1Fit For School

Health Outcome Study:

LAO PDR

In partnership with:

Acknowledgement 1

Tables, Figures, Abbreviations and Acronyms 2

Executive Summary 4

1. The Fit for School Health Outcome Study - Background and Introduction 6 Country background 6 The Fit for School Program 7 Objectives of the Health Outcome Study 7

2. Study Materials and Methods 8 Study design 8 Study population and sample size 9 Research team organization 9 Data collection 10 Data analysis 11

3. The Study Results 12 Demographic indicators 12 Socio-economic indicators 12 Nutritional status indicators 13 Soil-transmitted helminths 15 Oral health indicators 16 Oral and abdominal pain experience 16

4. Discussion, Conclusion and Outlook 17

5. References 19

Annex 1: List of Schools Surveyed by the Research Teams 22Annex 2: Survey Assessment Form 24Annex 3: Health Outcome Study Indicators 25

Table of Contents

© Regional Fit for School Program 2014Deutsche Gesellschaft für International Zusammenarbeit (GIZ) GmbH

7/F PDCP Bank Centrecor. V.A. Rufino and L.P. Leviste StreetsSalcedo Village, Makati City 1227Philippineswww.giz.de

February 2014

GIZ implements programs and projects for sustainable development on behalf of the Federal Ministry for Economic Cooperation and Development (BMZ). The Regional Fit for School Program is realized in the Philippines, Indonesia, Cambodia and Lao PDR in partnership with the Southeast Asian Ministers of Education Organization’s Regional Center for Educational Innovation and Technology (SEAMEO INNOTECH).

Disclaimer:No part of this report shall be reproduced in any way without written permission of the GIZ Fit for School Program.

1Fit For School

!e Lao PDR Fit for School Health Outcome Study is conducted under the following research team:

Principal InvestigatorDr. Martin HobdellVisiting Professor in Dental Public Health, Department of Epidemiology and PublicHealth, University College London

Chief InvestigatorMs. Panith SoukhanouvongTechnical O"cer, Department of Preschool and Primary Education, Ministry of Education and Sports

Co-InvestigatorsDr. Amphayvanh HomsavathTechnical O"cer, Academic Division and Research, Faculty of Dentistry, University of Health Sciences in Laos

Dr. Phonesavanh Soundara,Head, Community Dentistry, Faculty of Dentistry, University of Health Sciences in Laos

Dr. Phouphet KanolathLecturer, Faculty of Dentistry, University of Health Sciences in Laos

Dr. Khamphoumy ChanbounmyLecturer, Faculty of Dentistry, University of Health Sciences in Laos

!e research was made possible through the support and cooperation of the Lao PDR Ministry of Education and Sports: Department of Primary and Pre-school Education and Vientiane Capital Education Department; the Ministry of Health: Faculty of Dentistry, and Center for Malaria, Parasitology, and Entomology who coordinated and conducted the survey in the #eld and laboratory. !anks go to the principals, teachers, parents, and children in the participating schools who gave their consent and time for the research activities, the National Institute of Public Health who supported the ethical clearance of the study, Bella Monse (GIZ), Wim van Palenstein Helderman

(Radboud University, Nijmegen, !e Netherlands), Habib Benzian (Fit for School International) who contributed to the design of the study, Mitch Miijares-Majini, Nicole Siegmund, Bouachanh Chansom, and Kat Javier of the GIZ Fit for School Program Project team who provided technical, administrative, and logistical support, and to Malikhone Morakoth (Lao Research Coordinator), Rodgelyn Amante (Fit for School, Inc.), Ella Cecilia Naliponguit, Ma. Rosalia Vivien P. Maninang, Francis Luspo (Department of Education, Philippines), Vicente Belizario (National Institutes of Health, Philippines), Katrin Kromeyer-Hauschild (University of Jena, Germany), and to Douglas Ball (consultant) for their expertise and contributions.

Special thanks go to the in-country research team members: Kikham Phimbounyor, Noy Sidavong, !ippaphone Banphet, Kingphetdara Bounyong, Souvannaly Vongsay, Visith Phouthavong, Phaylorh Sangthong, Bounmy Southisane, Phimphone Vorajack, Bouavanh Kietisack, Phonesavanh Soundara, Sinthilath Berakoun, !ipphaphone Sengbourlom, Lienthong Watsana, Pengthong Keomahavong, Douangta Nanhboudy, Somphet Sonesackda, Phonesavanh !alachanh, Bounta Phimmasone, Phongsy Phimmasone, Moukda Sengmanivong, Soulilammone Insixiengmai, Phouphet Kanolath, Dien Sisai, Keothanouthong Bounma, Southyphone Siphaingam, Sengasanh Souvannalithong, Manivone Sayyachack, Phonedavanh Bounyadeth, Somphane Sengphimthong, Bounpone Phimmalath, Manisack Phommasansack, Phinnakone Lassachack, Kaysone Vongsypasom, and Phonethong Simalavong, and to !ippaphone Banphet, Kingphetdara Bounyong, Souvannaly Vongsay, and Visith Phouthavong for administrative support.

Acknowledgement

Fit For School2

Tables

Table 1 Number of Intervention and Control schools according to location page 9

Table 2 Main Survey indicators page 11

Table 3 Number and average age of students page 12

Table 4 Socio-economic background of students page 12

Table 5 Mean height of students according to sex page 13

Table 6 Mean BMI of students according to sex page 14

Table 7 DMFT and PUFA indices page 16

Figures

Figure 1 Percentage HFA distribution of students page 13

Figure 2 Percentage BMI-for-age distribution of students page 14

Figure 3 Intensities of STH infection by helminth type page 15

Figure 4 Prevalence of dental caries and odontogenic infection page 16

Tables, Figures, Abbreviations and Acronyms

3Fit For School

Abbreviations and Acronyms

BMI Body Mass Index

CMPE Center for Malaria, Parasitology, and Entomology

DMFT or dmft Decayed, Missing, Filled Teeth (permanent/deciduous)

DPPE Department of Primary and Pre-school Education

FoD Faculty of Dentistry

GIZ Deutsche Gesellschaft für Internationale Zusammenarbeit

HFA Height-for-Age

HOS Health Outcome Study

Lao PDR Lao People’s Democratic Republic

MDA Mass drug administration

MoES Ministry of Education and Sports

MoH Ministry of Health

PUFA or pufa Pulp involvement, Ulceration, Fistula, Abscess (permanent/deciduous)

SEAMEO-INNOTECHSoutheast Asian Ministers of Education Organization Regional Center for Educational Innovation and Technology

STH Soil-transmitted Helminth

UNESCO 8QLWHG�1DWLRQV�(GXFDWLRQDO��6FLHQWL¼F�DQG�&XOWXUDO�2UJDQL]DWLRQ

UNICEF United Nations Children’s Fund

WHO World Health Organization

Tables, Figures, Abbreviations and Acronyms

Fit For School4

Despite declining poverty rates and consistent positive socio-economic development, the health status of children in Lao PDR remains problematic. To help address this issue, the Lao Ministry of Education and Sports, Southeast Asian Ministers of Education Organization Regional Center for Educational Innovation and Technology (SEAMEO INNOTECH), and the Deutsche Gesellschaft für Internationale Zusammenarbeit GmbH (GIZ) have partnered to implement a school health program based on the Fit for School Approach which focuses on three school-based interventions: 1) daily handwashing with soap as a group activity, 2) daily toothbrushing with $uoride toothpaste as a group activity, and 3) annual mass deworming according to the guidelines of the World Health Organization (WHO). Currently, around 4,800 students in pilot public elementary schools in Vientiane Capital are reached by the program.

In order to assess the impact, a Health Outcome Study is being conducted as an essential part of the research and development component of the program. !e study is a longitudinal clustered controlled trial that aims to determine the e%ects of the program interventions on health and school attendance of six to seven-year old public primary school students in Lao PDR in 22 intervention and 22 control schools. Speci#cally, the study looks at nutritional status, parasitological status, oral health status, prevalence of oral and abdominal pain, as well as school attendance. It is part of a bigger regional study using a similar research protocol in Cambodia, Indonesia and the Philippines.

A total of 675 children participated in the baseline survey, 334 from the intervention schools and 341 from control schools. Each child was assessed for weight, height, presence of soil-transmitted helminth (STH) infection, caries experience, odontogenic infection, and oral and abdominal pain.

About a third of children showed a low height-for-age with a higher proportion in the intervention (37.5%) compared to control schools (29.8%). !ere was also a higher proportion of stunting in males (36.7%)

compared to females (30.2%). Around a third of the surveyed children had below normal Body Mass Index (BMI) for their age – 29.6% in intervention schools and 33.5% in control schools. !ere also appeared to be a tendency for more female than male students to be thin (i.e. below normal BMI, 36.3% vs. 27.3% across all schools). !is discrepancy was more pronounced in the intervention schools where the proportion of thin girls was 12.1% higher than that of boys.

Around 10.7% of children from the intervention group and 15.2% from the control group were infected with at least one of the three STH worm types – Ascaris spp. Trichuris spp., or hookworm. !e prevalence of moderate to heavy intensity infection was similar in both groups. Hookworm was the most prevalent of the worms.

Nine out of ten children had tooth decay and 58.7% of these children had odontogenic infection. A slightly greater proportion of children in the intervention group than in the control group had tooth decay (94.3% vs. 88%) and a tooth infection (60.2% vs. 57.2%). On average, the surveyed children had tooth decay in seven to eight primary teeth based on a dmft index (decayed, missing, #lled teeth) of 7.5, and odontogenic infections in two primary teeth based on a pufa (pulp involvement, ulceration, #stula, and abscess) index score of 1.9. Of the permanent teeth examined, on average, one tooth per child was found to have caries and infection based on mean DMFT and PUFA scores. !ese results mirror #ndings of other studies and underscore the high burden of oral disease a%ecting the majority of school children in Lao PDR.

Around half of the children reported oral pain (54.2% of those in the intervention group and 49.7% of those on the control group) while only 11.1% of intervention group children and 12.9% of control group children reported abdominal pain at the time of the survey.

A follow-up survey involving the same respondents will be conducted 24 months after the baseline to

Executive Summary

5Fit For School

determine if there are signi#cant improvements in the health status of children from intervention schools compared to those from control schools.

Further analysis of the baseline data may help to identify regional variations of health states and correlations between variables. Yet, these baseline results clearly highlight the need for scaling-up e%ective interventions to address the burden of preventable child diseases and will help to improve advocacy e%orts in this context.

Fit For School6

1. Background and Introduction

Country Background

!e Lao People’s Democratic Republic (Lao PDR) is a landlocked country located in Southeast Asia. It shares borders with Myanmar to the west, China to the north, Viet Nam to the east, and with !ailand and Cambodia to the south.1 In recent years, Lao PDR has seen robust economic growth. In 2009, the Gross Domestic Product (GDP) increased by 7.6% and the GDP per capital was US $914.2 However, despite declining poverty rates and consistent socio-economic development, the United Nations Development Programme Human Development Index still categorized Lao PDR in 2010 as one of the medium-low level countries, ranking 122 of 169 listed states with a value of 0.497.3 Lao PDR has a population of approximately 6,320,000. Life expectancy at birth for males is 62 years and 64 years for females while the under-#ve mortality rate is 59 per 1,000 births. !e amount spent per capita on health was US $86 in 2009.4

!e health status of children in Lao PDR is problematic. Based on a report from the Ministry of Health (MoH), nearly 40% of children under #ve are stunted, 37% underweight, and about 7% are wasted.5 According to the 2nd Lao National Oral Health Survey done in 2010, the prevalence of tooth decay was 73% among 3-year old children and

84% among 6-year old children. In addition, the prevalence of dental caries in permanent teeth of 12-year old children was more than 57% while gingival bleeding was 79%.6

A nationwide survey of soil-transmitted helminth (STH) infections, conducted between 2000 and 2002, showed a high prevalence of infections ranging between 1% and 96%. As a consequence, the Ministry of Education and Sports (MoES) and MoH joined forces and launched a pilot deworming program in #ve districts of Vientiane Province from 2001 to 2004. Results after six rounds of treatment showed that the overall infection rates decreased by 43%.7

!ese diseases, albeit not life-threatening, have a huge impact on the physical and mental development of children, their school attendance, productivity and quality of life. Worm infections can cause anemia, reduced physical growth, delayed development of motor skills, and poor mental development. Malnourished children become even more malnourished. Children who su%er from toothache can have di"culty in eating, sleeping, and concentrating. !ese disease conditions are strongly associated with poverty. Poor living conditions, overcrowded classrooms, lack of water, poor sanitation facilities at home, as well as in the schools, and insu"cient healthy food are among the root

7Fit For School

causes that trap children in the cycle of poverty. !ese aforementioned diseases can be controlled through relatively simple, evidence-based, and cost-effective interventions.

The Fit for School Program

!e MoES, Southeast Asian Ministers of Education Organization Regional Center for Educational Innovation and Technology (SEAMEO INNOTECH), and the German Organisation for International Cooperation (Deutsche Gesellschaft für Internationale Zusammenarbeit GmbH; GIZ) have partnered to implement a school health program based on the Fit for School Approach — an internationally award-winning integrated approach developed in the Philippines. !e program consists of three interventions:

ñ daily handwashing with soap as a group activityñ��daily toothbrushing with $uoride toothpaste as a group activity ñ��biannual mass deworming according to the guide- lines of the World Health Organization (WHO)

!is program is being implemented in pilot public primary schools in Vientiane Capital, and currently covers around 4,800 students. !e cornerstone of the program is an intersectoral strategy that uses schools as venues to reach the child population with simple evidence-based preventive interventions. All interventions of the program have demonstrated their positive e%ects on the health status of children in numerous studies.8-12 However, an assessment of the impact in Lao PDR will be conducted through a health outcome study on the Fit for School Program implementation in pilot schools. !e study is part of a bigger regional study involving Cambodia, Indonesia and the Philippines where similar programs are implemented and monitored according to a common research protocol.

Objectives of the Health Outcome Study

!e Health Outcome Study (HOS) of the Fit for School Program is a survey that aims to determine the e%ects of school-based program interventions on health and school attendance of public primary school students in Lao PDR, and provide evidence for informed program management. Speci#cally, the study examines:

ñ Nutritional status ñ Parasitological status ñ Oral health status ñ Prevalence of oral and abdominal pain ñ School attendance

Demonstrating the positive health impact of the Fit for School Program will provide essential arguments for advocacy to stakeholders for sustaining the program and scaling-up. !e study can also contribute to increasing the body of evidence and scienti#c literature on health interventions in the Lao PDR context, which is currently very limited regarding integrated school-based health programs.

Laotian schoolchildren incorporate washing and toothbrushing into their daily routine.

Fit For School8

2. Study Materials and Methods

!e study is a longitudinal clustered controlled trial, which involves the implementation of program interventions in 22 public primary schools — the intervention schools. Another 22 public primary schools that will not implement the Fit for School Program serve as control schools. !e general methodology used is largely following the protocol of the Philippine Fit for School Health Outcome Study.11

!e study received ethical clearance from the National Ethics Committee for Health Research, Council of Medical Sciences, Ministry of Health, Lao PDR and is registered with the German Clincal Trials Register maintained by the University of Freiburg (DRKS-ID: DRKS00004485).

Study Design

Selection of Intervention and Control

Schools

!e study is being conducted in selected public primary schools located in four districts within Vientiane Capital: Sangthong Sikhottabong, Sisattanack, and Saythany. !e schools were selected and categorized as intervention schools and control schools by the MoES. Intervention schools

were selected by the MoES based on accessibility, safety, school size, and support from the school administration. Children in intervention schools apply daily handwashing with soap and daily $uoride toothbrushing with 0.3 ml of toothpaste that contains 1,450 ppm of free available $uoride as group activities, and receive a single dose of mebendazole (500 mg tablet) per year as part of a mass drug administration (MDA) campaign against STH. For each intervention school, another school located nearby with similar parameters (e.g. size, socioeconomic background of enrolled children) was assigned to control schools. Children in control schools continue to receive the regular health education programs of the government which, despite a de#ned policy to promote healthy environments in schools, remain largely limited to a series of lessons in the curriculum, although a national mass deworming program has been implemented.

9Fit For School

Research Team Organization

In preparation for the baseline survey, two teams of local researchers from partner institutions were formed. Each team included representatives from the Department of Primary and Pre-school Education (DPPE) and the Vientiane Capital Department of Education, both of which fall under the MoES, and the Faculty of Dentistry (FoD), under the MoH. All researchers underwent three days of training on data collection methods. To ensure consistency of assessment among researchers, height and weight measurement, and the oral examination technique were calibrated with those of experienced researchers and a WHO consultant on oral health survey methods during the training exercise.

Each research team covered intervention and control schools in two of the four districts. Team 1 collected data from Sikhottabong and Saythani districts while Team 2 surveyed schools from Sisattanak and Sangthong districts.

Representatives from the MoH Center for Malaria, Parasitology, and Entomology (CMPE) laboratory conducted orientation sessions with parents and teachers on the correct stool specimen collection technique and distributed stool specimen cups in preparation for the stool examination of participating children.

Table 1. Number of intervention and control schools according to location

School Group Sangthong Sikhottabong Sisattanack Saythany No. of Schools

Intervention 7 5 5 5 22

Control 7 5 5 5 22

No. of schools 14 10 10 10 44

Study Population and Sample Size

Study population: !e assessment focuses on six to seven-year old children enrolled in Grade 1 of the intervention and controls schools at the time of the baseline evaluation (October to November 2012). In cases of schools with insu"cient numbers of Grade 1 pupils to meet the calculated sample size, the numbers were complemented with children selected from Grade 2. !e same children will undergo a follow-up assessment after 24 months.

Sample size: !e target number of children was calculated as 600: 300 from intervention and 300 from control schools. !is number was increased to 720 (360 students in each group) to cover for an estimated drop-out rate of 20%. !e sample size was based upon detecting a 20% di%erence in mean caries increment between intervention and control schools after a 24 month period (with power of 80% and signi#cance level of 5%). !is would also provide adequate power to detect a 15% decrease in the proportion of children with a de#ned indicator e.g. those of low BMI, with caries, or with helminth infection.

In each school, 17 children were randomly selected from the list of enrolled students who were aged six or seven-years old at the time of the baseline survey. Consent for their participation was secured from the parents or guardians by school representatives. Children with no parental or guardian consent, or who had a systemic or chronic infection were excluded from the study.

!e distribution of schools across the four Vientiane districts are shown in Table 1 and a list of the schools is provided in Annex 1.

Fit For School10

Data Collection

Baseline data collection took place on the school grounds.

ñ Registration and stool collection. The survey began with identification of children and labeling of submitted stool specimens. General information including name, birthdate, and gender were recorded in the standard survey form. A few socio-economic indicators were collected such as the number of siblings and family ownership of a television set as a proxy of socio-economic status (Annex 2).

ñ Anthropometric measurement. Weight and height measurement followed standards described by Cogill.13 Weight was measured to the nearest 0.1 kilogram (kg) using a SECA digital weighing scale. Children were instructed to remove shoes, heavy clothing, and objects before stepping on the scale. Every scale was calibrated with a five-kilogram weight at the start of data collection in each school and then after every 5th child thereafter. Height was measured using a microtoise. Children, with their shoes removed, were asked to stand with their backs against the wall where the microtoise was mounted and height was measured to the nearest 0.1 centimeter (cm).

ñ Oral Examination. For the oral examination, children first brushed their teeth to remove food debris. As much as possible, the examinations were performed in the school yard with sunlight as a direct light source, otherwise the examinations were done in a room designated by the school head. The children were placed in a supine position on a long classroom bench, table or series of chairs, with their heads on a pillow on the lap of the examiner, who sat behind them. A ball-end probe and disposable mouth mirror with illumination were used as examination tools to score caries and oral infection according to procedures defined by WHO methodology for oral health surveys14 as well as Monse, et. al.12,15 Data collection conducted in the schools.

11Fit For School

ñ Interview on oral and stomach pain. Children were also asked by a trained interviewer if they had oral pain or abdominal pain at the time of the interview.

ñ Survey forms were examined onsite to check completeness of the recorded information. A sample of the survey form is presented in Annex 2. Children with incomplete information returned to the corresponding survey station to complete the data collection process. Ten per cent of the surveyed children in each school were randomly pre-determined to undergo the examination a second time to assess quality and consistency of data collected by the same or a di%erent examiner.

ñ Parasitologic examination. Stool specimens collected in the morning were immediately taken to the CMPE laboratory to determine presence of infection with any of the three soil-transmitted helminths (Ascaris species, hookworm and Trichuris species) using the standard Kato Katz technique according to the WHO Bench Aids for the Diagnosis of Intestinal Parasites.16 A standard

Table 2. Main Survey Indicators

Socio economic status Percentage of children who reported having a television set at home

Mean number of siblings

Nutritional statusi Body Mass Index (BMI)

Height- for-Age (HFA)

Parasitologic status Cumulative Prevalence of STH infection

Prevalence of Heavy Intensity Infections

Oral health status Caries prevalence and experience

Odontogenic infection prevalence and experience

Prevalence of oral and abdominal pain

Percentage of children who reported having oral pain at the time of examination

Percentage of children who reported having abdominal pain at the time of examination

School attendance Absenteeism (number of days absent)ii

i Data of 103 children from 4 intervention schools and 3 control schools in Sisattanak district were excluded in the analysis of nutritional indicators due to inconsistencies in the use of the microtoise for height measurement found through random checks during the data gathering.ii Absenteeism rate will be determined after completion of classes for school year 2012-2013.

Kato Katz cellophane thick smear kit and report template was provided to the laboratory examiners. Ten per cent of stool samples were re-examined by a senior parasitologist for quality control purposes.

Data to measure absenteeism will be collected at the end of the current school year (2012 -2013) by checking attendance re$ected in school records.

Data Analysis

Raw data was encoded separately by two di%erent encoders and then cross-checked by a data manager for completeness and consistency. Descriptive statistical analysis was done using STATA software (version 12.1) for all indicators presented in Table 2 with the exception of height-for-age (HFA). !e latter was computed using WHO AnthroPlus Software.17 BMI-for-age was calculated according to the methods of Cole and colleagues.18,19 !e operational de#nitions of these indicators are found in Annex 3 of the report.

Fit For School12

group was slightly higher than that of the control group (51.5% and 48.7%, respectively). !e average age of the survey participants was 6.8 years. Control school children were slightly older than those in intervention schools and males were slightly older than females as shown in Table 3.

Demographic Indicators

A total of 675 children participated in this baseline survey – 334 from intervention and 341 from control schools. !e proportion of males in the intervention

3. Study Results

Table 3. Number and average age of students

IndicatorIntervention schools (n=22) Control schools (n=22)

Male Female All Male Female All

No. of students (%) 172 (51.5%) 162 (48.5%) 334 (100%) 166 (48.7%) 175 (51.3%) 341 (100%)

Ave. age (yrs.) 6.79 6.71 6.75 6.85 6.79 6.82

Table 4. Socio-economic background of students

School Group TV ownershipMean number of siblings (range)

Intervention 95.2%i 2.5 (0-11)

Control 94.1%ii 2.6 (0-9)

Total 94.6%iii 2.5 (0-11)

i (n=332) 2 of the 334 students from the intervention group have missing data on TV ownershipii (n=340) 1 of the 341 students from the control group has missing data on TV ownershipiii (n=672)

Socio-economic Indicators

A majority of children in both intervention and control schools reported that they had a television set at home (95.2% and 94.1%, respectively). !e average number of siblings was also similar in both groups, two to three siblings, with wide ranges (Table 4).

13Fit For School

Nutritional Status Indicators

!e mean height of children was 111.7 cm (Table 5). Control school children were slightly taller than those in intervention schools (111.9 cm vs. 111.4 cm resp.) and males in both control and intervention schools were taller than their female contemporaries (112.3 cm vs. 111.1 cm resp.).

According to WHO HFA standards, about a third of children were found to have low HFA; the proportion was greater in the intervention compared to control schools (37.5% vs 29.8%, respectively). !ere was also a slightly higher proportion of stunting in males (36.7%) compared to females (30.2%). Figure 1 shows the HFA distribution of children by type of school and gender. Note that none of the children were considered as “very tall” for their age using the WHO categories.

Table 5. Mean height of students (in cm), according to sex

School Group

Male Female Total

Intervention (n=280)

112.2 110.5 111.4

Control (n=292)

112.3 111.5 111.9

Total (n=572)*

112.3 111.1 111.7

*Data from 103 children were excluded due to measurement inconsistencies (see Methods)

Note: n(intervention)=280; n(control)=292; data from 103 children were excluded (see Methods).

Male

20

40

60

80

100

Figure 1. Percentage Height-for-Age (HFA) distribution of students

Female Total

7.3

32.7

60.0 65.4 62.5

28.5 30.7

6.2 6.8

Intervention

Male Female Total

9.7

23.6

66.7 73.7 70.2

22.3 23.0

4.0 6.8

Control

Male Female Total

8.5

28.2

63.3 69.8 66.4

25.2 26.8

5.0 6.8

Total

Normal

Stunting

Severe stunting

Fit For School14

At least half of the respondents in three schools had below normal BMI — Nongtaeng in Sikhottabong district (60%), and Oudomphon and Phon-Ngam in Saythani district, (50% in both schools). In fact 14% of thin children were from these three schools alone suggesting that undernutrition may be a problem in communities where these schools are located.

Male

20

40

60

80

100

Figure 2. Percentage BMI-for-age distribution of students

Female Total

2.7

20.0

74.7 63.9 69.6

27.7 23.6

6.94.6

Intervention

Male Female Total

3.5

25.0

68.1 62.8 65.4

26.4 25.7

6.85.1

Control

Male Female Total

3.1

22.5

71.4 63.3 67.5

27.0 24.7

4.9

Total

Normal

Grade 1 thinness

Grade 2 thinness

Note: n(intervention)=280; n(control)=292; data from 103 children were excluded (see Methods).

1.3

Grade 3 thinness

Overweight

Obese

0.70.7

1.5 1.4

0.40.4

2.1

1.4

3.4

0.7

2.7

0.70.3

1.7

0.31.0

0.4

6.8

2.5 2.1

0.40.5

!e mean BMI of children in intervention schools was almost the same with that of the control schools, 14.6 and 14.5, respectively, with males having slightly higher #gures than females (Table 6).

However, interpreting the BMI measurement in children needs to take account of their age as further described below. Following the categories used by Cole and colleagues18,19 and the International Obesity Task Force, around a third of the surveyed children had below normal BMI for their age, 29.6% in intervention and 33.5% in control schools (Figure 2).

!ere also appeared to be a tendency for more female than male students to be thin (36.3% vs. 27.3% across all schools). !is discrepancy was also more pronounced in the intervention schools where the proportion of thin females was 12.1% higher than that of males.

Table 6. Mean BMI of students (in kg/m2), according to sex

School Group

Male Female Total

Intervention (n=280)

14.9 14.3 14.6

Control (n=292)

14.6 14.3 14.5

Total (n=572)

14.7 14.3 14.5

*Data from 103 children were excluded due to measurement inconsis-tencies (see Methods)

15Fit For School

Int

10%

20%

Figure 3. Intensities of STH infection by helminth type

Cont Total

7.4

3.3

89.3 84.7

62.5

8.4 5.9

6.8 7.1

STH

Int Cont Total

1.0

0.7

98.3 97.7 98.0

1.6

0.6 0.8

Ascaris

Int Cont Total

1.3

98.0 95.8 96.9

2.3

1.5

1.91.6

Trichuris

Negative

Light

Mod-Heavy

Note: n(intervention)=299; n(control)=308; vertical axis was cropped at 20%

Int Cont Total

5.4

2.3

92.3 89.6

5.5

5.14.9

Hookworm

87.0

1.2 0.7

90.9

4.0

Soil-Transmitted Helminths

A total of 607 students had stool examination results - 299 from the intervention group and 308 from the control group. As shown in Figure 3, 10.7% of children from the intervention group and 15.2% from the control group had an infection with at least one of the three STH worm types – Ascaris spp., Trichuris spp., or hookworm. However, moderate to heavy intensity rates were higher in the intervention than the control groups (7.4% and 6.8%, respectively).

Of the three STH parasites, hookworm was more prevalent than Ascaris and Trichuris — 7.7% of intervention group children and 10.4% of control group children had hookworm infection while infection rates of Ascaris and Trichuris ranged from 1.7 to 4.2% in both groups.

Almost half of the children surveyed in one school located in Saythani district, Phonexay, had moderate to heavy STH infection. !ese children constituted 10% of reported STH cases in the 33 schools that had at least one STH case. Interestingly, eleven participating schools did not have any cases of STH infection.

Fit For School16

Int

40

80

100

Figure 4. Prevalence of dental caries and odontogenic infection

Cont Total

Caries Prevalence

Int Cont Total

Prevalence of odontogenic infection

60

20

94.3 88.0 91.1

60.2 57.2 58.7

Oral Health Indicators

Nine out of ten children had tooth decay and 58.7% had odontogenic infection (Figure 4). A slightly greater proportion of children in the intervention group than the control group had tooth decay (94.3% vs. 88%, respectively) and odontogenic infection (60.2% vs. 57.2%, respectively).

Schools from Sikhottabong district had the highest caries prevalence (97%); all children in seven of the ten surveyed schools in the district were found to have tooth decay. Meanwhile, those from Sisattanack district also had a high caries prevalence and had the highest prevalence of dental infections (74%). On the other hand, schools from Sangthong and Saythany districts had a lower prevalence of tooth infection (52% and 51%, respectively).

1XPEHU�RI�GHFD\HG��PLVVLQJ�DQG�¼OOHG�WHHWK��GPIW�DMFT) and teeth with pulp involvement, ulceration, ¼VWXOD�DQG�DEVFHVV��SXID�38)$��LQGLFHV�IRU�GHFLGRXV�and permanent teeth. On average, the surveyed children had tooth decay in seven to eight primary teeth measured through the dmft index of 7.5, and infections in two primary teeth re$ected in the pufa index score of 1.9.

!e mean number of permanent teeth with caries and infection was found to be less than one tooth per child as re$ected in DMFT and PUFA indices of less than one (Table 7). !is may appear to be a small number, but at ages of six and seven years children still have relatively few permanent teeth.

Oral and Abdominal Pain Experience

Around half of the children reported oral pain (54.2% in the intervention group and 49.7% in the control group), while 11.1% of intervention group children and 12.9% of control group children reported abdominal pain at the time of the survey.

7DEOH����GPIW�'0)7�DQG�SXID�38)$�LQGLFHV����

Indices Dentition Intervention Control Total

Mean dmft

Primary 7.7 7.3 7.5

Mean DMFT

Permanent 0.3 0.4 0.3

Mean pufa

Primary 1.9 1.8 1.9

Mean PUFA

Permanent 0.01 0.01 0.01

17Fit For School

4. Discussion, Conclusion and Outlook

!is survey provides the baseline results of nutritional, STH, and oral health indicators for six to seven-year old school children in 44 selected public primary schools in Vientiane Capital, Lao PDR. Half of the schools are implementing the Fit for School Program while the other half are control schools implementing the standard governmental school health program.

Nutritional status

Chronic malnutrition is an acknowledged problem in Lao PDR. Reports from the WHO indicate that stunting in children below #ve years remained at 48% from 2000 to 2006,20 a #gure much higher than the 33.6% prevalence obtained from the HOS survey participants. !e discrepancy could be partly attributed to the di%erent target age groups. It is also possible that conditions in$uencing nutritional status of school children in Lao, especially in the urban areas, have improved over the past six years since the last national survey was conducted. Still, chronic malnutrition needs to be addressed as it leads to poor growth, general development and negatively a%ects the child’s cognitive capacity.21

On the other hand, the high proportion of thin 6- to 7-year old respondents (31.7%) in this survey approximates the reported 31% prevalence of

underweight children below #ve years in the 2006 report, suggesting that acute malnutrition is also an ongoing health issue.

Soil-transmitted helminth infections

In 2004, it was reported that 38% of Vientiane province school-aged children had an STH infection. More recent literature revealed that the STH prevalence among school children dropped to 28% based on a 2012 survey of ten sentinel schools across the country.22 !e reduction in STH prevalence across the years is believed to be a result of aggressive deworming campaigns in both the community and school settings. !e even lower prevalence rates of the current survey respondents (13%) could be due to the urban location of the survey schools which are all situated in Vientiane, the capital city. Children in urban schools may have better access to hygiene and sanitation facilities in schools and at home, as well as deworming program interventions compared to those from schools located in more remote and rural areas.

Infection with STH parasites has been shown to adversely a%ect nutritional status, resulting in malnutrition. It has also been linked to school absenteeism, compromised attention and memory, and ultimately, poor school achievement.23

Fit For School18

depth analysis, and such investigations may serve to indicate where problems might exist but that will require further study.

Lastly, the research activity also provided an opportunity to enhance research capability and intersectoral cooperation between the participating MoES and MOH personnel. Better research capacity is envisioned to bene#t both agencies in terms of policy and program evaluation. Meanwhile, closer links between the education and health sectors, and in particular the academe and national agencies, will encourage development and implementation of evidenced-based health interventions in the school setting by bridging theory and practice.

Conclusion and Outlook

!is baseline survey showed that about one third of 6- to 7-year old students from selected public primary schools su%ered from acute and chronic malnutrition while around a tenth of them were infected with at least one of the soil-transmitted helminths. Almost all children had dental caries, with the majority having concurrent odontogenic infection.

It is crucial that the baseline results will be used as advocacy tools to shed a light on widely neglected and socially accepted negative health conditions of children in Lao PDR, which impact greatly on their health and development. Clear and understandable communication of the results and presentation to decision makers will help to sustain commitment for long-term support of effective school health interventions.

!us, endeavors to further reduce infections in children should be pursued, especially where moderate-to-heavy infections are present.

Oral health status

Tooth decay #ndings in this survey mirrored those of the 2010 Lao National Oral Health Survey, where eight to nine out of ten children were found to have dental caries. !ese baseline results clearly show the severity and dimension of the oral disease burden a%ecting the vast majority of school children in Lao PDR with negative impact on educational attainment. At the same time, the #ndings reveal an area of neglect which has received only marginal attention in the past compared to other health priorities. Taking into account that untreated dental caries and infections are associated with low BMI, the high numbers of untreated decay are even more alarming.24-26 As a consequence, the integration of preventive oral health interventions in the school context is crucial when addressing low BMI and malnutrition in children.

!e Fit for School program packages evidenced-based interventions that target the aforementioned health problems in line with the “Focusing Resources on E%ective School Health (FRESH) Framework” promoted by the WHO, UNICEF, UNESCO, and the World Bank.27 !e purpose of the current study is to further establish evidence of the e%ectiveness of simple, sustainable, and scalable school based interventions to improve child health. A follow-up survey involving the same respondents will be conducted 24 months after the baseline to determine if there are signi#cant improvements in the health status of children from intervention schools compared to those from control schools.

Further investigation of the baseline data may help to identify local variations of health states and correlations between variables. For example, based on frequency distributions there seemed to be relatively higher proportions of children who had dental infections in Sisattanak district, dental caries in Sikhotabong district, and STH infections in Saythani district. However, it should be borne in mind that the study was not designed for such in-

19Fit For School

5. References

UN-Lao. Laos in Brief [Internet]. 2012 [cited 2012 July 17]. Available from: http://www.un.int/lao/country_pro#le.php.

Lao Statistic Bureau [Internet]. 2009 [cited 2012 July 18]. Available from: http://www.nsc.gov.la/

United Nations Development Programme (UNDP). Lao People’s Democratic Republic Country Pro#le: Human Development Indicators [Internet]. [cited 2012 July 18]. Available from: http://hdrstats.undp.org/en/countries/pro#les/LAO.html

World Health Organization. Countries: Lao People’s Democratic Republic [Internet]. 2012 [cited 2012 July 17]. Available from: http://www.who.int/countries/lao/en/

Ministry of Health. National Nutritional Strategy and Plan of Action 2010-2015. 2009.

Paik Di, Jin BH, Phantumvanit P, Songpaisan Y, Phommavongsa K, Sensombath S, Khounsiri V. 2nd Lao National Oral Health Survey. Korean Dental Association, Korean Research Foundation, Faculty of !ammasat University, and Seoul National University; 2010.

Rim H, et al. Prevalence of intestinal parasite infections on a national scale among primary schoolchildren in Laos. Parasitology research. 2003; 91.4: 267.

Acs G, Lodolini G, Kaminski S, Cisneros GJ. E%ect of nursing caries on body weight in a pediatric population. Pediatr Dent. 1992 Sept-Oct;14(5):302.

Adyatmaka A, Sutopo U, Carlsson P, Bratthall D. School-Based Primary Preventive Programme for Children A%ordable toothpaste as a component in primary oral health care. Experiences from a #eld trial in Kalimantan Barat, Indonesia [Internet]. Available from: http://www.whocollab.od.mah.se/searo/indonesia/a%ord/whoa%ord.html

Albonico M, Crompton DW, Savioli L. Control strategies for human intestinal nematode infections. Adv Parasitol. 1999; 42: 277.

Alderman H, Konde-Lule J, Sebuliba I, Bundy D, Hall A. E%ect on weight gain of routinely giving albendazole to pre-school children during child health days in Uganda: cluster randomised controlled trial. Br Med J. 2006; 333: 122.

Monse B, Benzian H, Naliponguit E, Belizario VJ, Schratz A, van Palenstein Helderman W. !e Fit for School health outcome study - a longitudinal survey to assess health impacts of an integrated school health programme in the Philippines. BMC Public Health. 2013;13(1):256.

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Cogill B, Food and Nutrition Technical Assistance Project. Anthropometric indicators measurement guide. Food and Nutritional Technical Assistance Project, Academy for Educational Development; 2003.

World Health Organization. Oral Health Surveys: Basic methods. 4th ed. Geneva: WHO; 1997.

Monse B, Heinrich-Weltzien R, Benzian H, Holmgren C, van Palenstein Helderman WH: PUFA – An index of clinical consequences of untreated dental caries. Community Dent Oral Epidemiol 2010, 38:77.

World Health Organization. Bench Aids for the Diagnosis of Intestinal Parasites. Geneva: World Health Organization; 1994.

World Health Organization. AnthroPlus Manual [Internet]. 2009 [cited 2013 July]. Available from: http://www.who.int/growthref/tools/en/

Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard de#nition for child overweight and obesity worldwide : international survey. BMJ 2000; 320:1240.

Cole TJ, Flegal KM, Nicholls D, Jackson AA. Body mass index cut o%s to de#ne thinness in children and adolescents: international survey. BMJ 2007;335:194.

World Health Organization. Nutrition Landscape Information System Country Pro#le [Internet]. [cited 2012 July]. Available from: http://apps.who.int/nutrition/landscape/report.aspx?iso=lao

Food and Agriculture Organization of the United Nations. Stories from the #eld: Fighting malnutrition in Lao PDR [Internet]. [cited 2012 July]. Available from: http://www.fao.org/#leadmin/templates/rap/#les/Field_programme/lao-#ghting_malnutrition.pdf

Morakoth M. Lao PDR Soil-Transmitted Helminths Report. GIZ; 2013.

Sakti H. Cognitive Behavior Change for the Improvement of Health Care, Cognitive Function and School Achievement in Helminth Infected Children. Indonesian Journal of Tropical and Infectious Disease 2010; 1(1).

Benzian H, Monse B, Heinrich-Weltzien R, Hobdell M, Mulder J, Helderman WvP. Untreated severe dental decay: A neglected determinant of low BMI in 12-year old Filipino children. BMC Public Health 2011; 11:558.

Ngoenwiwatkul Y, Leela-adisorn N. E%ects of dental caries on nutritional status among #rst-grade primary school children. Asis Pac J Public Health 2009; 21(2): 177.

Monse B, Duijster D, Sheiham A, Grijalva-Eternod CS, Helderman WvP, Hobdell M. !e e%ects of extraction of pulpally involved primary teeth on weight, height and BMI in underweight Filipino children. A cluster randomized clinical trial. BMC Public Health 2012; 12:725.

PDC. Focusing Resources on E%ective School Health (FRESH): a FRESH start to improving the quality and equity of education [Internet]. [cited 2010 March]. Available from: http://www.freshschools.org/Pages/default.aspx.

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21Fit For School

Annexes

Fit For School22

1. Sikhottabong District (October 22 – 25, 2012)

No. School Type Date Time

1. Sikhaitha Intervention 22 Oct 2012 8:00 – 9:30 am

2. Ya-Pha Control 22 Oct 2012 10:00 – 11:30 am

3. Arkad Intervention 22 Oct 2012 1:00 – 2:30 pm

4. Wattaynoy Control 23 Oct 2012 8:00 – 9:30 am

5. Chansavang Intervention 23 Oct 2012 10:00 – 11:30 am

6. Nongniew Control 23 Oct 2012 1:00 – 2:30 pm

7. Nongtaeng Intervention 24 Oct 2012 8:00 – 9:30 am

8. Na-Lao Control 24 Oct 2012 10:00 – 11:30 am

9. Viengkham Intervention 24 Oct 2012 1:00 – 2:30 pm

10. Banmai Control 25 Oct 2012 9:00 – 10:30 am

2. Saythani District (November 12-16, 2012)

No. School Type Date Time

1. Tha-Ngone Intervention 12 Nov 2012 8:30 – 11:00 am

2. Phoukham Control 12 Nov 2012 1:30 – 3:00 pm

3. Ladkhouay Intervention 13 Nov 2012 8:30 – 11:00 am

4. Oudomphon Control 13 Nov 2012 1:30 – 3:00 pm

5. Phonexay Intervention 14 Nov 2012 8:30 – 11:00 am

6. Phon-Ngam (Veunkham) Control 14 Nov 2012 1:30 – 3:00 pm

7. Dansang Intervention 15 Nov 2012 8:30 – 11:00 am

8. Dongmakkhai Control 15 Nov 2012 1:30 – 3:00 pm

9. Nonsa-Ath Intervention 16 Nov 2012 8:30 – 11:00 am

10. Ban-Na Control 16 Nov 2012 1:30 – 3:00 pm

Annex 1: List of Schools Surveyed by the Research Teams

Research Team 1

23Fit For School

Research Team 2

1. Sisattanak District (October 22 – 25, 2012)

No. School Type Date Time

1. Phonesinouan* Intervention 22 Oct 2012 8:00 – 9:30 am

2. Saphanthong Neu* Control 22 Oct 2012 10:00 – 11:30 am

3. Thadkhao* Intervention 22 Oct 2012 1:00 – 2:30 pm

4. Phaxay* Control 23 Oct 2012 8:00 – 9:30 am

5. Thaphalanxay* Intervention 23 Oct 2012 10:00 – 11:30 am

6. Wat Si-amphone* Control 23 Oct 2012 1:00 – 2:30 pm

7. Chomphet* Intervention 24 Oct 2012 8:00 – 9:30 am

8. Sangveuy* Control 24 Oct 2012 10:00 – 11:30 am

9. Dongsavath* Intervention 24 Oct 2012 1:00 – 2:30 pm

10. Donekoi* Control 25 Oct 2012 9:00 – 10:30 am

* Height measurements of children from these schools were excluded from the analysis due to measurement technique inconsistencies.

2. Sangthong District (November 12-16, 2012)

No. School Type Date Time

1. Kouay Intervention 12 Nov 2012 8:00 – 9:30 am

2. Na-Por Control 12 Nov 2012 10:00 – 11:30 am

3. Pialath Intervention 12 Nov 2012 1:00 – 2:30 pm

4. Thanakharm Control 13 Nov 2012 8:00 – 9:30 am

5. Pakton Intervention 13 Nov 2012 10:00 – 11:30 am

6. Hin-Lub Control 13 Nov 2012 1:00 – 2:30 pm

7. Pakthaep Intervention 14 Nov 2012 8:00 – 9:30 am

8. Nasaonang Control 14 Nov 2012 10:00 – 11:30 am

9. Haitai Intervention 14 Nov 2012 1:00 – 2:30 pm

10. Hinsiew Control 15 Nov 2012 8:00 – 9:30 am

11. Kangmor Intervention 15 Nov 2012 10:00 – 11:30 am

12. Houaykham Control 15 Nov 2012 1:00 – 2:30 pm

13. Sumphanna Intervention 16 Nov 2012 8:00 – 9:30 am

14. Khokpheng Control 16 Nov 2012 10:00 – 11:30 am

Fit For School24

Annex 2: Survey Assessment Form

25Fit For School

1. Anthropometric Indicators 1.1 Mean Body Mass Index (BMI): Numerator: Sum of all BMI Denominator: Total number of students examined

1.2 Prevalence of thin (grades 1 – 3), overweight, and obese children Numerator: Number of students within a BMI classi#cation Denominator: Total number of students examine

BMI &ODVVL¼FDWLRQ

Age group (in years) and corresponding BMI cut-offs by gender

5.75 to <6.25 6.25 to <6.75 6.75 to <7.25 7.25 to <7.75 7.75 to 8.25

Male Female Male Female Male Female Male Female Male Female

Grade 3 thinness

������ ������ ������ ������ ������ ������� ������� ������ ������ �������

Grade 2 thinness

12.51-13.15

12.33-12.93

12.46-13.10

12.29-12.90

12.43-13.08

12.27-12.91

12.42-13.09

12.28-12.95

12.43-13.11

12.32-13.00

Grade 1 thinness

13.16-14.07

12.94-13.82

13.11-14.04

12.91-13.82

13.09-14.04

12.92-13.86

13.10-14.08

12.96-13.93

13.12-14.15

13.01-14.02

Normal14.08-17.54

13.83-17.33

14.05-17.70

13.83–17.52

14.05- 17.91

13.87–17.74

14.09– 18.15

13.94– 18.02

14.16– 18.43

14.03– 18.34

Overweight17.55-19.77

17.34-19.64

17.71-20.22

17.53-20.07

17.92-20.62

17.75-20.50

18.16-21.08

18.03-21.00

18.44-21.59

18.35-21.56

Obese ������ ������ ������ ������ ������ ������ ������ !������ ������ ������

Annex 3: Health Outcome Study Indicators

References:

al., 2000)

2007)

Fit For School26

1.3 Prevalence of children with severe stunting, stunting, and very tall children based on Height-for-Age (HFA) Numerator: Number of students within an HFA classi#cation Denominator: Total number of students examined

2. Parasitological Indicators 2.1 Cumulative prevalence of STH infections: Prevalence of infection with at least one STH Numerator: Number of students who have an STH infection with any of the three soil- transmitted helminths Denominator: Total number of students examined

2.2 Prevalence of speci#c STH infection (Ascaris, Trichuris, or Hookworm) Numerator: Number of students who have a speci#c STH infection (Ascaris, Trichuris, or Hookworm) Denominator: Total number of students examined

2.3 Prevalence of heavy intensity STH infections: Prevalence of moderate to heavy intensity infection with at least one of the three helminths Numerator: Number of students with moderate to heavy intensity STH infection Denominator: Total number of students examined

2.4 Prevalence of heavy intensity infection of a speci#c helminth: Prevalence of moderate to heavy intensity infection of a speci#c helminth Numerator: Number of students who have moderate to heavy intensity infection of a ` speci#c helminth (Ascaris, Trichuris, or Hookworm) Denominator: Total number of students examined

HelminthModerate to heavy intensity infection

Ascaris ��������HJJV�SHU�JUDP

Trichuris ��������HJJV�SHU�JUDP

Hookworm ��������HJJV�SHU�JUDP

+)$�&ODVVL¼FDWLRQ Severe Stunting Stunting Very tall

Z-score < -3 > -3 but < -2 > 3

References:

(http://www.who.int/growthref/tools/en/)

Reference:

27Fit For School

3. Oral Health Indicators 3.1 Caries Prevalence Numerator: Number of children with at least one tooth with caries Denominator: Total number of students examined 3.2 Caries Experience Numerator: Total number of decayed (D or d), missing (M or m), and #lled (F or f ) teeth (permanent or primary) of each student1

Denominator: Total number of students examined

3.3 Odontogenic Infection Prevalence Numerator: Number of children with at least one tooth with pulp involvement Denominator: Total number of students examined 3.4 Odontogenic Infection Experience Numerator: Total number of teeth (permanent or primary) with open pulp involvement (P or p), traumatic ulceration (U or u), #stula (F or f ), and abscess (A or a) of each student2

Denominator: Total number of students examined

Notes1 “DMFT” for permanent dentition and “dmft” for primary dentition2 “PUFA” for permanent dentition and “pufa” for primary dentition

References: