WHO INFORMATION SERIES ON SCHOOL HEALTH
Item
- Title
-
WHO INFORMATION
SERIES ON
SCHOOL HEALTH - extracted text
-
11
J •
WHO/SCHOOL/96.1
WHO/HPR/HEP/96.10
Distr.: General
Original: English
WHO INFORMATION
SERIES ON
SCHOOL HEALTH
DOCUMENT ONE
Strengthening
Interventions
to Reduce
Helminth
Infections
As an Entry Point
for the Development
of Health-Promoting
Schools
•/' • . •
World Health Organization
Geneva, 1997
J
r\--
WHO
INFORMATION
SERIES
ON
SCHOOL
HEALTH
FOREWORD...
1.
CONTENTS
V
INTRODUCTION
1
1.1 Why did WHO prepare this document?
1
1.2 Who should read this document?
1
1.3 What is a helminth infection?
1
1.4 Why reduce helminth infections?
1
1.5 Why focus efforts through schools?
1
1.6 How will this document help people to take control over and to
2
improve health?...................................................................
2.
3.
CONVINCING OTHERS THAT HELMINTH REDUCTION
INTERVENTIONS IN SCHOOLS IS IMPORTANT.........
3
2.1 Argument: Helminth infections destroy the welhbeing and learning
potential of millions of children in countries struggling to help
their people develop better lives.................................................
3
2.2 Argument: Intestinal helminths are stunting the growth and
development of millions of children in countries which must
count on their development to achieve progress............
3
2.3 Argument: Schistosomiasis infects millions of young people,
then causes chronic diseases in their productive years of life .
4
2.4 Argument: Foodbome trematode infection due to consuming
certain raw foods affects children’s liver, lungs and intestines..
4
2.5 Argument: Guinea worm disease is a risk to millions of people
who are without safe water.......................................................
4
CONVINCING OTHERS THAT HELMINTH REDUCTION
INTERVENTIONS IN SCHOOLS WILL REALLY WORK......
5
3.1 Argument: We know how to prevent and reduce helminth
infections in ways which are cost-effective........................
5
3.1.1 Drugs are safe, effective and easy to use............................
5
3.1.2 Simplified diagnostic methods are available.....................
5
3.1.3 These infections can be prevented...................................
5
3.1.4 Sanitary interventions help control infections other than
6
those caused by helminths..................................................
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
3.2 Argument: Schools are a remarkably efficient means to prevent
and reduce helminth infections
......................
6
3.3 Argument: Helminth reduction interventions can have a positive
impact on children’s health, learning potential and school attendance
6
3.4 Argument: Helminth reduction interventions in schools can
benefit the entire community..........................................
6
4.
5.
PLANNING OF THE INTERVENTIONS
7
4.1 Situation analysis...............................................
7
4.1.1 Purpose of conducting a situation analysis
7
4.1.2 Data items needed....................................
7
4.2 Political/cultural acceptability...............
8
4.2.1 Political commitment...................
8
4.2.2 Community commitment.............
9
4-2.3 Supportive school policy/practices
9
4.3 Goal and objectives of helminth reduction interventions in schools
10
4.3.1 Goal..........................................................................................
10
4.3.2 Short'term objectives...............................................................
10
4.3.3 Long-term objectives................................................................
11
INTEGRATING HELMINTH REDUCTION INTERVENTION
WITHIN VARIOUS COMPONENTS OF A SCHOOL
HEALTH PROGRAMME...................................................................
11
5.1 School health education
11
5.1.1 Behaviours related to helminth infections.............................
12
5.1.2 Knowledge, values, beliefs, skills and attitudes that influence
behaviours associated with helminth infection.....................
13
5.1.3 Information needed to plan health education.......................
14
5.1.4 Designing and/or selecting lessons and materials for health
education......................................
14
5.1.5 Training school personnel and others to implement health
education..........................................
15
iv
5.2 A healthy school environment......................................................
16
5.2.1 General criteria for hygienic facilities and safe water supply
16
5.2.2 School latrines......................................................................
17
WHO
6.
INFORMATION
SERIES
ON
SCHOOL
HEALTH
5.2.3 Safe water supply.........................................
17
5.2.4 Hand washing facilities.................................
18
5.2.5 Safe collection and disposal of waste in school
18
5.3 School health services........................
18
5.3.1 Screening/Diagnosis...................
18
5.3.2 Treatment.................................
19
5.3.3 Experience from past programmes
20
5.4 School/community projects and outreach
21
5.5 Health promotion for school staff
22
5.6 Nutrition and food safety............................................................
22
5.6.1 Helminth infection and malnutrition.................................
22
5.6.2 Micronutrient supplementation (iron, iodine and vitamin A)
23
5.6.3 Prevention of food'bome parasitic infections.......................
23
EVALUATION
24
6.1 Evaluation throughout the project
24
6.2 Types of evaluation
24
6.3 What to evaluate
25
BIBLIOGRAPHY
26
ANNEX I - IMPORTANT HELMINTHS IN SCHOOL CHILDREN
28
ANNEX II DOSAGE AND ESTIMATED EFFECTIVENESS OF DRUGS IN
CURRENT USE FOR HELMINTH INFECTIONS....................................... 29
V
WHO
INFORMATION
SERIES
ON
SCHOOL
HEALTH
FOREWORD
T nvestments in schools are intended to yield benefits to communities, nations and
| individuals. Such benefits include improved social and economic development,
JL increased productivity and enhanced quality of life. In many parts of the world,
such investments are not achieving their full potential, despite increased enrolments
and hard work by committed teachers and administrators. This document describes
how educational investments can be enhanced, by increasing the capacity of schools to
promote health as they do learning.
For better or worse, health influences education. Healthy children learn well. If
children are healthy, they can take full advantage of every opportunity to learn. But,
children who cannot attend school because of poor health or unhealthy conditions
cannot seize the opportunities that schools provide. Similarly, schools cannot achieve
their full potential if children who attend school are not capable of learning well. Poor
health and unhealthy conditions jeopardize the value of school attendance.
This document is the first of a technical series on school health promotion pre
pared for WHO’s Global School health Initiative. It is appropriately the first, because
helminth infections are the world’s leading cause of diseases among school-age chil
dren.
WHO’s Global School Health Initiative is a concerted effort by international or
ganizations to help schools improve the health of students, staff, parents and community members. Education and health agencies are encouraged to use this document to
strengthen helminth interventions as part of the Global School Health Initiatives goal:
to help all schools become “health promoting” schools.
Although definitions will vary, depending on need and circumstance, a “health
promoting” school can be characterized as a school constantly strengthening its capacity as
a healthy setting for living, learning and working (see box).
The extent to which each nation’s schools become health promoting schools will
play a significant role in determining whether the next generation is educated and
healthy. Education and health support and enhance each other. Neither is possible
alone.
Dr Ilona Kickbusch, Director
Division of Health Promotion, Education and
Communication, WHO
••
VII
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
HEALTH PROMOTING SCHOOL
A "health promoting" school:
♦ fosters health and learning with oil the measures ot its disposal.
♦ engages health ond education officials, teachers, students, parents, ond community leaders in efforts
to promote health.
♦ strives to provide a healthy environment, school health education, ond school health services olong with school/
community projects ond outreach, health promotion programmes for staff, nutrrtion ond food safety programmes,
opportunities for physical education ond recreation, ond programmes for counselling, social support ond mental
health promotion.
♦ implements policies, practices ond other measures that respect on individual's self-esteem, provide multiple
opportunities for success, ond acknowledge good efforts ond intentions os well as personal achievements.
♦ strives to improve the health of school personnel, families ond community members os well os students; ond works
with community leaders Io help them understood how the community contributes to health ond education.
WHO
INFORMATION
SERIES
ON
SCHOOL
HEALTH
WHO INFORMATION SERIES ON SCHOOL HEALTH
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS THROUGH SCHOOLS
This document is intended to help people use Health Promotion strategies to improve
health. It is based on the recommendations of the Ottawa Charter for Health Promo
tion (1986). It will help individuals and groups move towards a new approach to public
health, one that creates on-going conditions conducive to health, as well as reductions
in prevailing health problems.
1 INTRODUCTION
1.1 Why did WHO prepare this document?
The World Health Organization (WHO) has prepared this document to help peo
ple take control over and to improve their health. It provides information that will
help people implement interventions that will reduce helminth infections through
schools often by relatively low-cost measures.
1.2 Who should read this document?
This document should be read by:
(a) Policy- and decision-makers, programme planners and coordinators at local, dis
trict (provincial) and national levels.
(b) Officials and institutions responsible for planning and implementing the interven
tions described in this document, especially those from the ministries of health and
education.
(c) Programme staff and consultants of international health, education and develop
ment programmes which are interested in promoting health through schools.
(d) Community leaders, school personnel, health workers, service providers and mem
bers of organized groups, e.g., women’s groups, interested in improving health, edu
cation and well-being in the school and community.
1.3 What is a helminth infection?
The term “helminth” is often used to refer to a variety of worms that live as para
sites in the human body. A helminth infection occurs when worms (or eggs) enter,
mature, lay eggs and feed off a person. The names of the important helminths, where
they live in the human body and their geographical distribution are presented in
Annex I.
1.4 Why reduce helminth infections?
Helminth infections are one of the leading causes of diseases among young people
and adults in the world today. They affect the health and well-being of millions of
people, especially young people. The figure on the next page shows an example that
the highest rates of roundworm amd whipworm infections are often demonstrated in
the groups of 5-9 and 10-14 years old (cited from the Bulletin of the World Health
Organization, 1995, 73:510).
1.5 Why focus efforts through schools?
In countries where helminth infections prevail, schools provide the most effective
and efficient way to reach large portions of the population, including young people,
1
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
wr
Roundworm infection
i
40
CD
2
30
a>
Hookworm infection
ro
®
a.
20
Whipworm infection
10
e
K
1
0-5-10-
20-
3040' 50Age group (year)
KHz
70-
80-
school personnel, family and community members; and to reduce infections and pre
vent re-infections. School children are often the group that has the highest infection
rate as well as the highest worm burden which contribute greatly to the contamination
of the environment. These efforts may be most effective when integrated into more
comprehensive approaches to school health, such as in the development of “health
promoting schools”.
1.6 How will this document help people to take control over and to improve health?
This document is based on the latest scientific research and control experience
related to helminth infection, but it is more than a technical document. It is designed
to help people address the broad range of factors that must be changed to reduce helminth
infections, to prevent re-infections and to improve health through schools. It will help
you and others to:
(a) Create Healthy Public Policy: This document provides information that you can
use to argue for increased local, district and national support for helminth reduc
tion and school health efforts. It also provides a basis for justifying the decisions to
increase such support.
(b) Develop Supportive Environments: This document describes the environmental
changes that are required to reduce helminth infections and how those changes
can be made at the lowest possible costs.
(c) Reorient Health Services: This document describes how current health services
can be changed to seize the new opportunities afforded by schools resulting from
the development of safer medications and more effective school health promotion
programmes.
(d) Develop Personnel Skills: This document identifies the skills that young people
need to avoid helminth infection. It also identifies skills needed by others to cre
ate conditions conducive to helminth reduction and health through the school.
(e) Mobilize Community Action: This document identifies essential actions that
must be taken by the school and community together to reduce and prevent
helminth infections; identifies ways in which the school can help to mobilize the
community to implement such actions and to strengthen school health programmes.
It also provides arguments and facts that can be communicated through the mass
media to call attention to the problem of helminth infections.
2
WHO
INFORMATION
SERIES
ON
SCHOOL
HEALTH
This section provides information that one can use to convince others of the impor
tance of reducing helminth infections, especially through schools. It also contains ar
guments to help policy- and decision-makers justify their decisions to increase such
support.
The following arguments strongly support the importance of helminth reduction
interventions as part of a school health programme and the need for increased invest
ment in such programmes.
2.
CONVINCING OTHERS
THAT HELMINTH
REDUCTION
INTERVENTIONS
IN SCHOOLS
IS IMPORTANT
2.1 Argument: Helminth infections destroy the well-being and learning potential
of millions of children in countries struggling to help their people develop better
lives!
Although the majority of the children in developing countries now survive beyond
their fifth birthday, they still face major problems of ill-health and malnutrition. One
of the major health problems faced by hundreds of millions of school-age children is
infection by roundworm, whipworm, hookworm, schistosome and other flukes, and/or
guinea worm. These parasites consume nutrients from the children they infect. In
doing so, they bring about or aggravate malnutrition and retard children’s physical de
velopment. They also destroy the tissues and organs in which they live; and cause
abdominal pain, diarrhoea, intestinal obstruction, anaemia, ulcers, and various health
problems. All of these consequences of infection compromise children’s attendance
and performance at school. And, not uncommonly, heavy or long-term infection can
result in death, if treatment is not given in time. Thus, as the number one cause of
diseases among 5-14 year-old children, helminth infection should be one of the first
problems addressed to enhance the quality of life, health and productivity of chil
dren throughout the world.
2.2 Argument: Intestinal helminths are stunting the growth and development of
millions children in countries which must count on their development to achieve
progress!
Roundworm, whipworm and hookworm are helminths that infect about 400 mil
lion school-age children throughout the world. In fact, roundworm and whipworm
alone are estimated to affect one quarter of the world’s population. Their eggs or young
worms are found in the soil. People become infected by coming into contact with soil
or vegetables that contain these eggs or young worms. Roundworm, whipworm and
hookworm infections each affect the health and well-being of infected populations dif
ferently:
-
Roundworm infections can retard growth. They decrease the absorption of nutri
ents that the body needs to grow. They cause structural problems in the small
intestine in children. They are thought to be a cause of frequent or serious pulmo
nary disease among children. Intestinal obstructions frequently result in the hospi
talization of children. Death is not uncommon in children when worms move to
organs outside of the intestines such as the trachea, liver, and heart, and when
complications occur.
-
Whipworm infections are associated with high incidence of dysentery, chronic
colitis, anaemia and growth retardation, where intense infections are reported.
-
Hookworm infections cause iron deficiency anaemia and even minor infections
may result in severe anaemia in children and in adolescent girls.
I
)
3
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
These infections also contribute to poor appetite and decreased food intake. Each
can contribute to malnutrition, anaemia or other states of poor health, which in turn,
can lead to an impairment of learning and poor school performance. It is important to
note that the stunting of children’s growth is not readily recognized, because it occurs
almost imperceptibly over time. Thus, the full impact of helminth infections is greatly
under-reported.
2.3 Argument: Schistosomiasis infects millions of young people, then causes chronic
diseases in their productive years of life!
Over 200 million persons are infected by schistosome, the parasite that causes schis
tosomiasis. Of those infected, approximately 88 million are under 15 years of age. Schis
tosome infection is acquired by contact with freshwater that contains the young para
sites. Schistosomiasis, usually a chronic disease observed in adults, is often a conse
quence of the heavy infections acquired in childhood.
The highest rate and the heaviest worm load of urinary schistosomiasis in African
countries occur among children of 10-14 years old. Bloody urine may be visible in 1020% of infected children. Most of the persons heavily infected by intestinal schisto
somiasis in Africa and South America are between 10 and 14 years of age.
There is a relationship between heavy schistosome infections (infections that in*
volve very large numbers of the parasites) and chronic schistosomiasis in children. Schis
tosomiasis has a detrimental effect on the growth and development of school-age chil
dren, especially in association with anaemia, malnutrition and stunting of growth. In
Asia, dwarfism due to schistosome infection is not uncommon in areas reporting a large
number of cases of a certain type of schistosomiasis.
2.4 Argument: Food-bome trematode infection due to consuming certain raw foods
affects children’s liver, lungs and intestines!
Globally, some 40 million persons are infected with trematodes, i.e., flukes, which
affect the liver, lungs and intestinal tract. Of these infections, approximately 15 mil
lion are among children.
People contract fluke infections by ingesting raw or inadequately cooked fish, shell
fish or aquatic vegetables that contain the larvae of the fluke. Widely distributed in the
world, these infections have a considerable impact on health of children and adults.
The impact of these diseases on children is not well documented, but high infection
rates and even deaths due to heavy fluke infections in children are reported in many
countries.
2.5 Argument: Guinea worm disease is a risk to millions of people who are without
safe water!
Guinea worm disease (dracunculiasis) is acquired only by drinking water contain
ing tiny but visible organisms which have been infected by the parasite. The disease
occurs among populations without access to safe sources of drinking water, particularly
where people have to enter the source (e.g. stepwells or shallow ponds) to fetch water.
The infection usually causes blisters and ulcer on the lower leg or foot of the victim
and leads to serious adverse effects on health, agricultural production, and school at-
4
WHO
INFORMATION
SERIES
ON
SCHOOL
HEALTH
tendance. Since the World Health Assembly adopted a resolution calling for the eradi
cation of this disease in 1986, major progress has been made in reducing this disease.
However, in Africa and south Asia, over 100 million people are living in areas where
they still could be infected. School children are among the groups at risk.
This section provides information that you can use to convince others that helminth
reduction interventions will really work, especially when implemented in schools. It
also contains arguments to help policy- and decision-makers justify their decisions to
implement such efforts.
The following arguments strongly support the efficacy of helminth reduction programme
in schools.
3.1 Argument: We know how to prevent and reduce helminth infections in ways
which in many cases are cost-effective!
3.
CONVINCING
OTHERS
THAT HELMINTH
REDUCTION
INTERVENTIONS
IN SCHOOLS WU
REAUYWORK
All the above health problems and consequences can be prevented or greatly re
duced through cost-effective interventions. In many countries, the school plays a ma
jor role in making these interventions available to the people who need and will benefit
from them.
The basic interventions for reducing helminth infections are three: drug treat
ment, sanitary improvement, and health education. The advances in drug develop
ment during the last two decades have made mass treatment acceptable and affordable.
However, for achieving sustainable results, drug treatment should be provided in com
bination with sanitary improvements and health education.
3.1.1
Drugs are safe, effective and easy to use!
The available drugs are highly effective in treating intestinal helminth,
schistosome and other fluke infections. The single oral dose administra
tion and the safety of the drugs allow them to be delivered outside of the
medical setting. Therefore, a strategy of mass treatment could be targeted
to school-age children through school settings.
3.1.2
Simplified diagnostic methods are available!
Qualitative and quantitative diagnostic methods for helminth infections
are available for both individual and mass examinations without a need
for sophisticated facilities.
3.1.3
These infections can be prevented!
The above-mentioned helminth infections are all preventable. An es
sential barrier to most helminths is to prevent human faeces from pollut
ing the ground or surface water. The infections of the major intestinal
helminths can be prevented through avoiding ingestion of, or contact
with the contaminated soil. To avoid entering the infested water greatly
reduces schistosomiasis. Food safety measures help prevent fluke infec-
5
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
tions which are transmitted by meat or vegetables. Provision of safe water sources have been shown to be extremely effective in preventing guinea
worm infection. Obviously, health education highly complement the
above measures.
3.1.4
Sanitary interventions help control infections other than those caused by
helminths!
Improved sanitation, including disposal of human waste, creation of safe
water supplies and personal and food hygiene, greatly contributes to a
reduction of diseases, especially those spread through human faeces. Some
of the diseases that can be reduced are those caused by viruses, bacteria or
protozoa, all of which can be seen only with a microscope.
3.2 Argument: Schools are a remarkably efficient means to prevent and reduce
helminth infections!
The school system in many developing countries offers an existing and compre
hensive means of delivering the combination of interventions needed to achieve sus
tainable results. In most communities there are more schools than health centres and
more teachers than nurses. This does not mean that teachers are expected to work as
nurses. But teachers can play an important role as health educators and as facilitator of
community actions to improve sanitary conditions. Schools are settings through which
children, as well as much of the rest of the community, can be easily reached. Thus,
schools provide a remarkably efficient means of reducing health problems that are caused
by helminth infections.
3.3 Argument: Helminth reduction interventions can have a positive impact on
children’s health, learning potential and school attendance!
Studies indicate that helminth reduction programmes in schools can have a sig
nificant impact on health and learning among school children. Outcomes of deworming
interventions among school children show remarkable spurts in their growth and de
velopment. In addition, evidence suggests that cognition improves concomitantly al
though careful long-term studies of the nature and magnitude of this effect are needed.
Thus, mass treatment can reduce existing infections, and periodic use of anti-helminth
treatments can prevent the development of symptomatic disease as well as improve
growth, nutritional status and possibly cognitive status.
There is a positive correlation between education and production. Thus, if helminth
infection inhibits educational achievement it could also eventually affect production
during adulthood.
3.4 Argument: Helminth reduction interventions in schools can benefit the entire
community!
Children with heavy worm infections are more likely to contaminate the environ
ment and thus increase the risk of infection to others. When effective helminth reduc
tion programmes are implemented in schools, they can help to reduce the spread of
helminth infections within the community. Repeated treatments targeted to those
6
WHO
INFORMATION
SERIES
ON
SCHOOL
HEALTH
most heavily infected, e.g., pre-school and school children, have helped to lower the
prevalence of soil-transmitted helminth infections in the whole community.
School health education provided to children about helminths can also serve as a
means to inform families and other community members about ways to reduce helminth
infections and prevent reinfections. The establishment of sanitary facilities and safe
water supplies in schools is also an excellent way to demonstrate to villagers how to
improve the facilities in their communities.
Once the importance and feasibility of providing helminth reduction interventions
through schools become understood by citizens, school officials and policy- and deci
sion-makers, the next step is to plan a programme. This section describes important
steps that should be considered in the planning process, which include conducting a
situation analysis, obtaining political and community commitments, and setting objec
4.
PLANNING OF
THE INTERVENTIONS
tives for the programme.
4.1 Situation analysis
4.1.1
Purpose of conducting a situation analysis
Policy- and decision-makers will want a strong basis for their support,
especially when their policies and decisions involve the allocation of re
sources. Accurate and up-to-date data and information can provide a
basis for discussion and justification for action. Data are also essential for
planning interventions that can reduce helminth infections and promote
health.
4.1.2
Data items needed
It is useful to know what proportion of persons are infected with helminths
and how heavily they are infected. Heavy infections are associated with
disease and other problems. Death rates are also important as helminth
infections may be life-threatening conditions under certain circumstances.
These data are useful in determining the importance of helminth infec
tions to health and well-being in the community. Data about rates and
levels of infection, as well as deaths, may already be available from the
local health unit. If they are not available, they can be obtained through
a sample survey in a given area or population. Data are needed about
factors that might strengthen activity, or barriers that need to be over
come. The table below shows the basic questions that need to be an
swered for situation analysis and the methods for collecting data.
(S)
F5R
7
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
Methods for Dola Collection
Basic Questions
How prevalent ore helminth infections in the community?
Review of existing data;
Questionnaire (Rapid assessment for urinary schistosomiasis);
Sample survey by faecal or urine examinations
How prevalent ore helminth infections in schookge children?
Same as drove.
Data for infection rote and worm burden
How frequent ae the major health problems in school children caused
or affected by worm infections, such as obdomind pain, cfiarrhoeo,
anaemia, bloody urine, intestind Needing, growth retardation oral
malnutrition?
Interviews with school nurses or teochersin charge;
Consult school health records;
Interviews with parents;
Review of data available al district hospitals and local health
centres
How frequent ae hospital admittance and surgical emergency of
school age children (be to worm infection?
Review of data available at district hospitals
and locd health centres
Are there data on deaths due to worm tafection in school age
children?
Some os above
What ore the important unhealthy behaviours m relation to worm
mfedion in school children?
Observation;
Questionnfflre;
Problem solving discussions
Do parents and children hove basic knowledge on worm infection?
Ouestionn(®e;
Focal group
What ore the common attitudes on infection and deworming in
parents and chttren?
OuestionntBre;
focol group
Are sonitaiy facilities (water supply ord latrines) ovoSoble and prop
erty maintained In schools?
Survey and interview with school heods
Are there other health interventions being implemented in selected
schools and is if possible to integrate them with deworming ?
Interview with school and community leaders
4 2 Political/cultural acceptability
4.2.1
Political commitment
The success of efforts to reduce helminth infections through schools de^
pends on the will, commitment, attention, support and action of health
and education authorities. Experience indicates that the main constraints
to such efforts are more inherent in administrative rather than technical
systems. Therefore, endorsement and support from senior officials in both
sectors are essential.
8
WHO
INFORMATION
SERIES
ON
SCHOOL
HEALTH
Increased political commitment is evidenced by:
♦
Designating someone with responsibility and authority to deal with issues concerned
♦
Providing financial support.
♦
Providing technical equipment, services and materials.
♦
Giving dear sanction and support from the Ministries of Education and Health.
♦
Public acknowledgement by ministries of the importance of the problem and the feasibility to handle through schools.
■
4.2.2
Commitment of community
The success of efforts to reduce helminth infections also relies on the
awareness and commitment of the community to want such a programme
and to ensure that it is maintained within the community. The collective
recognition and understanding of the problem by families and commu
nity members can help to bring about support and action for on-going
efforts to influence behaviours and conditions that will reduce and pre
vent helminth infection.
Community commitment is strengthened/morked by
♦
Acknowledgement of the importonce of the problem from heohh, education and other groups.
♦
Allocating local resources, e.g. public money, for deworming in school children.
♦
Combining the programme with other programmes in the community, such as primary health care and sanitary
environment.
♦
Ongoing efforts to ottroct medio attention.
♦
Involving existing councils, school board, organizations such as women's group to gain a critical moss of support.
♦
Use of both problem solving as well as health promoting opprooches to improve school health.
4.2.3
Supportive school policies/practices
Development of supportive school policies and practices related to
helminth reduction interventions is important to make a programme sus
tainable. For example, regulations for improving and maintaining ad
equate sanitary facilities and a safe water supply at school are essential.
Also, collaboration and coordination between the health and education
sectors, and between the school and the community are important re
quirements for success.
9
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
Examples of supportive policies and regulations
♦
Required periodic coordination between health ond education authorities at focal and district levels
♦
Rules about deonliness for students and personnel, ond about the proper use of latrines and water supply facilities
♦
Rules about keeping the school environment dean
honples of supportive prodices
♦
School curriculum Bidudes helminth infection ond its prevention
♦
Proper use of hygienic toilets/htrines
♦
Regufor deeming of toilets/fotmes
♦
Existence ond use of proper hondwoshing focittties
♦
Safe food and water
♦
Mutuo! (faily hygienic check among students fw bonds ond fingernails
♦
“(hid to child*, 'little health inspector* programmes
♦
foochers' ttoining
♦
Drug supply on on ongoing basis
4.3 Goal and objectives of helminth reduction interventions in schools
4.3.1
Goal
The overall goal of any helminth reduction intervention effort should be
to reduce infections and prevent re-infections to that helminth infection
levels cease to be of public health importance in the community.
4.3.2
Short-term objectives
A crucial aim of short-term objectives should be to reduce helminth in
fections among children to levels at which harmful effects on growth and
nutritional status, and the occunence of such problems as abdominal pain
and intestinal obstruction become uncommon.
Through the first two years’ effort, the proportion of children who have
helminth infections is considerably reduced.
During the same period, discomfort and school absenteeism in children
due to worms become significantly less frequent.
&
Helminth reduction interventions are integrated into a comprehensive
approach to school health, such as the development of a “health promot
ing School”.
J
10
WHO
INFORMATION
43.3
SERIES
ON
SCHOOL
HEALTH
Long-term objectives
The long-term objectives should be to maintain the school-based inter
ventions for helminth reduction and prevention, and to expand the ef
forts to other schools and the community as feasible and needed to effec
tively control helminth infections.
By the end of and beyond the third year, the interventions have been
sustained and the project schools become core elements in expanding
their experience to others.
Certain proportion of schools in the district will have implemented
helminth interventions and a network of health promoting schools estab
lished.
These schools in the district will offer helminth interventions to mem
bers of the community.
The attitude of the students and community members about the impor
tance of helminths will be changed.
The school offers many opportunities to reduce helminth infections. A ‘ Health Pro
moting School” strives to improve health through interventions which include health
education, health services and environmental modifications. The more comprehen
sive approaches include, but not limited to:
-
School health education
A healthy school environment
School health services
School/community projects and outreach
Health promotion for school staff
Nutrition and food programmes
Physical exercise, recreation and sport
Counselling and social support.
imEGRATING HELMINTH
RHJUCTION
INTERVamON WITHIN
VARIOUS COMPONENTS
OFASCHOOL HEALTH
PROGRAMME
The effectiveness of interventions integrated into each of the areas above is influ
enced by the extent to which the interventions are supported by school health-related
policies and provided by staff who are trained. The following information describes
how helminth interventions can be integrated into relevant school health programme
components.
5.1
School health education
The success of helminth reduction interventions substantially depend on whether
individuals are willing and able to practise behaviours that reduce the likelihood of
infection. The essential goal of health education is to influence health-related behav
iours and conditions by stimulating students’ interest in good health and by guiding
their efforts to improve their own health and that of their family.
11
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
In selecting important information to convey to students about helminths, scien
tific terms and details may seem to be important. However, for the purposes of health
education, they are considered less important than practical and basic information that
will enable students to avoid infection. For example, it is more important for a student
to know how to practise hygienic behaviours than to learn the names of each parasite
that lives in the water.
5.1.1
Behaviours related to helminth infections
The clear and precise delineation of behaviours specifically relevant to
helminth infections in each community is essential to the development
of effective school health education programmes. Important and common behaviours associated with helminth infection are listed in the box.
These are not all inclusive as there may be other behaviours, specific to
communities, that are not listed. Close collaboration between education
and health officials is thus necessary to identify the behaviours that must
be addressed to reduce helminth infections in any particular community.
Common behovioors related to hebninth mfectioas
♦ Unhygienic hdjits that olow helminth eggs to enter the mouth from the hands indude:
Fcimg to wash hands before eating;
Ffflfeig to dean onus and wash hands after defecating;
Frsfeig to wosh holds after ploying on the pound, and
Allowing dirt to remain under the frigemoils;
Sucking on fingers.
♦ Behoviours that (flow hookworms to penetrate the skin or enter the body indude:
-
Writfig or working in the field without wearing shoes or sandals;
Working in the field with bare hands; and
Ingesting unwashed raw vegetables.
♦ Behoviours that allow eggs k young worms to be spreod back mto the environment include:
Defecating on soil or tfi water with which others come in contact.
Urinating (in the case of winery schistosomiasis) in water (such os a stream) with which others come in contact;
Using untreated or partly treated human excreta as fertfcer for crops;
Also, persons with guinea worm disease spreod young worms if they enter water to bathe or collect the waler while a guinea
worm is emeqpng through their skin
♦ Behaviours that (flow young worms to enter the body with water include:
Swimming, bathing, fishing, washing Kid wading in water infected with schistosome;
Drinking untreated or unfiltered waler in areas where guinea worm infection exists.
♦ Behaviours that allow worms and eggs to enter the body with food include:
-
Eating unwashed raw vegetables may lead to intestinal helminth infection Kid fluke infection; and
Eating raw or undercooked fish, shellfish and meal con result hi infection with flukes and tapeworms (a group of helminths which
are not described in this document).
♦ Behoviours Ihcl may result in continuation of infaction or spread to others mdude:
*
*
12
Not having stool samples examined when the service is available; and
Fifing to comply with treatment.
INFORMATION
WHO
SERIES
ON
SCHOOL
HEALTH
Knowledge, attitudes and skiis related to worm transmission (Bid reduction
Knowledge: Students and others w8 learn that
There ore a number of worms thot can infect students ord their commuraty.
Some worms infect persons by entering through the mouth. Others enter the body through the skim
Worm infections con be prevented by evading the practice of some very specific behaviours (isted above).
Poor environmental saratation is the bash for worm tnnsmission.
Worms in the body cause abdominal tomfort, loss of nutrients, retarded development, rmd even death.
Worm infection causes school absenteeism, poor learning ability ond poor performance;
Worm infections con be easily detected and treated at a reasonably low cost;
Reinfection can be prevented;
The elmination of worm infection will benefit the infected inividuol ord will also help to reduce the spread of infection to others
in the community.
-
■
'
■
■
•
■
■
•
■
■
Attitudes: Students ond others will denwistiote
Responsibility for personal, fomiy ond community health;
-
Compliance to screening ond freotment in the school/commumty;
Confidence to change unhealthy habits;
Willingness to use school end community resources for ffiformotion dtout preventing worm infection.
Skis: Students ond others will be able to
Avoid behaviours thot are likely to cause infection
Communicate messages about worm infection to families, peers ond members of the community;
Encourage peers, sibtogs ond family members to take port in deworming activities;
Encourage others to change their unhealthy hdxts;
Follow the regulations of maintoirang a healthy school environment;
Form o group to ploy a leadership for dl in supporting the worm reduction programme;
Help stwt similar interventions in the commimity.
5.1.2
Knowledge, values, beliefs, skills and attitudes that influence behaviours
associated with helminth infection
First and foremost, people must be taught specifically what behaviours are
likely to result in helminth infection so that such behaviours can be
avoided. However, other information is also needed to encourage and
enable students to practise healthy behaviours. Important knowledge,
attitudes and skills are listed in the box. These are not all inclusive as
teachers and health workers each must identify the knowledge, values,
beliefs, skills and attitudes that are most relevant to reducing helminth
infection in any one community. Close collaboration between education
and health officials, as well as the involvement of parents, students and
community members is necessary.
13
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
Information needed to plan Health Education
5.1.3
Information about values, beliefs and attitudes that may influence behav
iours and conditions associated with helminth infection can be obtained
from students and parents through interviews, informal discussions or ques
tionnaires. Knowledge of existing values, beliefs and attitudes is needed
to design an effective health education strategy. Such factors can posi
tively or negatively influence health behaviours or actions needed to
change unhealthy conditions. For example, people may choose to ignore
helminth infections because they have been with them for generations;
local beliefs or superstitions may prevent people from accessing health
services; and poorly maintained facilities like latrines may significantly
influence a student’s attitude about their use.
Information about values, beliefs and attitudes that may influence the
behaviours and conditions associated with helminth infection, is also im
portant to the appropriate development of educational efforts that are
carried out through mass media, health workers, religious groups and other
organizations.
Information about student/parent knowledge and skills, as well as local
beliefs, values and attitudes enhances understanding among teachers, other
school personnel and health workers. Without such information, educa
tional interventions are not likely to be targeted to the most relevant
factors that contribute to helminth infection in the community and thus
are unlikely to achieve the desired results.
Tbe foflowfag steps are important to acquire the information needed to plan health echicatioo:
♦
Secure the colloborotion of education md health authorities and involve parents, students, community members os well os locd
organizations in the information collection process.
♦
Identify of the specific behaviours and conditions most relevant to helminth control in the community.
♦
Identify the specific factors associated with the behaviours and conditions that ore most relevant. This involves specifically
delineating the knowledge, attitudes, beliefs and skils that students need to practise healthy behaviours ond avoid unhealthy
ones.
5.1.4
Designing and/or selecting lessons and materials for Health Education
Educational methods (lessons, learning experiences, teaching materials,
learning materials) should be designed or selected to increase knowledge,
build positive attitudes and values, dispel myths, increase skills, and pro
vide support to the reduction and prevention of helminth infections. They
must focus on the knowledge, attitudes, values, beliefs and skills that con
tribute to spreading or reducing helminth infection in the community.
Some educational interventions are better than others in influencing cer
tain factors.
The design or selection of an education method should be based on the
extent to which that method is appropriate to influence the factor which
is to be influenced. For example, a lecture is an effective way to increase
14
WHO
INFORMATION
SERIES
ON
SCHOOL
HEALTH
knowledge, but it is less effective in influencing beliefs and building skills.
Discussions, debates and carefully prepared written materials can be more
effective than a lecture in dispelling the logic or foundation of local myths.
Practice sessions and role play exercises can be more effective than lec
tures, discussions, debates and written materials in building skills.
The design or selection of an educational method should also give con
sideration to the targeted group. Lessons for first grade students may be
too simple for parents or religious leaders. Debates and discussions may
be too complex for young students but may be very effective for commu
nity leaders and the adults of the community. Since it will be important
to educate beyond the classroom, a variety of educational methods will be
needed.
The following steps ore important in designing and selecting methods of health education:
♦
Design ond/or select lessons ond leaning materials that am best influence specific factors that contribute to reducing (Bid/or
preventing helminth infections in the community. The methods selected should be ones that we most likely to influence the
factor.
♦
Identify target groups beyond classroom, such as porents, relgious group ond health workers and develop or select educotiond
methods that ore consistent with their level of understanding, the setting si which they will learn ond the factors that ore most
relevant to them in recking ord preventing helminth infection in the community.
5.1.5 Training school personnel and others to implement Health Education
The implementation of health education involves training school teach
ers to use a variety of educational methods. Some teachers rely on one or
two educational methods, such as lectures and worksheets, to teach about
academic subjects. Because health education involves influencing atti
tudes, values and skills, as well as knowledge to bring promote healthy
behaviours and conditions, teachers must be trained to use a wide variety
of teaching methods.
Health education methods that are simple, inexpensive, and culturally
acceptable may be the most feasible to implement, but they will not be
useful unless the methods are effective in influencing the factors that are
relevant to reducing and preventing helminth infection in the commu
nity. For example, all teachers are quite familiar with the lecture method
of education. Thus, the provision of relevant information to them is a
simple, economical and feasible way to enable them to lecture about
helminth infection. However, if attitudes and beliefs are also relevant to
helminth infection in the community, lectures which contain the most
important helminth information may not be enough to reduce or prevent
infection.
In many communities, teachers will need training to learn to use teaching
methods that are most effective in influencing a variety of factors that
contribute to helminth infections in the community. Methods that en-
15
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
gage students and parents in the educational process and require their
participation should be given priority, such as discussions, debates, role
playing, community education projects.
Health education to reduce helminth infections can not rely on any single
means of education. A variety of learning experiences are needed and
teachers must be trained to use them.
The troffiing of school personnel shodd involve:
\
.
■/
_■
;
,
.
■
.
♦
A rotionole fa Implementing helminth reduction cal prevention interventions in schools.
♦
Aiocotion of authority, personnel, time ond resources to a staff member who wil be responsible for initiating, managing ond
coordinoting the training.
♦
Regularly scheduled follow-up sessions or other means by which to provide updates about status of helminth infections ond
progress in reducing and preventing helminth infection.
♦
The development of a core group of towers or training teams that will enoble all relevant teachers ond school personnel to receive
towing in a timely rramer.
♦
An evaluation to determine how confident teachers ond other school personnel feel diout educating to reduce ond prevent
helminth infections.
■
5.2 A healthy school environment
The school and communities’ environment plays a significant role in determining
whether interventions to reduce and prevent helminth infections in the school popular
tion will be effective and sustainable. Human excreta disposal, water supply and
handwashing facilities are key factors that must be addressed in creating a healthy school
environment.
5.2.1
General criteria for hygienic facilities and safe water supply
There are many methods that can be used to provide hygienic sanitation
facilities and a safe water supply at schools. The principles and criteria
involved in the selection of appropriate methods stipulate that those chosen should be:
♦
Techndly and enwonmentdly sound
Finonddly affofxJabte.
16
♦
Sodolly ond culturally occeptdile.
♦
Rehont on labour ond resources ovoilobfe in the community.
♦
Simple to instol, operate and maintain.
♦
Easily accessible by the students.
♦
Related to reducing public health problems that ore perceived os priorities within the community.
WHO
INFORMATION
SERIES
ON
SCHOOL
HEALTH
5.2.2 School latrines
School latrines help students and staff avoid exposure to human excreta
(faeces and urine). Human excreta is the biggest source of disease-pro
ducing organisms including parasites, bacteria and viruses. Helminth eggs
in faeces are spread to the soil by persons who defecate where others may
be exposed to the faeces, by persons who use faecal material as fertilizer
and by animals which may carry faeces or contaminated soil on their body
or feet. In the case of urinary schistosomiasis eggs are spread by persons
who urinate in water (e.g. canals, ponds). Therefore, it is extremely im
portant to provide latrines for the school population to keep the school
environment free from faecal pollution.
There are many types of latrines, however latrine technology and its use
are culture and location specific. Various latrine systems are adopted in
different parts of the world. Their differences are due to a wide variety of
cultural, environmental and economic conditions. Guidelines or manu
als may be available locally. The community leaders, parents, teachers
and students should be involved in determining the most acceptable type
of latrines. Education and health officials will need to collaborate to as
sure the construction of latrines that are technically appropriate as well as
acceptable.
For a school latrine to function properly it must be maintained and cleaned
on a daily basis. Somebody must have specific responsibility for this and
compliance must be checked. Groups of school children might do the
cleaning in rotation.
5.2.3
Safe water supply
A “safe water supply” is a source of water that is not contaminated by dirt,
bacteria, parasites or anything else that could cause contamination.
Building a well is an example for providing safe water in many parts of the
countryside. However, wells must be protected as noted in the box.
Protecting a well from contominotion
o
locate wefls at least 1S meters cwoy from sources of contominotion such os brines, livestock sheds, etc.
♦
M o fessed wall, or (Hence, around the weB to keep ommohawoy
♦
Place o drainage ditch around the well to prevent surface water ami spiled water from contaminating the well and keep the
surrounding ground dry
♦
Keep the water bucket decsi and use a raised block on which to (dace waler bucket to avoid contominotion
♦
Use o well cover to prevent pollution from dust, insects and onimok when not in use
There are successful practices to make water safe for drinking. For instance, simply
storing water for over 24 hours and then decanting can help remove helminth eggs
which fell to the bottom of the container. Boiling is a good method of killing worms/
17
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
eggs and other germs that may contaminate the water. A filtration system established
with stones and sand, or gauze/filters in guinea worm areas, is another method of mak
ing water safe from worms.
Storing safe water to ovoid recoatsninatioo
♦
Wash containers with clean water once a day or whenever they ore empty
♦
Install a dosely fitting cover on the container
♦
Idedly, fit o top obout 5 cm dxtve its bottom of the container
♦
Race the contdner off the floor on o box or shelf
5.2.4
Hand washing facilities
Many children become infected with helminths when faeces or dirt which
contain helminth eggs get on their hands and then into their mouths. To
prevent helminth infection as well as ingestion of other pathogenic or
ganisms, it is essential to establish hand washing facilities in schools and
train students to wash hands after using the latrine or playing on the
ground, and before eating or handling food. There must be functioning,
convenient hand-washing arrangements somewhere between the latrines
and the classrooms.
5.2.5
Safe collection and disposal of waste in school
Improper disposal of rubbish is also a factor in the spread of communica
ble diseases. It is important that children and school personnel under
stand what they can do to safely dispose of waste. It will be useful to find
out the common practices for disposing of waste in the community and to
encourage people to follow those practices which are safe. Three ways to
safely dispose of solid waste which can kill worms and eggs when the waste
is contaminated with faecal materials are: composting, burning and bury
ing.
5.3 School health services
Screening and treatment for helminth infections in schools can be an excellent
entry point for the delivery of health services in schools. Helminth reduction is now
more feasible than ever before owing to the discovery of safe and effective broadspectrum
drugs, and the improvement and simplification of certain diagnostic procedures.
5.3.1
Screening/Diagnosis
Identification of eggs or young worms in faeces (or urine) provides evi
dence of helminth infection. In a school deworming programme, the
objective of faecal screening is to measure the level of the proportion of
students who are infected by worms and the worm load of the infected
individuals to help design a deworming schedule (drugs and dosages, in
terval of treatments in a year) prior to intervention. For evaluation, post-
18
INFORMATION
WHO
SERIES
ON
SCHOOL
HEALTH
treatment faecal examination is needed. Levels of infections revealed by
a baseline survey of school children can help decision-makers and plan
ners to determine which type of interventions should be used in schools.
The screening is done by trained tednriaans rod hedth workers. Schools will be responsible for.
♦
Explaining to the students the purpose of faecal examination ond obtaining full compliance.
♦
Helping prepare a list of students, labels with name, ID number ond doss of each student to be exomined ond distribution to
students of the labels and containers for foecol specimen.
o
Providing o room with benches for the exaninations if the school is for from o health centre (taboratory). This would also give on
oreno Io show eggs/wms Io the students, teochers ond porents for educotionol benefit.
♦
Working with the students' parents to moke sure that every student submits o specimen for examination.
Direct thin smear and cellophane thick smear are the techniques most
commonly used for detecting helminth eggs in stool. Urine filtration
technique is recommended for detecting eggs for urinary schistosomiasis.
If workers and a microscope are available locally, limited cost is needed
for the screening by using these techniques. For an experienced techni
cian, one specimen may take a few minutes.
Helminth eggs have a characteristic shape, size, definite shell and con
tents inside. The “Bench Aids for the Diagnosis of Intestinal Parasites”, pub
lished by WHO, provides microphotographs of helminth eggs, and de
tailed information on procedures of relevant laboratory techniques.
For screening urinary schistosomiasis, a rapid assessment guide contain
ing questionnaires on blood in urine has been developed by WHO/TDR,
which is easy and cheap to use and requires no laboratory equipment.
The proportion of children who report blood in their urine in the past
two weeks has proved to be a reliable way of identifying schools which
have a high prevalence of urinary schistosomiasis and which can be
targetted for early treatment.
5.3.2
Treatment
WHO (1990) recommends that treatment without prior individual
screening be given to populations where surveys of school age children
show that the prevalence of intestinal helminth or schistosome infec
tions exceeds 50%. This offers significant logistic and economic ad
vantages.
New, safe and efficient drugs to deworm children are potent tools for re
ducing and controlling intestinal helminth infections. Although drug
treatment can achieve immediate results, the effect may not be lasting if
the treatment is not repeated at appropriate intervals for a prescribed
length of time and if it is not supported by sanitary measures and health
education programmes. The expansion of deworming activities to pre
school children and adults will strengthen the effect of the interventions
in schools.
J
Wr1
19
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
Drug selection Important criteria in selecting a drug are: single dosage, ease of
administration, limited side effects, and relatively low cost. These factors contribute to
ensuring maximum efficacy and compliance. As many children may have two or three
different kinds of worm infections at the same time, it will be desirable if the available
drug is effective against more than one kind of helminth.
Cost The cost of the drugs for one treatment varies depending on the drug chosen,
the manufacturers and the countries where the drug is purchased. Low price generic
products with recognized quality are available in some developing countries. Drug treat
ment plays an important but not exclusive role in helminth reduction. A partnership
with drug manufacturers that are capable of providing technical, material and/or finan
cial support to an effective and sustainable effort needs to be encouraged, in addition to
a favourable price for the drug.
As many infections (particularly when there are small numbers of worms present)
show no symptoms, it is very important that the treatment given to children should
have minimal side-effects. Neither children nor parents want to replace minor symp
toms caused by infection with more apparent ones caused by medication taken to elimi
nate the infection.
Annex II shows the essential drugs and their dosages for treating infections of in*
testinal helminths, schistosome and other flukes.
School personnel and stadeats have nnportant roles to play *m the deworming treatment process. They can:
♦
Obtain o paentol consent for children to be treated.
♦
Coll the students together by dosses raid supply water for drug-taking.
♦
Help nurses/health workers who ore in charge of delivering tablets to monitor for possible side-effects among students, ord
report any ^scomfoit which may or may not be relevant to the treatment.
Techmcd points of drug treatment
Side-effects Side effects with these drugs are mild and transient. Abdominal discomfort and skin rashes have rarely been reported.
Joint dreg delivery Concurrent administration of albendazole and praziquantel has been shown to be safe, which may be considered in
areas where both schistosomiasis and intestinal helminth infections roe prevalent.
Efficacy refers to how well a drug work in eliminating infections. The term ’cure rate- is used to assess Aug efficacy, which refers to the
proportion of persons with no eggs found in faeces after treatment.
Frecpency The frequency of treatment depends on the goal of the project and local conitions. For intestinal helminth infection, no less
than two treatments a year ore recommended.
53.3
Experience from past programmes
Japan has been successful in helminth control in its entire population
since the end of World War II by starting with deworming programmes in
school children. Following the Japanese experience, the Republic of Ko
rea launched a deworming campaign in 1969 which was primarily directed
20
WHO
INFORMATION
SERIES
ON
SCHOOL
HEALTH
at school children. As a result of the campaign, and also of the significant
improvement of environmental sanitation, the prevalence of roundworm
infection in students decreased from 55.4% in 1969 to 0.07% in 1992,
and similarly in the whole population. The major factors which influ
enced the success of these programmes are the commitment of health and
education authorities to sustain the programmes over time, social involve
ment of parents and community members, and supplemental long term
programme support from nongovernmental agencies and academic groups.
Similar experience was also reported in some other countries of Africa
and South America.
5.4 School/community projects and outreach
The success of efforts to improve sanitation, reduce communicable diseases, im
prove personal hygiene, child development and human nutrition, is intimately linked
to communal as well as individual behaviours and decisions. It is therefore increasingly
recognized that the school and community must work together to support health. School/
community projects provide a way for students to become actively involved in learning
about how to reduce helminth infection. Community participants in the projects can
acquire specific health-related knowledge as well as skills needed to take community
actions that will result in sustainable helminth reduction. Helminth reduction activi
ties provide excellent opportunities to undertake school/community projects that can
affect the health status of the entire community.
The deworming process can be an educational experience which can be used to
stimulate community participation. The result of deworming is immediate and visible
and thus easily understood by both students and parents. The passing of adult worms by
treatment can provide evidence of effectiveness that will help win community enthusi
asm and support. A feeling of appreciation and trust towards service providers will lead
to an enhancement of teachers and parents’ credibility. Furthermore, when deworming
is accompanied by relevant health education, the impact will be strengthened, showing
the community how - by their own efforts - they can improve their school and village
and the welfare of their families. Some examples of school/community activities are
described below.
♦ Children ore erxovroged to talk Io their mothers ond community members obout worms, espedolly when they feel better offer the
progrow, rd to tavite them to the school's deworming progmmme.
♦ fhld-tofhild oppmoches hove been effective in bringng heohh messoges to chSdren, either in schools or in their community. When
pupils understand the benefits of dewormii^ they often bring their siblings for examination and treatment.
♦ Mote who predominate in the role of 'hedth educte and child core witter househoM an moke o infant contention to
improving the level of inderstcmrlng on helminth redudkm end prevention within the household and then the commutey.
♦ Demonstration of worms or eggs under a miaoscope is a convincing way to stimulate the students ond community members for active
support and porfidpotioQ.
♦ Approaches ore needed to ensrxe that deworming programme in schools ore olso ovteoble to school age children who ore not attening
schools and to pre-school children who ore often heavily infected ond responsible for contaminating the environment through their
defecation hotes.
♦ Outreach con be mast successful when there is cooperation ond coorination between the school health programme ond the kxol health
centres.
C.H
I M S"
*■>
06791
k.
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
5.5 Health promotion for school staff
A school health programme should not be limited to improving the health of chil
dren enrolled in school. The protection and improvement of the health of its employ
ees - teachers, administrators and supporting staff - should also be emphasized. As
school personnel in most countries, particularly in developing ones, have had little or
no health education preparation, strategies to promote their health should form part of
all pre- and in-service training.
Teacher training is an important prerequisite for providing health education to
students. In addition, teachers traditionally have an influential role to play in their
communities.
Teachers need to know:
♦ How to ovoid helminth infection themselves.
♦ Behaviours and conditions in the community that affect helminth infection.
♦ Knowledge, attitudes, values, beliefs and skills of chiWren/porents and community members that affect behaviours and conditions.
♦ Specific teaching moterids to influence knowledge, attitudes, values, beliefs and skills that affect behaviours and conditions.
♦ How to explain the importance of helminth reduction to students and communities.
♦ What to do in helping plan and organize deworming activities, and obtain compliance from students.
MIBi
Helminth infections can also be an important problem among staff, especially in
rural schools. Improvements in their health-related knowledge, attitudes and behav
iours through health promotion activities can help improve helminth interventions
and other school health programmes.
5.6 Nutrition and food safety
The interactions of nutrition and infection have been generally recognized: indi
viduals become debilitated as a result of malnutrition and are susceptible to infections
and, conversely, certain infections have a profound influence on nutritional status. The
“malnutrition-infection” complex remains the most prevalent public health problem in
the world today, especially in children.
5.6.1
Helminth infection and malnutrition
Intestinal helminth infection may be associated with a reduction in food
intake due to discomfort, poor appetite, and malabsorption, and may lead
to malnutrition. As indicated by studies, roundworm infection may in
fluence the utilization of fat, protein and vitamin A precursors, and hook
worm disease can result in anaemia as well as iron and protein deficiency.
Recently it has been shown three times yearly deworming can prevent
the loss of quarter of a litre of blood per child every year. Regular an
thelmintic treatment is an extremely cost effective way of improving the
general health status of the school children. The schools should be aware
22
WHO
INFORMATION
SERIES
ON
SCHOOL
HEALTH
■
that the two conditions frequently co-exist in school children and a suc
cessful deworming programme can improve the nutritional status of chil
dren.
WHO recommends that in areas where the prevalence of mild-moder
ate underweight in children is greater than 25%, and where parasites
are known to be widespread, high priority should be given to deworming
programmes.
Micronutrient supplementation (iron, iodine and vitamin A)
5.6.2
Iron deficient school-age children tend to exhibit reduced levels of alert
ness, attention and concentration, and display lower levels of overall in
tellectual performance than those without the deficiency. The conse
quences of iodine deficiency disorder (IDD), though not related to para
sitic infections, are also significant in terms of learning results among pri
mary school students. Vitamin A deficiency may be associated with in
creased prevalence of infection and influence school attendance of the
children.
A micronutrient supplementotiOT programme is proposed to be integrated into deworming programmes. Uns involves:
♦
Iodine supplementation through iorfized soil which is available in many countries.
♦
Vitamin A supplementation using capsules ot low cost.
Iron tablets for those with iron-deficiency anaemia.
♦
Nutrition education which provides food-based interventions for the micronutrient defidendes. For instance, students should
be encouraged to take vitamin A rich food such as carrot which may not be customarily o port of the local det.
5.6.3
Prevention of foodbome parasitic infections
Humans can be infected by dozens of parasitic helminths through ingest
ing uncooked or inadequately cooked meat, fish or other animal food and
vegetables. School children are often the victims of foodbome parasitic
infections and other illnesses from foods prepared in their homes, in the
school canteens, or bought from street food vendors. Dianhoea and ab
dominal discomfort caused by unsafe food increase school absenteeism
while impairing children’s health.
23
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
Food safety through schools
♦
Educating students with knowledge ond practices of preventing food-bome helminth infections.
♦
Establishing rules in school feeding programme, i.e.:
Cook food (meat, fish, etc.) thoroughly;
Do not eat raw fish, meat or vegetables known to be possibly hfected/contominoted by worms;
Wash vegetables thoroughly when they are taken raw;
Avoid contact between raw foods ond cooked foods;
Wash hfflids carefully.
6.
Rluation
♦
Providing handwashing facilities ond enough water for students as well os school canteen workers.
♦
Iroirang food handers for safe processing oral supply in school canteen.
♦
Encouraging students to communicate food safety message to parents ond other children.
6.1 Evaluation throughout the project
An objective evaluation of the implementation and accomplishments of deworming
and behavioral modification should be scheduled at the beginning, middle and end of
the programme cycle. The evaluation component should include a needs assessment,
baseline data collection including biomedical and behavioral indicators, monitoring
procedures, and periodic and final assessments.
Evoluatiofl is hportost becouse it helps:
6.2
♦
Plufl the project by providng informotion to policymakers, sponsors, planners, administrators ond participants;
♦
Make improvements or adjustments in the process of implementation;
♦
Provide feedback to those involved in project planning to determine which parts of the project are working well ond which ore
not;
♦
Schools ond communities to value the effort;
♦
Documeat experience gained from the project so that it can be steed with others.
Type of evaluation
Process and impact evaluations provide information that can be invaluable in
reshaping and revising programme development. The process evaluation assesses how
well the programme is being implemented and the impact evaluation measures the
impact of the programme on the target population.
Quite often, the evaluation component is neglected because resources, including
time, personnel and budget, are scarce. Evaluation of the extent to which the planned
interventions are being implemented as intended may be more feasible in countries
with limited resources than evaluation to measure the impact of interventions on health
24
WHO
INFORMATION
SERIES
SCHOOL
ON
HEALTH
and behaviour. The measurement of the impact on students health status can be costly
and complex. Countries with limited resources might invest in process evaluation to
ensure that their intended programme is effectively implemented before attempting
impact evaluation.
6.3 What to evaluate
Evaluation may be addressed to various aspects of the programme including goals
and objectives, implementation, effect on participants, and cost-effectiveness. Practi
cally, however, the basic items listed in the table below should be measured in all pro
grammes.
Method of measurement
Basic Items
_____ ___
Proportion of targeted school children who received drug
treatment
Record review
Extent of reduction of prevalence/ worm burden of helminth
infection
Biomedical screening
Any specific side^ffect which may frustrate the process of
moss treatment
Record review;
Interview with health workers ond school heads
Extent to which children improved knowledge on worms
Questionnaire;
Focal group discussion
____
Extent of changes on children's behaviours, attitudes and skills
related to helminth infections
Questionnoire;
Focal group discussion;
Interview with parents iand teachers;
Observations
Extent to which parents ore satisfied with their children
Questionnaire;
Interview
.
•______________________________________________ ___________________________________________________
_
.
■
Physical installations - availability of water and its quality ond
quantity, latrines/toilets and their use ond maintenance,
handwashing facilities ond functioning
Affordability of the programme for families and community
Observations;
Interview with students ond teachers;
Focal group discussion
........................ ;
Cost analysis; Interview with parents ond conununity
feoders
How well the school health components are addressed in
helminth reduction efforts
Focal group discussion;
Interview with school health officers ond school heads
Extent of programme expansion to other schools in the
district
Interview with programme coordinator and school health
officers
Extent of improvement of intersectoral cooperation, especially
between health ond education
Interview with programme coordinator and school health
officers
____________________________
25
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
BIBLIOGRAPHY
Albonico, M., Smith, P.G., Ercole, E., Chwaya, H.M., Alawi, K.S. & Savioli, L. (1994).
A randomized controlled trial comparing mebendazole 500 mg and albendazole
400 mg against Ascaris, Trichuris and the hookworms: 4 and 6 months follow up.
Transactions of the Royal Society of Tropical Medicine and Hygiene, 88: 585-589.
Bundy, D.A.P. & Hall, A. (1993). Partnership for Child Development an interna
tional programme to improve the health and education of children through school
based services. A document distributed at the Meeting between WHO and the
Partnership for Child Development, Geneva.
Crompton, D.W.T., Nesheim, M.C. & Pawlowski, Z.S. (1989). Ascariasis and its pre^
vention and control. Taylor & Francis, London.
Cabrera, B.D. & Cruz, A.C. (1982). A comparative study on the effect of mass treat
ment of the entire community and selective treatment of children on the total
prevalence of soil-transmitted helminthiasis in two communities, Mindoro, Phil
ippines. In Yokogawa, M. et al. (eds): Collected Papers on the Control of Soiltransmitted Helminthiases. Tokyo. APCO, Vol II, pp 266-273.
Chen, M.G. & Mott, K.E. (19884989). Progress in assessment of morbidity due to
schistosomiasis. Tropical Diseases Bulletin, 85 (6,10), 86(4,8).
Falck, V.T, Kilcoyne, M.E. (1987). A health promotion programme for school person^
nel. Journal of School Health, 54:239-243.
INMED and SmithKline Beecham Pharmaceuticals (1995). Modules - Implementing
deworming programme: A comprehensive guide for field staff.
Nokes, C. et al. (1992). Moderate to heavy infections of Trichuris trichiura affect
cognitive function in Jamaican school children. Parasitology, 104-539^547.
Rim, H.J. (1994)- Introductory remarks. In: Collected Papers on Parasite Control in
Korea, In Commemoration of the 30th Anniversary of The Koi>rea Association of
Health, Seoul, Korea.
Savioli, L., Bundy, D. & Tomkins, A. (1992). Intestinal parasitic infections: a soluble
public health problem. Transactions of the Royal Society of Tropical Medicine and
Hygiene, 86:353-354.
Thein-Hlaing (1987). A profile of ascariasis morbidity in Rangoon Children’s Hospi
tal, Burma. Journal of Tropical Medicine and Hygiene, 90:165-169.
Trainer, E.S. (1985). Mass parasite control: a good beginning. World Health Forum,
6:248-253.
Tomkins, A. & Watson, F. (1989). Malnutrition and infection. A review. UN Admin
istrative Committee on Coordination/SubCommittee on Nutrition. Lavenham,
UK.
26
WHO
INFORMATION
SERIES
ON
SCHOOL
HEALTH
World Bank (1993). World Development Report 1993 - Investing in Health. Oxford
University Press.
WHO (1986). Charter adopted at an international conference on health promotion The move towards a new public health. November 1986, Ottawa, Canada.
WHO (1987). Prevention and control of intestinal parasitic infections. Report of a WHO
Expert Committee. Geneva, World Health Organization, 1987 (WHO Technical
Report Series No. 749).
WHO (1990). Health education in the control of schistosomiasis. Geneva.
WHO (1990). WHO Model Prescribing Information: Drugs used in Parasitic Diseases.
Geneva.
WHO (1993). The control of schistosomiasis. Second report of the WHO Expert Commit
tee. Geneva, World Health Organization, 1992 (WHO Technical Report Series,
No. 830).
WHO (1994). Bench aids for the diagnosis of intestinal parasites. Geneva.
WHO (1995). Control of foodbome trematode infections. Report of a WHO Expert Com
mittee. Geneva, World Health Organization, 1995 (WHO Technical Report Se^
ries, No. 849).
WHO (1995). Health of school children: treatment of intestinal helminths and schis^
tosomiasis. (Unpublished document WHO/SCHISTO/95.112; WHO/CDS/95.1).
WHO/UNESCO/UNICEF (1992). Comprehensive school health education Sug'
gested guidelines for action. WHO/UNESCO/UNICEF Consultation on strate^
gies for implementing comprehensive school health education/promotion pro
gramme, Geneva, November 1991.
Williams, T, Moon, A. & Williams, M. (1990). Food, Environment and Health. A
guide for primary school teachers. WHO, Geneva.
Winblad, U. &. Kilama, W. (1984). Sanitation without water. Macmillan.
Xu, L.Q., YU, S.H., Jiang, Z.X., Yang, J.L, Lai, C.Q., Zhang,
ZhengC.Q. (1995).
Soil-transmitted helminthiases: nationwide survey in China. Bulletin of the World
Health Organization, 73:507-513.
27
STRENGTHENING INTERVENTIONS TO REDUCE HELMINTH INFECTIONS
ANNEX I
Common Name
Scientific Name
Location of Parasitism
Geographical
Distribution
IMPORTANT
HELMINTHS IN
SCHOOLCHILDREN
Roundworm
Ascaris lumbricoides
Intestine
Global
Whipworm
Trichuris trichiuro
Intestine
Global
Hookworm
Ancylostomo duodenole
Necotor omericonus
Intestine
Global
Schistosome
(blood fluke)
Schistosome monsoni
Blood vessels of intestine
Africa
South America
Middle East
Liver fluke
Schistosoma japonicum
Schistosoma mekonqi
Blood vessels of intestine
Asia
Schistosome hoemotobium
Blood vessels of urinary bladder
Africa
Middle East
Fosciolo hepatico
Liver
Global
Asia
Clonorchis sinensis
Asia
Asia, Europe
Lung fluke
Intestine! fluke
Lungs, brain, skin
Asia, Africa
Americas
Paraqonimus westermoni
end others
■. L x" x 1
Fosciolopsis buski
Intestine :
Global
Skin
Africa
South and West
Asia
'
Echinostomo sp
Heterophyes sp.
and others
Guinea worm
28
l__ ___
Drocunculus medinensis
WHO
INFORMATION
Roundworm
Albendazole1
(400 mg)
-H-++
Levomisole’
-H4-+
SERIES
Whipworm
ON
Hookworm
SCHOOL
Schisto
some
HEALTH
intestinal
Flukes
Liver and
Lung
Flukes3
DOSAGE AND
ESTIMATED
EFFECTIVENESS OF
DRUGS IN
CURRENT USE FOR
HELMINTH
INFECTIONS
+++
++
44-*
+++4
+++<
(2.5 mg/kg2)
Mebendazole1
(500 mg)
+44-+
Pyrantel1
++++
(10 mgAg)
Praziquantel’
(40 mg/kg)
Praziquantel1
ANNEX 2
(Based on: WHO 1990
- Drugs Used in
Parasitic Diseases)
+44
+44+
4444
(25 mgAg)
Praziquantel
(up to 150 mg/kg
in 2 days)
1
2
3
4
44+4
In single dose
Kilogram body weight
Excluding Fasciola
1The usuol dose of mebendazole is 100 mg, twice doily, for 3 days. A single dose of 500 mg seems less effective.
+444-
Highly effective
Effective
Effective in mild to moderate infections
29
- Media
6791.pdf
Position: 984 (8 views)