Association of anthropometric status and residential locality factors with cognitive scores of 4-6-year-old children in Kwazulu-Natal, South Africa.

Background: The Asenze study has the long-term goal of promoting better physical, cognitive and psychosocial functioning of children in a rural area in KwaZulu-Natal, 50 km from Durban with a view to planning interventions to promote growth and development for very young children. The specific objective in this paper was to provide information for the Child Health and Development project of the Valley Trust to assist with intervention planning. The broader goal was to assess developmental delays in communities ravaged by the HIV epidemic.The Asenze study was designed in two phases from 2008 and 2012. The current paper reports on 1581 4-6years old children in the baseline phase (2008-2010) in the five adjacent tribal areas in the study area. Method: The participants included all the 4 - 6 year olds whose parents had consented to inclusion in the project and their caregivers. Data were derived from a brief questionnaire administered in the homes of participants, and subsequently from medical and psychological assessments of the children and their caregivers at the Asenze clinic. The association between child factors and other factors (geographic area, socioeconomic status (SES), parental level of education, the child's pre-school education) on the one hand and, the child's cognitive performance (as measured by the Grover Counter and subtests of the KABC-11) were analysed. Linear regression models were employed to determine which predictor variables of interest in a model were associated with the children's cognitive scores as the dependent variables. Results: Based on the data, the principal factors associated with children's cognitive outcomes were height-for-age z-score (HAZ), preschool education and the area of residence, Generally children who had low cognitive scores were more often stunted (as defined by the WHO anthropometric tables), had not had pre-school education, and came from areas less favourable in terms of local infrastructure and access to employment opportunities and arable land. Conclusion: The finding from this cross-sectional analysis of baseline data showed that in addition to height for age and pre-school education, which are commonly thought to impact on cognition, the local authority area where the children lived was associated with their scores on cognitive tests. This has implications for intervention planning. The functioning of local government in promoting the type of community development which will protect the rights of children should be taken into account.

Factors associated with retention intentions among Isibindi child and youth care workers in South Africa: results from a national survey.

BACKGROUND: Child and youth care workers (CYCWs) are a crucial and growing component of South Africa's national response to HIV and AIDS and other issues affecting children and families. CYCWs use the community-centred Isibindi model of care to reach the most vulnerable with key services including psychosocial, health, economic and education support. Like others in similar professions, they may be at risk for occupational challenges affecting retention. METHODS: This study uses data from the first nationally representative survey of CYCWs in South Africa to identify factors associated with workers' retention intentions. Data were collected in 2015 as part of a formative evaluation conducted around the mid-point of a nationwide Isibindi programme expansion. A total of 1158 CYCWs from 78 sites participated. The response rate for the sample was 87%. Questions addressed demographics, work history, retention intentions, training, mentorship and supervision experiences, workload and remuneration. Mixed effects regression models with random intercepts for project site and mentor were used to estimate factors associated with retention intentions. RESULTS: High-quality mentorship and frequent supervision support retention intentions among CYCWs. Respondents who indicated that wanting to help children or the community was their primary motivator for seeking work as a CYCW were also more likely to report intending to continue working as a CYCW. High perceived workloads and feeling threatened or unsafe on the job were negatively associated with retention intentions. As CYCWs gained experience, they were also less likely to intend to stay. CONCLUSIONS: Understanding the factors affecting retention in the CYCW workforce is vital to helping vulnerable children and families across South Africa access key social and health services. Findings highlight the importance of mentoring and supervision as part of the Isibindi model and the value of support for manageable workloads, workplace safety, and career advancement opportunities for promoting worker retention.

Schistosomiasis and Water-Related Practices in School Girls in Rural KwaZulu-Natal; South Africa

There is increasing evidence of an association between female genital Schistosoma haematobium infection and HIV. In KwaZulu-Natal; we aimed to explore girls' water contact practice and to determine whether a study exclusively on girls would be manageable and welcomed. Three primary schools that had participated in a parasite control programme eight years prior were approached. Subject to consent; girls aged 9 to 12 years were interviewed on water-body contact; symptoms and household composition. Urine samples were analysed for S. haematobium infection eggs. Good dialogue was achieved in all schools and 95consented to participation; 43had an S. haematobium infection; geometric mean intensity 10.5 ova per 10 ml urine. Only 12had ever been treated for S. haematobium. Water-body contact was significantly associated with S. haematobium (OR 2.8; 95CI 1.3-5.9; p= 0.008); however; S. haematobium was also found in 20of girls who claimed to never have had water-body contact. Sixty-four percent thought they had no choice but to use unprotected water; 21had no mother in the household; and being an orphan increased the risk of having S. haematobium. The community welcomed the study. Prevalence levels in South Africa are so high that some communities are eligible for WHO-recommended regular mass treatment

Colloquium report: improving the health of school age children in an era of HIV/AIDS in Durban, South Africa.

Increased morbidity and mortality due to the HIV/AIDS epidemic in South Africa necessitates the examination of policies for the protection and support of school age children. At a colloquium held in Durban participants from government and non-government health and education sectors briefed delegates on key policies and programmes for promoting the health and mental health of school age children. Researchers gave evaluative accounts of the impacts of these measures and presented an overview of South African children's health and mental health needs. In the discussions that followed four critical issues emerged: intersectoral collaboration, accountability, retraining middle management, and a more comprehensive strategy to support pupils and teachers infected and affected by HIV/AIDS.

Effects of iron supplementation and anthelmintic treatment on motor and language development of preschool children in Zanzibar: double blind, placebo controlled study.

OBJECTIVE: To measure the effects of iron supplementation and anthelmintic treatment on iron status, anaemia, growth, morbidity, and development of children aged 6-59 months. DESIGN: Double blind, placebo controlled randomised factorial trial of iron supplementation and anthelmintic treatment. SETTING: Community in Pemba Island, Zanzibar. PARTICIPANTS: 614 preschool children aged 6-59 months. MAIN OUTCOME MEASURES: Development of language and motor skills assessed by parental interview before and after treatment in age appropriate subgroups. RESULTS: Before intervention, anaemia was prevalent and severe, and geohelminth infections were prevalent and light-Plasmodium falciparum infection was nearly universal. Iron supplementation significantly improved iron status, but not haemoglobin status. Iron supplementation improved language development by 0.8 (95% confidence interval 0.2 to 1.4) points on the 20 point scale. Iron supplementation also improved motor development, but this effect was modified by baseline haemoglobin concentrations (P=0.015 for interaction term) and was apparent only in children with baseline haemoglobin concentrations <90 g/l. In children with a baseline haemoglobin concentration of 68 g/l (one standard deviation below the mean value), iron treatment increased scores by 1.1 (0.1 to 2.1) points on the 18 point motor scale. Mebendazole significantly reduced the number and severity of infections caused by Ascaris lumbricoides and Trichuris trichiura, but not by hookworms. Mebendazole increased development scores by 0.4 (-0.3 to 1.1) points on the motor scale and 0.3 (-0.3 to 0.9) points on the language scale. CONCLUSIONS: Iron supplementation improved motor and language development of preschool children in rural Africa. The effects of iron on motor development were limited to children with more severe anaemia (baseline haemoglobin concentration <90 g/l). Mebendazole had a positive effect on motor and language development, but this was not statistically significant.

Helminth control as an entry point for health-promoting schools in KwaZulu-Natal.

OBJECTIVES: To use a health promotion model to investigate the risk factors (predisposing, enabling and reinforcing) for geohelminth and schistosomiasis infections, in order to develop and implement effective intervention strategies. DESIGN: Phase 1: Qualitative study using focus group discussions (FGDs) with parents, pupils and teachers; and interviews with health workers. Phase 2: Quantitative study using a semi-structured questionnaire to investigate whether the determinants identified in phase 1 were generalisable. SETTING: Rural primary schools in Vulamehlo magisterial district, southern KwaZulu-Natal. STUDY POPULATION: Qualitative study: 9 schools with 179 pupils, 93 parents and 82 teachers; and local clinics (4 fixed, 1 mobile), with 7 professional nurses. Quantitative study: 2 other schools, with 730 pupils. RESULTS: Predisposing factors: Respondents were familiar with symptoms, but did not know the cause or mode of transmission of helminth infections. Many respondents perceived food to be the cause of geohelminth infection and swimming in the river to be the cause of schistosomiasis. Although 649 (88.9%) pupils had toilets at home and at school, only 218 (29.9%) were motivated to 'always' use the toilet for faecal disposal (rural communities previously did not have toilets). Six hundred and seventy-eight pupils (92.9%) understood that it was necessary to wash their hands after using the toilet, but many schools lacked water. Personal cleanliness was a problem despite the emphasis on hygiene by health workers and teachers. Few pupils admitted to eating soil, but it was agreed that geophagia affected young children between the ages of 8 months and 6 years. Enabling factors (positive/negative): Barriers to health promotion frequently included inadequate toilet facilities at school and home, and river-water contact resulting from a lack of clean water. A dearth of recreational facilities resulted in children swimming and playing in the river. Positive factors were the health-seeking behaviour of the majority of the target group, who identified helminth infections as a health problem and sought treatment. Parents and pupils in the FGDs unanimously supported health education and 655 (89.8%) questionnaire respondents indicated that they wished to learn how to avoid helminth infections. CONCLUSIONS: Although the Government strategy is to provide clean water and adequate sanitation, provision of services does not necessarily ensure usage. A comprehensive approach to health promotion is required and the complementary development of the 'health-promoting school' would support, reinforce and sustain a helminth control programme.

Effect of iron-, iodine-, and beta-carotene-fortified biscuits on the micronutrient status of primary school children: a randomized controlled trial.

BACKGROUND: Deficiencies of iron, iodine, and vitamin A are prevalent worldwide and can affect the mental development and learning ability of schoolchildren. OBJECTIVE: The aim of this study was to determine the effect of micronutrient-fortified biscuits on the micronutrient status of primary school children. DESIGN: Micronutrient status was assessed in 115 children aged 6-11 y before and after consumption of biscuits (fortified with iron, iodine, and beta-carotene) for 43 wk over a 12-mo period and was compared with that in a control group (n = 113) who consumed nonfortified biscuits. Cognitive function, growth, and morbidity were assessed as secondary outcomes. RESULTS: There was a significant between-group treatment effect on serum retinol, serum ferritin, serum iron, transferrin saturation, and urinary iodine (P <0.0001) and in hemoglobin and hematocrit (P <0.05). The prevalence of low serum retinol concentrations (<0.70 micromol/L) decreased from 39.1% to 12.2%, of low serum ferritin concentrations (<20 microg/L) from 27.8% to 13.9%, of anemia (hemoglobin <120 g/L) from 29.6% to 15.6%, and of low urinary iodine concentrations (<100 microg/L) from 97.5% to 5.4%. There was a significant between-group treatment effect (P <0.05) in cognitive function with the digit span forward task (short-term memory). Fewer school days were missed in the intervention than in the control group because of respiratory- (P = 0.097) and diarrhea-related (P = 0.013) illnesses. The intervention had no effect on anthropometric status [corrected]. CONCLUSIONS: Fortified biscuits resulted in a significant improvement in the micronutrient status of primary school children from a poor rural community and also appeared to have a favorable effect on morbidity and cognitive function [corrected].

Schistosomiasis and the use of indigenous plant molluscicides: a rural South African perspective.

In the last decade plant molluscicides have received considerable attention in the search for cheaper alternatives to chemotherapy and synthetic molluscicides in schistosomiasis control. The attraction of a locally grown molluscicidal plant is based on the development of a philosophy of self-reliance and community involvement. This approach is dependent on community recognition of the infection as a public health problem and their acceptance of proposed control measures. The objectives of this study were: (i) firstly, to assess the knowledge of schistosomiasis in a rural community and their attitude to the use of indigenous plant molluscicides; (ii) secondly, to assess the prevalence and intensity of infection in relation to its severity as perceived within the community. Study sites were located at Mtwalume (KwaZulu-Natal, South Africa). Sixty-nine community members were interviewed during six focus-group interviews and two depth interviews. Urine and stool samples (354 and 306, respectively) from children and young adults (2-25 years old) were analysed for Helminth and Protozoal infections. Results indicate that despite a poor understanding of schistosomiasis, it is a primary health concern for those dependent on river-water for their water requirements. Concern for schistosomiasis is indeed matched by a prevalence of 75.14% for Schistosoma haematobium. Oral antischistosomal drugs are inaccessible primarily due to the cost of transport and secondarily, due to the cost of treatment. The concept of molluscicidal control, as an alternative, was enthusiastically received by all respondents.

Targeted chemotherapy for parasite infestations in rural black preschool children.

OBJECTIVE: To investigate whether targeted chemotherapy can reduce parasite prevalence rates in rural black preschool children. DESIGN: The study consisted of a before/after trial. Stool and urine samples were analysed on four occasions over a 21-week period. SETTING: Crèches in two rural areas of southern KwaZulu/Natal (coastal and inland). PATIENTS: Two hundred children of 4-6 years of age attending 19 crèches in the area. INTERVENTION: Targeted chemotherapy using albendazole for nematode infestations, praziquantel for trematode and cestode infestations and metronidazole for protozoal infections was administered twice at an interval of 14 weeks. MAIN OUTCOME MEASURE: Prevalence rates. RESULTS: The prevalence of Ascaris lumbricoides, Trichuris trichiura and Necator americanus infestation decreased significantly after treatment. Reinfestation rates 12 weeks after treatment were 16% for A. lumbricoides, 33% for T. trichiura, 24% for Giardia lamblia and 3% for N. americanus. No reinfestation was noted for Schistosoma haematobium, Hymenolepsis or Taenia species. CONCLUSION: The study suggests that parasite prevalence rates in children can be reduced by the administration of appropriate chemotherapy at regular intervals. However, the provision of clean water and adequate sewerage facilities remains a high priority for black communities living in rural areas of South Africa.

Infection, nutrition and cognitive performance in children.

The paper considers briefly the nature of cognition and its relationship to intelligence. The information processing model of human cognition is outlined and IQ and DQ are explained. The literature dealing with the effects of malnutrition and parasitic infection on cognitive performance and development in children is selectively reviewed. A speculative hypothesis concerning the psychological effects of parasitic infection is sketched and brief consideration is given to models and measures in research on development.

The effects of parasite infections on cognitive processes in children.

Two studies were carried out in the Nyuswa area of Natal to investigate the effects of parasitic infection on cognitive function in children. In the first study, children infected with intestinal helminths were given tests of information processing and perceptual speed before and after treatment with a single 500 mg dose of Mebendazole. The pattern of results was consistent with the hypothesis that parasitic infections combine with nutritional deficits to impair the efficiency of cognitive processes. There was, however, some confounding of variables, and the single drug treatment reduced but did not eliminate the parasites. The second study removed the confounding effects due to age and nutrition and employed a more comprehensive drug-treatment programme. A memory task and a test of sustained attention were administered. Poor performance on the attention task showed a significant association with parasite status, but no association was observed with educational attainment or memory function. The study also examined various ways of assessing parasite load, and an index weighted for estimated pathogenicity was found to give the best estimate. The results provide evidence of the effects of parasitic infection on attentional processes.

Selective exposure of active and sociable children to schistosomiasis.

Investigations into the impact of schistosomiasis on the physical and psychological development of children have yielded contradictory findings. This may be due to a failure to take account of transmission factors. In areas where Schistosoma haematobium is endemic, children who bathe regularly in contaminated water are more likely to contract the disease. The harmful effects of the disease may be masked in these more active and gregarious children, particularly when infections are mild and other parasitic infections and nutrional deficiencies are common. The social interaction of schoolchildren in an endemic area was monitored over a period of four months, and the principal finding was that infected children were more sociable than uninfected children in terms of their membership of the main playground groups. This paper discusses the evidence for selective exposure and the implications of the hypothesis for future research.

The effects of Schistosomiasis haematobium on the activity of school children.

Schistosomiasis haematobium is prevalent in many parts of Africa, especially among school-age children. It is thought to cause lethargy, but the effect may be masked by the selective exposure of more active children to the disease. Infected children at a primary school in an endemic area in South Africa were used as their own controls in a before-and-after treatment study. Energetic activity was monitored by means of electronic meters before treatment, and at 3 and 6 months after treatment with an antischistosomal drug. Results indicated that the scores of treated children had increased significantly relative to the untreated controls, and that there were differences between the sexes in the change of activity level.

The role of human water contact patterns in the transmission of schistosomiasis in an informal settlement near a major industrial area.

Human contact with schistosome-infested water was studied in a rapidly growing community near an industrial area: water-contact was observed and categorized; interviews concerning water usage were conducted and schoolchildren and adult women were tested for schistosome infections. Results indicated that swimming amongst certain young people was an important contact activity in summer. To a lesser extent the washing of clothes and blankets was found to be an activity of importance, providing a focus for the social gathering of women and young children in contact with the water throughout the year. One of the aims of the study was to develop cost-effective methods for use in this and other endemic areas to provide guidelines for control programmes. A comparison was made between methods of assessing exposure to the infection in their ability to predict the prevalence of Schistosoma haematobium and S. mansoni across age-sex classes of the human host; an exposure index which included an assessment of body surface area was found to be preferable to one based on duration of contact only. The differing relationships between exposure to infested water and prevalence of the two schistosome species were in accordance with reports from other areas, thus supporting the choice of minimum requirements for a survey prior to control.

The effects of schistosomiasis on spontaneous play activity in black schoolchildren in the endemic areas. An ethological study.

An ethological study was undertaken in two primary schools in Natal to assess the effect of schistosome infections on the spontaneous activity of schoolchildren in endemic areas. Results indicate that there is selective exposure of more active children to the disease. In low-level infections with Schistosoma haematobium (less than 1000 eggs excreted in a 2-hour midday period) or S. mansoni (less than 1000 eggs/g dry weight of stool) there is little evidence of a decrease in energetic activity under normal conditions in subjects with higher egg counts or infections with both schistosomes activity levels generally fall, especially under hot, humid weather conditions, when the fall in activity is greater than that for control subjects.