randomized controlled trial, the divisions of Roxas City and Passi City were randomly assigned to the intervention or control group. Schools in Roxas City (n = 14) implemented the packaged O&M interventions; schools in Passi City (n = 16) formed the control group. Outcome variables were toilet usability-defined as accessible, functional and private-and toilet cleanliness, measured using the Sanitation Assessment Tool (SAT) and the Cleaner Toilets, Brighter Future (CTBF) instruments at baseline and at four months follow-up through direct observation of school toilets. SAT results showed that intervention schools had a 32.0% (4.6%; 59.3%) higher percentage of usable toilets than control schools at follow-up after full adjustment (p = 0.024). CTBF results found a similar result, although this was not statistically significant (p = 0.119). The percentage of toilets that were fully clean was 27.1% (3.7%; 50.6%) higher in intervention schools than in control schools after adjustment (p = 0.025). SAT results also showed an improvement in cleanliness of toilets in intervention schools compared to those in controls, but this did not remain significant after adjustment. The findings indicate that the additional implementation of O&M interventions can further stimulate progress towards reaching Water, Sanitation and Hygiene service levels aligned with the Sustainable Development Goals.

Self-perceived oral health-related salutogenic factors in orally healthy older Swedes. A qualitative interview study

OBJECTIVE

This study aimed to explore oral health-related salutogenic factors in orally healthy older Swedish people, applying the three components of Antonovsky's Sense of Coherence (SOC) concept: comprehensibility, manageability and meaningfulness.

MATERIAL AND METHOD

Interviews were conducted with 12 orally healthy patients, aged 75 years and older, enrolled at public dental clinics. The interviews were subjected to qualitative content analysis, applying the SOC concept as the theoretical framework.

RESULTS

Three themes were formulated under the predefined SOC components, describing the central meaning of the informants' perception of factors favourable to their good oral health. The theme 'comprehension of cause and effect' consisted of three categories, for example importance of oral hygiene, and reflected the component comprehensibility. The theme 'living in confidence and trust in supporting society' consisted of five categories, for example self-esteem, and reflected the component manageability. The theme 'good oral health as a basis for satisfaction and social confidence' consisted of two categories, for example social norms, and reflected the component meaningfulness.

CONCLUSION

This study discloses how orally healthy elderly Swedish people perceive the lifelong impact of salutogenic factors in response to lifelong stressors on their oral health and highlights the important roles of their internal resources, dental professionals, family and society in supporting and reinforcing lifelong oral health.

Effectiveness of Oral Health Educational Methods among School Children Aged 5–16 Years in Improving their Oral Health Status: A Meta-analysis

Background

Oral health is an essential component of health throughout life. Two major oral diseases, dental caries and gingival conditions are prevalent in young population. School-based oral health education (OHE) programs with recognized technology and traditional lecturing could be strategic in promotion of oral health behavior in developed and developing countries.

Aim

The aim of the study is to summarize existing evidence in order to evaluate the effectiveness of OHE programs in school children aged 5–16 years in improving their oral health status.

Methodology

Clinical trials with school children between 5 and 16 years were included. Eligible studies were those which had outcomes as caries, plaque and gingival indices, and oral hygiene status. Articles published from 2010 to 2019 in English language from PubMed, Directory of Open Access Journal (DOAJ), and Google Scholar were searched. Forty-one articles were identified and relevance was determined by examining title and full article. Nine articles were included for qualitative synthesis and seven were eligible for meta-analysis. The risk of bias was assessed by Cochrane Handbook. A meta-analysis was done using Review Manager 5.3 software.

Results

After the meta-analysis results for cumulative mean difference was found as 0.05 (–0.17, 0.27), –0.37 (–0.74, 0.00), –0.20 (–0.33, –0.07), and –0.17 (–0.73, 0.38) for plaque status, Oral Hygiene Index-Simplified (OHI-S), debris status, and dental caries, respectively showing a significant difference favoring the experimental group than traditional group.

Conclusion

Interventions given by various aids like lectures, albums, models, flipcharts, leaflets, E-programs, games, drawings, and presentations proved effective in improving oral hygiene status and dental caries, but no reduction in plaque levels and gingival inflammation as compared to oral health talk/counseling by dentists.

How to cite this article

Gurav KM, Shetty V, Vinay V, et al. Effectiveness of Oral Health Educational Methods among School Children Aged 5–16 Years in Improving their Oral Health Status: A Meta-analysis. Int J Clin Pediatr Dent 2022;15(3):338-349.

Effectiveness of primary school-based interventions in improving oral health of children in low- and middle-income countries: a systematic review and meta-analysis

Background

Risk factors for oral disease can potentially be ameliorated by school-based interventions. This review evaluates the effectiveness of primary school-based interventions in improving oral health among children in low-and middle-income countries (LMICs).

Methods

Our systematic review was conducted in accordance with the Joanna Briggs Institute methodology for systematic reviews of effectiveness. Medline, Embase, Global Health, CINAHL, Emcare, Scopus, Web of Science, WHO website, Google Advanced and Google Scholar were searched for experimental and observational studies published between 1995 and 2021 in English. Quality assessment and data extraction of the articles were performed by two independent reviewers. The primary outcome was decayed, missing, and filled teeth/surfaces [dmft(s)/DMFT(S)] scores. Seven meta-analyses were conducted.

Results

The search yielded 1178 publications and after removing duplicates, 753 remained. A further 648 publications were excluded after screening titles and abstracts. 105 publications were reviewed in full and 34 were included. Narrative synthesis showed school-based interventions had a positive effect on oral health outcomes. Meta-analysis showed a significant positive effect on dental caries measured by DMFT scores (standardised mean difference (SMD) =  − 0.33; 95% CI − 0.56 to − 0.10; P = 0.005), net increment in DMFS scores (SMD =  − 1.09; 95% CI − 1.91 to − 0.27; P = 0.009), dmft and DMFT/S score > 1 (Risk Ratio = 0.70; 95% CI 0.53 to 0.94; P = 0.02) and plaque scores (SMD =  − 0.32; 95% CI − 0.46 to − 0.18; P < 0.00001). Non-significant positive effect was observed for dental caries measured by net increment in DMFT scores (SMD =  − 0.34; 95% CI − 0.69 to 0.02; P = 0.06) and DMFS scores (SMD =  − 0.26; 95% CI − 0.70 to 0.18; P = 0.24), and gingival health (SMD = 0.12; 95% CI − 0.32 to 0.55; P = 0.60). Certainty of evidence was assessed as very low for all oral health outcomes.

Conclusion

School-based interventions can be effective in reducing the burden of oral disease among primary school children in LMICs, with skills-based education, teacher training, provision of access to oral health services and parental engagement emerging as particularly promising. Further research is required to provide evidence of effectiveness of primary school-based interventions to improve oral health.

Systematic review registration The title of this review was registered with PROSPERO (registration number: CRD42020202599).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02291-2.

Interventions to improve water, sanitation, and hygiene for preventing soil-transmitted helminth infection

BACKGROUND

It is estimated that 1.5 billion people are infected with soil-transmitted helminths (STHs) worldwide. Re-infection occurs rapidly following deworming, and interruption of transmission is unlikely without complementary control efforts such as improvements in water, sanitation, and hygiene (WASH) access and behaviours.

OBJECTIVES

To assess the effectiveness of WASH interventions to prevent STH infection.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 19 October 2021.

SELECTION CRITERIA

We included interventions to improve WASH access or practices in communities where STHs are endemic. We included randomized controlled trials (RCTs), as well as trials with an external control group where participants (or clusters) were allocated to different interventions using a non-random method (non-RCTs). We did not include observational study designs. Our primary outcome was prevalence of any STH infection. Prevalence of individual worms was a secondary outcome, including for Ascaris lumbricoides, Trichuris trichiura, hookworm (Ancylostoma duodenale or Necator americanus), or Strongyloides stercoralis. Intensity of infection, measured as a count of eggs per gram of faeces for each species, was another secondary outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed titles and abstracts and full-text records for eligibility, performed data extraction, and assessed risk of bias using the Cochrane risk of bias assessment tool for RCTs and the EPOC tool for non-RCTs. We used a random-effects meta-analysis to pool study estimates. We used Moran's I² statistic to assess heterogeneity and conducted subgroup analyses to explore sources of heterogeneity. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 32 studies (16 RCTs and 16 non-RCTs) involving a total of 52,944 participants in the review. Twenty-two studies (14 RCTs (16 estimates) and eight non-RCTs (11 estimates)) reported on our primary outcome, prevalence of infection with at least one STH species. Twenty-one studies reported on the prevalence of A lumbricoides (12 RCTs and 9 non-RCTs); 17 on the prevalence of T trichiura (9 RCTs and 8 non-RCTs); 18 on the prevalence of hookworm (10 RCTs and 8 non-RCTs); and one on the prevalence of S stercoralis (1 non-RCT). Sixteen studies measured the intensity of infection for an individual STH type. Ten RCTs and five non-RCTs reported on the intensity of infection of A lumbricoides; eight RCTs and five non-RCTs measured the intensity of infection of T trichiura; and eight RCTs and five non-RCTs measured the intensity of hookworm infection. No studies reported on the intensity of infection of S stercoralis. The overall pooled effect estimates showed that the WASH interventions under study may result in a slight reduction of any STH infection, with an odds ratio (OR) of 0.86 amongst RCTs (95% confidence interval (CI) 0.74 to 1.01; moderate-certainty evidence) and an OR of 0.71 amongst non-RCTs (95% CI 0.54 to 0.94; low-certainty evidence). All six of the meta-analyses assessing individual worm infection amongst both RCTs and non-RCTs had pooled estimates in the preventive direction, although all CIs encapsulated the null, leaving the possibility of the null or even harmful effects; the certainty of the evidence ranged from very low to moderate. Individual studies assessing intensity of infection showed mixed evidence supporting WASH. Subgroup analyses focusing on narrow specific subsets of water, sanitation, and hygiene interventions did very little to elucidate which interventions might be better than others. Data on intensity of infection (e.g. faecal egg count) were reported in a variety of ways across studies, precluding the pooling of results for this outcome. We did not find any studies reporting adverse events resulting from the WASH interventions under study or from mass drug administration (MDA).

AUTHORS' CONCLUSIONS

Whilst the available evidence suggests that the WASH interventions under study may slightly protect against STH infection, WASH also serves as a broad preventive measure for many other diseases that have a faecal oral transmission route of transmission. As many of the studies were done in addition to MDA/deworming (i.e. MDA was ongoing in both the intervention and control arm), our data support WHO recommendations for implementation of improvements to basic sanitation and adequate access to safe water alongside MDA. The biological plausibility for improved access to WASH to interrupt transmission of STHs is clear, but WASH interventions as currently delivered have shown impacts that were lower than expected. There is a need for more rigorous and targeted implementation research and process evaluations in order that future WASH interventions can better provide benefit to users. Inconsistent reporting of the intensity of infection underscores the need to define the minimal, standard data that should be collected globally on STHs to enable pooled analyses and comparisons.

A Structured Review of Emotional Barriers to WASH Provision for Schoolgirls Post-Disaster

Pubescent girls face unique emotional barriers to returning to school after a disaster concerning water, sanitation and hygiene (WASH). This paper explores themes of WASH, gender violence, the lack of dignity and sense of shame arising from inadequate WASH facilities for girls in disaster settings. We conducted a structured literature review of 126 sources to investigate the emotional constraints facing pubescent girls concerning WASH in schools in Indonesia, a region prone to frequent disasters. Findings are synthesised into four major themes: psychological experiences of WASH, challenges faced by girls in schools, barriers to inclusive WASH provision and how to create a holistic approach to WASH. Key conclusions include the need for interdisciplinary research, cross sectoral collaboration, more evidence and research in Indonesia, especially regarding menstrual hygiene management, improved toilet design to reduce the physical barriers linked to emotional barriers and inclusive design for those with disabilities.

School Based Tooth Brushing and Annual Silver Diammine Fluoride Application as a Highest Priority Package for Achieving Universal Oral Health Care for Cambodian Children

Background: Achieving Universal Oral Health Care among Low-to Middle-Income settings is challenging and little literature exists around exploring what a “Highest Priority Package” of care might look like in the context of oral health. The Healthy Kids Cambodia (HKC) program differs from most conventional school dental services in that the initial package of care that is offered is daily toothbrushing with 1,500 ppm fluoride toothpaste (DTB) together with the topical application of Silver Diamine fluoride (SDF) for management of lesions in primary teeth.

Aim: To examine tooth level outcomes for 8- to 10-year old children from two schools that performed DTB with application of SDF at differing time-points.

Design: This was an observational cohort study that examined lesion progression among children in late mixed dentition at two schools. Data were collected using the dmft and pufa indices. Both schools received materials and training for DTB at baseline. School One received SDF at baseline while School Two received SDF after 9-months. Intraoral examinations were performed and the presentation of primary teeth with cavitated carious lesions were compared at baseline and 12 m. If a tooth was still caries-active or had become pulpally involved, this was considered to be an unacceptable outcome. Descriptive analysis was performed the chi-squared test was used to examine differences in the proportion of teeth with unacceptable outcomes by school membership.

Results: Of the 521 children recruited, 470 (90.2%) were followed. Where there was a delay in SDF application (School 2) there was a three times greater chance of an unacceptable outcome. Ten percentage of primary teeth in School One and 33% of primary teeth in the School Two had unacceptable outcomes.

Conclusion: The present study offers data on expected effect sizes that might inform future step-wedged clinical trials to validate an oral health Highest Priority Package of care for Cambodian children. The delivery of a package of care that includes both DTB and SDF can prevent adverse outcomes, such as dental infections, in primary teeth with carious lesions.

A scoping review of intervention components of school-based oral health-related behavioural interventions using the Theoretical Domains Framework

The aim of this study was to review the intervention components of school-based oral health-related behavioural interventions using the Theoretical Domains Framework (TDF). We identified relevant papers from the review of Cooper et al., and these papers came from both the original inclusion and exclusion article lists. We also modified and updated their search strategies (2013 - April 2019). The 53 included papers reported on 79 interventions (experimental groups = 57 interventions, control groups = 22 interventions). Most of the papers used three to nine domains (average = 5.6) in their experimental interventions, and the most commonly used domains were 'knowledge,' 'skills,' 'social influences,' and 'environmental context and resources.' Considering the complexity of intervention components in one programme, there is no one specific domain or domain set that can determine the success of behavioural interventions. The design of future programmes should be guided by a complex intervention methodology. However, the best combination set might not exist, and the choice of domains should depend on local context or resources. This study can be used as a resource for identifying previous papers, which have used the same domains.

Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies

Background

Lack of access to and use of water, sanitation and hygiene (WASH) cause 1.6 million deaths every year, of which 1.2 million are due to gastrointestinal illnesses like diarrhoea and acute respiratory infections like pneumonia. Poor WASH access and use also diminish nutrition and educational attainment, and cause danger and stress for vulnerable populations, especially for women and girls. The hardest hit regions are sub-Saharan Africa and South Asia. Sustainable Development Goal (SDG) 6 calls for the end of open defecation, and universal access to safely managed water and sanitation facilities, and basic hand hygiene, by 2030. WASH access and use also underpin progress in other areas such as SDG1 poverty targets, SDG3 health and SDG4 education targets. Meeting the SDG equity agenda to "leave none behind" will require WASH providers prioritise the hardest to reach including those living remotely and people who are disadvantaged.

Objectives

Decision makers need access to high-quality evidence on what works in WASH promotion in different contexts, and for different groups of people, to reach the most disadvantaged populations and thereby achieve universal targets. The WASH evidence map is envisioned as a tool for commissioners and researchers to identify existing studies to fill synthesis gaps, as well as helping to prioritise new studies where there are gaps in knowledge. It also supports policymakers and practitioners to navigate the evidence base, including presenting critically appraised findings from existing systematic reviews.

Methods

This evidence map presents impact evaluations and systematic reviews from the WASH sector, organised according to the types of intervention mechanisms, WASH technologies promoted, and outcomes measured. It is based on a framework of intervention mechanisms (e.g., behaviour change triggering or microloans) and outcomes along the causal pathway, specifically behavioural outcomes (e.g., handwashing and food hygiene practices), ill-health outcomes (e.g., diarrhoeal morbidity and mortality), nutrition and socioeconomic outcomes (e.g., school absenteeism and household income). The map also provides filters to examine the evidence for a particular WASH technology (e.g., latrines), place of use (e.g., home, school or health facility), location (e.g., global region, country, rural and urban) and group (e.g., people living with disability). Systematic searches for published and unpublished literature and trial registries were conducted of studies in low- and middle-income countries (LMICs). Searches were conducted in March 2018, and searches for completed trials were done in May 2020. Coding of information for the map was done by two authors working independently. Impact evaluations were critically appraised according to methods of conduct and reporting. Systematic reviews were critically appraised using a new approach to assess theory-based, mixed-methods evidence synthesis.

Results

There has been an enormous growth in impact evaluations and systematic reviews of WASH interventions since the International Year of Sanitation, 2008. There are now at least 367 completed or ongoing rigorous impact evaluations in LMICs, nearly three-quarters of which have been conducted since 2008, plus 43 systematic reviews. Studies have been done in 83 LMICs, with a high concentration in Bangladesh, India, and Kenya. WASH sector programming has increasingly shifted in focus from what technology to supply (e.g., a handwashing station or child's potty), to the best way in which to do so to promote demand. Research also covers a broader set of intervention mechanisms. For example, there has been increased interest in behaviour change communication using psychosocial "triggering", such as social marketing and community-led total sanitation. These studies report primarily on behavioural outcomes. With the advent of large-scale funding, in particular by the Bill & Melinda Gates Foundation, there has been a substantial increase in the number of studies on sanitation technologies, particularly latrines. Sustaining behaviour is fundamental for sustaining health and other quality of life improvements. However, few studies have been done of intervention mechanisms for, or measuring outcomes on sustained adoption of latrines to stop open defaecation. There has also been some increase in the number of studies looking at outcomes and interventions that disproportionately affect women and girls, who quite literally carry most of the burden of poor water and sanitation access. However, most studies do not report sex disaggregated outcomes, let alone integrate gender analysis into their framework. Other vulnerable populations are even less addressed; no studies eligible for inclusion in the map were done of interventions targeting, or reporting on outcomes for, people living with disabilities. We were only able to find a single controlled evaluation of WASH interventions in a health care facility, in spite of the importance of WASH in health facilities in global policy debates. The quality of impact evaluations has improved, such as the use of controlled designs as standard, attention to addressing reporting biases, and adequate cluster sample size. However, there remain important concerns about quality of reporting. The quality and usefulness of systematic reviews for policy is also improving, which draw clearer distinctions between intervention mechanisms and synthesise the evidence on outcomes along the causal pathway. Adopting mixed-methods approaches also provides information for programmes on barriers and enablers affecting implementation.

Conclusion

Ensuring everyone has access to appropriate water, sanitation, and hygiene facilities is one of the most fundamental of challenges for poverty elimination. Researchers and funders need to consider carefully where there is the need for new primary evidence, and new syntheses of that evidence. This study suggests the following priority areas:Impact evaluations incorporating understudied outcomes, such as sustainability and slippage, of WASH provision in understudied places of use, such as health care facilities, and of interventions targeting, or presenting disaggregated data for, vulnerable populations, particularly over the life-course and for people living with a disability;Improved reporting in impact evaluations, including presentation of participant flow diagrams; andSynthesis studies and updates in areas with sufficient existing and planned impact evaluations, such as for diarrhoea mortality, ARIs, WASH in schools and decentralisation. These studies will preferably be conducted as mixed-methods systematic reviews that are able to answer questions about programme targeting, implementation, effectiveness and cost-effectiveness, and compare alternative intervention mechanisms to achieve and sustain outcomes in particular contexts, preferably using network meta-analysis.

Water intake meets the Water from inside the human body – physiological, cultural, and health perspectives - Synthetic and Systematic literature review

Background. The average adult human body of 70 kilograms consists in about 67.85% water distributed evenly to an average of 70 % in all major organs of the body: skin, muscles, brain, spinal cord, liver, heart, lungs, spleen, kidneys, pancreas and gastro-intestinal tract. A smaller percentage is found in the bones (30%), teeth (5%) and fat tissue (50%). Objective. This review article attempts to present different perspectives on the physiological properties of water in the human body. We describe from the ancient Chinese medicine theory about water being one of the 5 elements of nature and its harmonious interrelation with the other elements in order to balance the human body, to the successful experiments of researchers which demonstrated waters’ capability to change its molecular structure based on feelings, intentions and energy it was exposed to. We briefly describe the role of water for the human body and what effects can the lack of it have, especially dehydration with all the phases of severity. Also, we present the health benefits of drinking water and which type of water is best to consume. We shorty review the different types of natural mineral waters in Romania and the importance of the Romanian researches for balneology and how the waters cand be administrated in crenotherapy for different types of pathologies. Methods. To elaborate our systematic review, we have searched for relevant open access articles and review articles in ISI Web of Science, published from January 2017 until August 2021. The terms used were water AND health in the title. Articles were excluded in the second phase if they did not reach the relevance citation criterion. The eligible articles were analyzed in detail regarding water importance for human health. Results. Our search identified, first, 548 articles. After applying a PEDro like selection filter and, we selected 93 articles with a minimum of 8 points on our PEDro like filtering scale (good, very good, and excellent articles with a minimum of 5 citations per year). Detailed analysis of the 93 selected articles has conducted us to the elimination of 33 of them as being on a different subject than that of our article. To the 60 full articles retained for this systematic and synthetic article, we have added 10 articles found through a separate Google search, as being considered of high relevance for our subject and necessary to be included. Conclusions. Water is essential for the entire planet and also indispensable for the survival of the human body. Keywords: water intake, water balance, body water, water molecular structure, dehydration, crenotherapy

[Global oral health in the international health policy spotlight-challenges and new opportunities for sustainable improvement]

Orale Erkrankungen sind ein signifikantes globales Gesundheitsproblem über alle Länder und Bevölkerungsgruppen hinweg. Mit fast 3,5 Mrd. Erkrankungsfällen (2017) sind so viele Menschen betroffen wie von keiner anderen Krankheitsgruppe. Die Haupterkrankungen sind unbehandelte Karies der bleibenden oder der Milchzähne, fortgeschrittene Parodontopathien, Zahnlosigkeit sowie Karzinome der Mundhöhle und Lippen. Bei weitgehend unverändert hoher globaler Prävalenz erhöhen durch Bevölkerungswachstum bedingte stark steigende Fallzahlen den Druck auf schwache oder überlastete Gesundheitssysteme, insbesondere in Ländern der unteren und mittleren Einkommensgruppen.

Dennoch wird der Mundgesundheit in vielen Ländern nur unzureichende Priorität eingeräumt und sie erhält als wichtiges Thema im gesundheitspolitischen Diskurs der deutschen und globalen Akteure nach wie vor wenig Aufmerksamkeit. Eine der fundamentalen Herausforderungen ist dabei die Gewährleistung eines allgemeinen und fairen Zugangs zu adäquater universeller Basisgesundheitsversorgung für alle Menschen ohne Verursachung von finanziellen Härten (Universal Health Coverage).

Dieser Beitrag gibt einen einführenden Überblick über die globalen Trends der weltweiten Krankheitslast der oralen Haupterkrankungen, die von starken Ungleichheiten geprägt sind. Verbesserungsansätze aus der bevölkerungsweiten Risikoreduktion und Prävention, der Versorgungsplanung sowie gesundheitspolitische Lösungen werden kurz vorgestellt. Dabei werden die im internationalen Diskurs wichtigen Themen angesprochen und die im Rahmen einer Lancet-Artikelserie zur globalen Mundgesundheit aus dem Jahr 2019 entwickelten Reformbereiche besprochen. Schließlich werden neue Initiativen diskutiert sowie Empfehlungen für die deutsche und internationale gesundheitliche Entwicklungspolitik gegeben, die in den kommenden Jahren die Situation der globalen Mundgesundheit entscheidend verbessern könnten.

Hand-washing promotion for preventing diarrhoea

BACKGROUND

Diarrhoea accounts for 1.8 million deaths in children in low- and middle-income countries (LMICs). One of the identified strategies to prevent diarrhoea is hand washing.

OBJECTIVES

To assess the effects of hand-washing promotion interventions on diarrhoeal episodes in children and adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases, the World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), and metaRegister of Controlled Trials (mRCT) on 8 January 2020, together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Individually-randomized controlled trials (RCTs) and cluster-RCTs that compared the effects of hand-washing interventions on diarrhoea episodes in children and adults with no intervention.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial eligibility, extracted data, and assessed risks of bias. We stratified the analyses for child day-care centres or schools, community, and hospital-based settings. Where appropriate, we pooled incidence rate ratios (IRRs) using the generic inverse variance method and a random-effects model with a 95% confidence interval (CI). We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 29 RCTs: 13 trials from child day-care centres or schools in mainly high-income countries (54,471 participants), 15 community-based trials in LMICs (29,347 participants), and one hospital-based trial among people with AIDS in a high-income country (148 participants). All the trials and follow-up assessments were of short-term duration. Hand-washing promotion (education activities, sometimes with provision of soap) at child day-care facilities or schools prevent around one-third of diarrhoea episodes in high-income countries (incidence rate ratio (IRR) 0.70, 95% CI 0.58 to 0.85; 9 trials, 4664 participants, high-certainty evidence) and may prevent a similar proportion in LMICs, but only two trials from urban Egypt and Kenya have evaluated this (IRR 0.66, 95% CI 0.43 to 0.99; 2 trials, 45,380 participants; low-certainty evidence). Only four trials reported measures of behaviour change, and the methods of data collection were susceptible to bias. In one trial from the USA hand-washing behaviour was reported to improve; and in the trial from Kenya that provided free soap, hand washing did not increase, but soap use did (data not pooled; 3 trials, 1845 participants; low-certainty evidence). Hand-washing promotion among communities in LMICs probably prevents around one-quarter of diarrhoea episodes (IRR 0.71, 95% CI 0.62 to 0.81; 9 trials, 15,950 participants; moderate-certainty evidence). However, six of these nine trials were from Asian settings, with only one trial from South America and two trials from sub-Saharan Africa. In seven trials, soap was provided free alongside hand-washing education, and the overall average effect size was larger than in the two trials which did not provide soap (soap provided: RR 0.66, 95% CI 0.58 to 0.75; 7 trials, 12,646 participants; education only: RR 0.84, 95% CI 0.67 to 1.05; 2 trials, 3304 participants). There was increased hand washing at major prompts (before eating or cooking, after visiting the toilet, or cleaning the baby's bottom) and increased compliance with hand-hygiene procedure (behavioural outcome) in the intervention groups compared with the control in community trials (data not pooled: 4 trials, 3591 participants; high-certainty evidence). Hand-washing promotion for the one trial conducted in a hospital among a high-risk population showed significant reduction in mean episodes of diarrhoea (1.68 fewer) in the intervention group (mean difference -1.68, 95% CI -1.93 to -1.43; 1 trial, 148 participants; moderate-certainty evidence). Hand-washing frequency increased to seven times a day in the intervention group versus three times a day in the control arm in this hospital trial (1 trial, 148 participants; moderate-certainty evidence). We found no trials evaluating the effects of hand-washing promotions on diarrhoea-related deaths or cost effectiveness.

AUTHORS' CONCLUSIONS

Hand-washing promotion probably reduces diarrhoea episodes in both child day-care centres in high-income countries and among communities living in LMICs by about 30%. The included trials do not provide evidence about the long-term impact of the interventions.

Impact of a school-based water, sanitation and hygiene programme on children's independent handwashing and toothbrushing habits: a cluster-randomised trial

Objectives

To explore whether a school-based water, sanitation and hygiene programme, which includes group hygiene activities, contributes to the formation of independent handwashing and toothbrushing habits among Filipino children.

Methods

In this cluster-randomised trial, twenty primary schools were randomly allocated to the intervention or control arm. Intervention schools received group handwashing facilities and implemented daily group handwashing and toothbrushing activities. A soap use to toilet event ratio was calculated to measure children’s independent handwashing behaviour after toilet use, and dental plaque accumulation on Monday morning was measured as a proxy indicator for children’s independent toothbrushing behaviour at home.

Results

Four months after implementation, handwashing and toothbrushing behaviours did not significantly differ between intervention and control schools. The mean soap use in intervention schools and control schools was 0.41 g and 0.30 g per toilet event, respectively (p = 0.637). Compared to baseline, mean plaque scores reduced by 4.2% and 3.5% in intervention and control schools, respectively (p = 0.857).

Conclusions

Although health benefits have been established, school-based group handwashing and toothbrushing may not be sufficient to increase children’s uptake of independent hygiene behaviours.

Electronic supplementary material

The online version of this article (10.1007/s00038-020-01514-z) contains supplementary material, which is available to authorized users.

Is oral hygiene as important as hand hygiene during COVID-19 pandemic?

Oral hygiene is an integral part of personal hygiene practices and should not be neglected. Similar to hand hygiene, oral hygiene is essential in reducing infection from the oral cavity, and thus, its transfer to the upper and lower respiratory tract. Although there is no randomized clinical trial, oral hygiene may imply to reduce the morbidity and mortality related to coronavirus disease pandemic potentially. At present, standard oral hygiene measures consist of thorough cleaning of all surfaces of teeth, interdental areas, and tongue daily. Oral health-care providers should emphasize its importance. Thorough toothbrushing for “Two Times For Two Minutes” in a day is an easy key to remember.

The impact of an operation and management intervention on toilet usability in schools in the Philippines: a cluster randomised controlled trial

Background

Access to usable water, sanitation and hygiene provision in schools is included within indicators in the Sustainable Development Goals. Progress towards these indicators is dependent on developing an understanding of which intervention components are most effective to operate and maintain usable services. This study aimed to determine the impact of a school toilet operation and management intervention in the Philippines on toilet usability and student and teacher satisfaction, adjusted for clustering at school level.

Methods

In a non-blinded cluster randomised controlled trial, we compared improvements in usability and cleanliness of school toilets among those schools receiving a low-cost, replicable intervention. Toilet usability was measured based on Sustainable Development Goal indicators related to school sanitation defined by the UNICEF/WHO Joint Monitoring Programme for Water, Sanitation and Hygiene. Intervention schools received consumables, support kits, and structured tools designed to facilitate operation and maintenance of sanitation facilities. The primary outcome, toilet usability and cleanliness, was compared through a difference-in-difference analysis of toilet usability. Secondary outcomes of student and teacher satisfaction were measured through a survey at endline. All outcomes were adjusted for clustering at school level.

Results

20 eligible schools in the Batangas region of the Philippines were randomly selected and allocated to either control or intervention group. We found that non-classroom toilets were 48% more likely to meet quality benchmarks in intervention schools, but this was not statistically significant. When including in-classroom toilets in the analysis, there were no significant differences in toilet usability - defined as accessible, functional, private and of high quality – between intervention and control schools. When stratified by toilet location, children in the intervention group clusters expressed a minor, but statistically significant increase in overall satisfaction with sanitation facilities (p = 0.035).

Conclusion

Water, sanitation and hygiene interventions in schools focusing on operation and maintenance showed potential to improve toilet usability, but universal achievement of SDG targets may require additional efforts addressing toilet infrastructure.

Trial registration

ClinicalTrials.gov NCT03204175, June 2017 prior to participant enrolment.

Healthy Kids Cambodia - A novel approach to triage for dental care in a population with extreme caries experience

OBJECTIVES

To describe the disease experiences and treatment provided according to a set of novel triage criteria among children in the Healthy Kids Cambodia project.

METHODS

The present study describes the management of caries using the Healthy Kids Cambodia (HKC) strategy at one school in Phnom Penh, Cambodia. Treatment was provided across three levels of care based on a set of simple screening criteria. All children received Level 1 (L1) care, which included application of 30% silver diammine fluoride (SDF) to arrest dental caries. Level 2 (L2) care involved use of atraumatic restorative treatment (ART) and GIC fissure sealants for children between six and eight years of age, and for older children who had one or more cavitated lesions on permanent posterior teeth. Level 3 care involved conventional dental rehabilitation for those children with cavitated lesions in permanent anterior teeth, acute infections, pulpally involved permanent teeth or carious permanent posterior teeth that were not restorable using ART. Three activities were evaluated: (i) screening of all children at the school using the HKC triage criteria; (ii) a detailed re-examination of children in Grades 3 and 4; and (iii) a clinical audit of treatment provided at Level 3 (L3).

RESULTS

1194 children were screened using the HKC approach, and a sample of 304 8- to 12-year-old children was re-examined. Among those who were re-examined, 48 (15.7%) had been referred for L3 treatment and 88 (28.9%) referred for L2 (only). There was a significant difference in baseline caries experience by referral level, whereby those referred to higher levels of care had more severe caries experience. All children in the L3 category required advanced rehabilitative care.

CONCLUSIONS

The application of a triage system by dental students was successful in identifying children in greatest need of complex care (L3). Further research may better validate the system for caries management.

Impact of a school-based water, sanitation, and hygiene intervention on school absence, diarrhea, respiratory infection, and soil-transmitted helminths: results from the WASH HELPS cluster-randomized trial

Background

Water, sanitation, and hygiene (WASH) in schools is promoted by development agencies as a modality to improve school attendance by reducing illness. Despite biological plausibility, the few rigorous studies that have assessed the effect of WASH in schools (WinS) interventions on pupil health and school attendance have reported mixed impacts. We evaluated the impact of the Laos Basic Education, Water, Sanitation and Hygiene Programme – a comprehensive WinS project implemented by UNICEF Lao People’s Democratic Republic (Lao PDR) in 492 primary schools nationwide between 2013 and 2017 – on pupil education and health.

Methods

From 2014-2017, we conducted a cluster-randomized trial among 100 randomly selected primary schools lacking functional WASH facilities in Saravane Province, Lao PDR. Schools were randomly assigned to either the intervention (n = 50) or comparison (n = 50) arm. Intervention schools received a school water supply, sanitation facilities, handwashing facilities, drinking water filters, and behavior change education and promotion. Comparison schools received the intervention after research activities ended. At unannounced visits every six to eight weeks, enumerators recorded pupils’ roll-call absence, enrollment, attrition, progression to the next grade, and reported illness (diarrhea, respiratory infection, conjunctivitis), and conducted structured observations to measure intervention fidelity and adherence. Stool samples were collected annually prior to de-worming and analyzed for soil-transmitted helminth (STH) infection. In addition to our primary intention-to-treat analysis, we conducted secondary analyses to quantify the role of intervention fidelity and adherence on project impacts.

Results

We found no impact of the WinS intervention on any primary (pupil absence) or secondary (enrollment, dropout, grade progression, diarrhea, respiratory infection, conjunctivitis, STH infection) impacts. Even among schools with the highest levels of fidelity and adherence, impact of the intervention on absence and health was minimal.

Conclusions

While WinS may create an important enabling environment, WinS interventions alone and as currently delivered may not be sufficient to independently impact pupil education and health. Our results are consistent with other recent evaluations of WinS projects showing limited or mixed effects of WinS.

Water, Sanitation and Hygiene (WASH) in Schools in Low-Income Countries: A Review of Evidence of Impact

Many schools in low-income countries have inadequate access to water facilities, sanitation and hygiene promotion. A systematic review of literature was carried out that aimed to identify and analyse the impact of water, sanitation and hygiene interventions (WASH) in schools in low-income countries. Published peer reviewed literature was systematically screened during March to June 2018 using the databases PubMed, Embase, Web of Science, the Cochrane Library, Science Direct, and Google Scholar. There were no publication date restrictions. Thirty-eight peer reviewed papers were identified that met the inclusion criteria. The papers were analysed in groups, based on four categories of reported outcomes: (i) reduction of diarrhoeal disease and other hygiene-related diseases in school students; (ii) improved WASH knowledge, attitudes and hygiene behaviours among students; (iii) reduced disease burden and improved hygiene behaviours in students' households and communities; (iv) improved student enrolment and attendance. The typically unmeasured and unreported 'output' and/or 'exposure' of program fidelity and adherence was also examined. Several studies provide evidence of positive disease-related outcomes among students, yet other assessments did not find statistically significant differences in health or indicated that outcomes are dependent on the nature and context of interventions. Thirteen studies provide evidence of changes in WASH knowledge, attitudes and behaviours, such as hand-washing with soap. Further research is required to understand whether and how school-based WASH interventions might improve hygiene habits and health among wider family and community members. Evidence of the impact of school-based WASH programs in reducing student absence from school was mixed. Ensuring access to safe and sufficient water and sanitation and hygiene promotion in schools has great potential to improve health and education and to contribute to inclusion and equity, yet delivering school-based WASH intervention does not guarantee good outcomes. While further rigorous research will be of value, political will and effective interventions with high program fidelity are also key.

Oral health behavior of children and guardians' beliefs about children's dental caries in Vientiane, Lao People's Democratic Republic (Lao PDR)

Dental caries is considered a major health problem among schoolchildren in Lao People’s Democratic Republic (Lao PDR). According to Health Belief Model (HBM)-based research, children’s oral health behavior can be determined by their guardians’ beliefs. This study aimed to describe children’s oral health behavior and its association with childhood dental caries, as well as to assess associations between children’s tooth-brushing behavior and guardians’ beliefs in an urban area of Lao PDR, using HBM. Data were collected from ten primary schools in the Sisattanak district, the Vientiane capital, between 2013 and 2014. Ten dentists with the help of dental hygienists and schoolteachers conducted dental health check-ups at the schools that diagnosed dental caries based on visual inspection. They also conducted a questionnaire-based survey with the schoolchildren’s guardians to collect data including socio-economic and demographic information, their children’s oral health behavior, and guardians’ beliefs derived from HBM, including perceived susceptibility to and perceived severity of child dental caries, perceived benefit of and perceived barrier to child’s tooth brushing, and self-efficacy in making their children brush their teeth twice daily. A mixed-effects logistic regression model assessed the association between dental caries and children’s oral health behavior and between children’s tooth-brushing behavior and guardians’ beliefs. Data from 1161 of 1304 (89.0%) children registered at the schools were used. The prevalence of dental caries was 82%. Children who brushed their teeth ≥ twice/day were significantly less likely to have dental caries than those brushing once or seldom (OR: 0.64, 95% CI: 0.45 to 0.91). The number of children who brushed twice daily also significantly increased with the increased level of guardians’ self-efficacy (OR: 2.14, 95% CI: 1.91 to 2.41). In conclusion, childhood dental caries was associated with daily tooth brushing. Children’s tooth-brushing behavior was associated with guardians’ self-efficacy in making their children brush twice daily.

Can a School-Based Intervention Improve the Oral Health-Related Quality of Life of Brazilian Children?

INTRODUCTION

Evidence of the effectiveness of oral health promotion strategies among children from different socioeconomic backgrounds is necessary to support the implementation of public health interventions.

OBJECTIVES

This study aimed to test the effectiveness of a school-based intervention to enhance the sense of coherence (SOC) and oral health-related quality of life (OHRQoL) of socially vulnerable Brazilian children. Furthermore, we explored the pathways by which the intervention may improve OHRQoL and SOC, assessing the direct and indirect pathways among demographic, clinical, socioeconomic, behavioral, and psychosocial variables.

METHODS

In this cluster-randomized trial, 5 primary schools in Brazil were randomly allocated into intervention and control groups. The intervention comprised 7 sessions of SOC-based activities over 2 mo, which focused on making the school environment a place to develop children's SOC through involving teachers, school staff, and children. Trained teachers delivered the intervention. OHRQoL and SOC data were collected at baseline, 2 wk after the intervention, and at 3-mo follow-up.

RESULTS

Information about oral clinical conditions, socioeconomic status, OHRQoL, and SOC was obtained from 356 children aged 8 to 14 y (165 in the intervention group and 191 in the control group). Children from the SOC-based intervention group reported fewer impacts of their oral health on their daily lives (Child Perceptions Questionnaire mean, 7.22) than those from the control group (9.14). The intervention group also reported greater improvement of SOC at 2 wk (SOC mean, 52.98) and 3 mo (52.75) than the control group (52.21 and 51.65, respectively).

CONCLUSION

The intervention was effective in improving SOC and OHRQoL among socially vulnerable Brazilian children. Moreover, SOC was a relevant predictor for oral symptom and functional status in this population (Brazilian Clinical Trials Registry RBR-2N9NHJ).

KNOWLEDGE TRANSFER STATEMENT

Clinicians and policy makers can use the results of this study to decide which approach to use when planning public health policy to improve the SOC and OHRQoL of socially vulnerable children. Our findings can assist policy makers in making more appropriate community health decisions in school environments that will improve community empowerment.

Establishing and implementing a health promoting school in rural Cambodia

Few studies have used a whole-of-school approach in implementing a health promoting schools (HPS) framework. Descriptions of how HPS is being implemented, particularly in low-resourced, developing countries, are limited. This study used an exploratory case study design to examine the planning and implementation of a HPS in a rural Cambodian village. Data were collected via observations of the school, school documentation, and interviews with stakeholders (n = 9). The data were analysed inductively as an iterative process, from initial coding, through to categorizing, leading to concept mapping and then identifying the emergent themes within the stages of school development and implementation of educational and health programming. The case study demonstrated how all six components of the HPS framework can be used to plan and implement a school in a rural village in a developing country. The key elements of implementation were building local and international partnerships, local leadership, and a culture of change and participation. These elements were used to establish a non-profit school that aimed to address the stated health and educational needs of local villagers. This case study adds to the limited evidence on the HPS components and implementation methods that are being applied in low-resourced, developing countries.

Nutritional status, dental caries and tooth eruption in children: a longitudinal study in Cambodia, Indonesia and Lao PDR

BACKGROUND

Untreated dental caries is reported to affect children's nutritional status and growth, yet evidence on this relationship is conflicting. The aim of this study was to assess the association between dental caries in both the primary and permanent dentition and nutritional status (including underweight, normal weight, overweight and stunting) in children from Cambodia, Indonesia and Lao PDR over a period of 2 years. A second objective was to assess whether nutritional status affects the eruption of permanent teeth.

METHODS

Data were used from the Fit for School - Health Outcome Study: a cohort study with a follow-up period of 2 years, consisting of children from 82 elementary schools in Cambodia, Indonesia and Lao PDR. From each school, a random sample of six to seven-year-old children was selected. Dental caries and odontogenic infections were assessed using the World Health Organization (WHO) criteria and the pufa-index. Weight and height measurements were converted to BMI-for-age and height-for-age z-scores and categorized into weight status and stunting following WHO standardised procedures. Cross-sectional and longitudinal associations were analysed using the Kruskal Wallis test, Mann Whitney U-test and multivariate logistic and linear regression.

RESULTS

Data of 1499 children (mean age at baseline = 6.7 years) were analyzed. Levels of dental caries and odontogenic infections in the primary dentition were significantly highest in underweight children, as well as in stunted children, and lowest in overweight children. Dental caries in six to seven-year old children was also significantly associated with increased odds of being underweight and stunted 2 years later. These associations were not consistently found for dental caries and odontogenic infections in the permanent dentition. Underweight and stunting was significantly associated with a lower number of erupted permanent teeth in children at the age of six to seven-years-old and 2 years later.

CONCLUSIONS

Underweight and stunted growth are associated with untreated dental caries and a delayed eruption of permanent teeth in children from Cambodia, Indonesia and Lao PDR. Findings suggest that oral health may play an important role in children's growth and general development.

TRIAL REGISTRATION

The study was restrospectively registered with the German Clinical Trials Register, University of Freiburg (trial registration number: DRKS00004485 ; date of registration: 26th of February, 2013).

Total observed caries experience: assessing the effectiveness of community-based caries prevention

OBJECTIVES

To compare common measures for dental caries in longitudinal caries research in support of a new measure, the Total Observed Caries Experience (TOCE).

METHODS

TOCE was calculated as the total number of decayed or filled teeth ever observed. TOCE was compared to dmft, DMFT, and the prevalence of untreated decay using data from a 4-year, cluster randomized community-based caries prevention program. Outcomes were analyzed using generalized estimating equations and assessed change over time and effects across treatment groups.

RESULTS

For TOCE and DMFT, the risk of caries over time increased. In contrast, risks decreased for dmft and the prevalence of untreated decay, driven largely by decayed primary teeth being exfoliated. Effects across treatment groups showed increased risk for some outcomes and attenuated risks in others; however, treatment effects for TOCE were more in line with expected results when compared with controls.

CONCLUSIONS

TOCE accounts for caries on primary and permanent dentition and is not subject to bias due to exfoliation. It can be used as a robust measure to evaluate community-based caries prevention programs.

Comparing the behavioural impact of a nudge-based handwashing intervention to high-intensity hygiene education: a cluster-randomised trial in rural Bangladesh

OBJECTIVE

To determine the impact of environmental nudges on handwashing behaviours among primary school children as compared to a high-intensity hygiene education intervention.

METHODS

In a cluster-randomised trial (CRT), we compared the rates of handwashing with soap (HWWS) after a toileting event among primary school students in rural Bangladesh. Eligible schools (government run, on-site sanitation and water, no hygiene interventions in last year, fewer than 450 students) were identified, and 20 schools were randomly selected and allocated without blinding to one of four interventions, five schools per group: simultaneous handwashing infrastructure and nudge construction, sequential infrastructure then nudge construction, simultaneous infrastructure and high-intensity hygiene education (HE) and sequential handwashing infrastructure and HE. The primary outcome, incidence of HWWS after a toileting event, was compared between the intervention groups at different data collection points with robust-Poisson regression analysis with generalised estimating equations, adjusting for school-level clustering of outcomes.

RESULTS

The nudge intervention and the HE intervention were found to be equally effective at sustained impact over 5 months post-intervention (adjusted IRR 0.81, 95% CI 0.61-1.09). When comparing intervention delivery timing, the simultaneous delivery of the HE intervention significantly outperformed the sequential HE delivery (adjusted IRR 1.58 CI 1.20-2.08), whereas no significant difference was observed between sequential and simultaneous nudge intervention delivery (adjusted IRR 0.75, 95% CI 0.48-1.17).

CONCLUSION

Our trial demonstrates sustained improved handwashing behaviour 5 months after the nudge intervention. The nudge intervention's comparable performance to a high-intensity hygiene education intervention is encouraging.