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

Abstract

Background: The Fit for School (FIT) programme integrates school health and Water, Sanitation and Hygiene interventions, which are implemented by the Ministries of Education in four Southeast Asian countries. This paper describes the findings of a Health Outcome Study, which aimed to assess the two-year effect of the FIT programme on the parasitological, weight, and oral health status of children attending schools implementing the programme in Cambodia, Indonesia and Lao PDR.

Methods: The study was a non-randomized clustered controlled trial with a follow-up period of two years. The intervention group consisted of children attending public elementary schools implementing the FIT programme, including daily group handwashing with soap and toothbrushing with fluoride toothpaste, biannual school-based deworming; as well as construction of group handwashing facilities. Control schools implemented the regular government health education curriculum and biannual deworming. Per school, a random selection of six to seven-year-old grade-one students was drawn. Data on parasitological infections, anthropometric measurements, dental caries, odontogenic infections and sociodemographic characteristics were collected at baseline and at follow-up (24 months later). Data were analysed using the χ²-test, Mann Whitney U-test and multilevel logistic and linear regression.

Results: A total of 1847 children (mean age = 6.7 years, range 6.0-8.0 years) participated in the baseline survey. Of these, 1499 children were available for follow-up examination - 478, 486 and 535 children in Cambodia, Indonesia and Lao PDR, respectively. In all three countries, children in intervention schools had a lower increment in the number of decayed, missing and filled permanent teeth between baseline and follow-up, in comparison to children in controls schools. The preventive fraction was 24% at average. The prevalence of soil-transmitted helminth infection (which was unexpectedly low at baseline), the prevalence of thinness and the prevalence of odontogenic infections did not significantly differ between baseline and follow-up, nor between intervention and control schools.

Conclusions: The study found that the FIT programme significantly contributed to the prevention of dental caries in children. This study describes the challenges, learnings and, moreover, the importance of conducting real-life implementation research to evaluate health programmes to transform school settings into healthy learning environments for children. The study is retrospectively registered with the German Clinical Trials Register, University of Freiburg (Trial registration number: DRKS00004485, date of registration: 26th of February, 2013).

Keywords: Dental caries; Deworming; Handwashing; School health; Soil-transmitted helminth infection; Toothbrushing; Underweight; Water sanitation and hygiene.

Fig. 1

Hypothesised health outcomes of the Fit for School programme, based on available evidence. Grey boxes represent hypothesised health outcomes resulting from the FIT programme interventions. White boxes with dashed lines represent intermediate health outcomes that were not assessed in this study. White boxes with dotted lines represent intermediate behavioural outcomes that were not assessed in this study. Summary of related evidence: a Biannual deworming reduces the prevalence and severity of intestinal worm infection [28]. b, c, d, e Handwashing with soap and improved access to WASH have been associated with lower prevalence of STH infections [25, 29] and other infectious diseases, such as diarrhoea [10, 30]. f, g Lower prevalence of worm infection and diarrhoea have been associated with weight gain [35, 46]. h Toothbrushing with fluoride toothpaste prevents dental caries and odontogenic infections [31]. i Lower prevalence of dental caries and odontogenic infections are associated with lower prevalence of thinness [38] and weight gain [39]