Epidemiological and clinical status of South African primary school children : investing in the future.
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Date
2001
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Abstract
The physical, psychological and social development of school children has been
neglected - partly because they were seen as healthy "survivors" of the ravages of
childhood illnesses, and partly because of the way in which health services are
organized (such as the traditional under-five maternal and child health (MCH)
services and the curative PHC clinic services). From the age of five years children
undergo rapid and profound bio-psycho-social development, to emerge in
adolescence as the next generation of leaders and workers. Securing their future
growth and development is vital for any society to be economically and socially
productive.
A substantial body of national and intemational literature has recognised the
detrimental impact of helminthic infections and micronutrient deficiencies on the
physical and psychological health and development of school children; which
requires appropriate nutritional interventions. Concern has been expressed that
these adverse biological, physical and social deprivations have a cumulative
impact on several dimensions of children's growth. Most important, apart from
stunting physical growth, is the inhibition of educational development of school
children. Recent evidence strongly suggests a powerful interaction between
physical and psychosocial growth and development of children. Inhibition of either
component of a child's well-being has adverse implications. Conversely,
investments in the physical and psychological development of children are likely to
generate substantial health and educational benefits and are a worthy investment
to secure a healthy future generation.
In summary, there are a number of reasons for, and benefits of, investing in
school-based health and nutrition interventions. They are likely to improve
learning at school and enhance educational outcomes; create new opportunities to
meet unfulfilled needs; redress inequity; build on investments in early child
development and promote and protect youth and adolescent development. Health
and nutrition interventions such as school feeding programmes, micronutrient
supplementation and deworming aim to improve primary outcomes of macro and
micro-nutrient deficiencies, parasitic and cognitive status; as well as secondary
outcomes of developing integrated comprehensive school health policies and
programmes. This rationale served as the conceptual framework for this study. This
theoretical framework views improvements of the health, nutritional, cognitive and
scholastic development status of school children as the primary focus of policies,
strategies and programmes in the health and education sector. This focus constitutes
the central core of this thesis. Optimum social development requires investments in
both the health and educational development of school children, so as to maximise
the synergies inherent in each sector and to operationalise national and international
strategies and programmes.
As part of the larger RCT study a comprehensive nutritional, health and
psychological profile of rural school children was established through a
community-based cross-sectional study. Eleven schools were randomly selected
from the Vulamehlo Magisterial District in southern KwaZulu-Natal (KZN). Within
each school, all Standard 1 pupils, aged between 8 - 10 years, were selected
giving a final study sample of 579 children. Some of the observed prevalence's
were stunting (7.3%), wasting (0.7%), anaemia (16.5%) (as measured by
haemoglobin below 12 g/dl), vitamin A deficiency (34.7%) (as measured by serum
retinol below 20 ug/dl) and serum ferritin below 12ng/ml (28.1%). This study
established that micronutrient deficiency, parasitic infestations and stunting remain
significant public health problems among school-aged children in South Africa.
Combining micronutrient supplementation and deworming are likely to produce
significant health and educational gains.
To determine the impact of single and combined interventions (anthelminthic
treatment and micronutrient supplements) on nutritional status and scholastic and
cognitive performance of school children, a double-blind randomised placebo
controlled trial was undertaken among 579 children 8-10 years of age. There was
a significant treatment effect of vitamin A on serum retinol (P<0.01), and the
suggestion of an additive effect between vitamin A fortification and deworming.
Vitamin A and iron fortification also produced a significant treatment effect on
transferrin saturation (P<0.05). Among the dewormed group, anthelminthic
treatment produced a significant decrease in the prevalence of helminthic
infections (P<0.02), but with no significant between-group treatment effect
(P>0.40). Scholastic and cognitive scores and anthropometric indicators were no
different among the treated or the untreated children. Fortified biscuits improved
micronutrient status among rural primary school children; vitamin A combined with
deworming had a greater impact on micronutrient status than vitamin A fortification
on its own; while anthelminthic treatment produced a significant reduction in the
overall prevalence of parasite infection.
The prevalence's of Ascaris lumbricoides, Trichuris trichiura and Schistosoma
haematobium declined significantly sixteen weeks post-treatment. The levels of
both prevalence and intensity in the untreated group remained constant. The cure
rates over the first two weeks of the study were 94.4% for Ascaris lumbricoides,
40% for Trichuris trichiura, and 72.2% for Schistosoma haematobium. The benefits
of targeted school-based treatment in reducing the prevalence and intensity of
infection supports the South African government's focus of using school-based
interventions as part of an integrated parasite control programme. These
strategies and programmes were found to be consistent with the
recommendations of WHO and UNICEF.
The nutritional transition facing developing and middle-income countries also has
important implications for preventive strategies to control chronic degenerative
diseases (Popkin B, 1994; WHO 1998; Monyeki KO, 1999). This descriptive study,
comparing BMI data of school children over three time periods, found a rising
prevalence of overweight and obesity among South African school children.
Obesity as a public health problem requires to be addressed from a population or
community perspective for its prevention and management.
Environmental risk factors such as exposure to atmospheric pollution remain
significant hazards for children. Lead poisoning is a significant, preventable risk
factor affecting cognitive and scholastic development among children. The
prevalence of elevated blood lead (PbB) levels in rural and semi-urban areas of
KwaZulu-Natal (KZN) as well as the risk factors for elevation of PbB among
children in informal settlements were examined. This study investigated over 1200
rural and urban children in two age groups: 3-5 and 8-10 years old. Average PbB
level in peri-urban Besters, an informal settlement in the Durban metropolitan
region, was 10 ug/dl with 5% of the children showing PbB level of greater than 25
ug/dl. By comparison, average PbB value in Vulamehlo, a rural area located
90-120 km from Durban, was 3.8 ug/dl and 2% of the children's PbB levels were
greater than 10 ug/dl.
Since the cognitive and scholastic performance of school children was a primary
outcome measure in this study, it was important to explore other factors that
influenced this variable. The performance scores of all four tests in the battery,
among the cohort of a thousand rural and urban children, were in the lower range.
The educational deficit identified in this test battery clearly indicates the impact of
the inferior "Bantu" educational system that African children have experienced in
South Africa.
Aspects of the School Health Services that were investigated in this descriptive
study included the services provided and their distribution; assessment of health
inspection; health education and referral processes undertaken by the School
Health Teams; perceptions of managers, providers and recipients of the service;
as well as the costs of the provision of the service in KwaZulu-Natal. In KwaZulu-Natal,
there were School Health Teams In all the 8 health and education regions in
the province. In total, there were 95 teams in the province, consisting of nearly 300
staff members. The School Health Teams were involved in a wide range of
activities - 74% of all teams were involved in health inspection and 80% were
involved in health education. The total annual cost of delivering School Health
Services in the province in 1995 was estimated to be approximately R8 750 000.
Given the rise of HIV and AIDS in the province, School Health Services need to
play a central role not only in prevention, but also in assisting with the acceptance
of HIV-positive children within schools. It is recommended that the current and
future draft SHS policy guidelines be approved by the relevant authorities for
immediate implementation. Districts should consider developing "Health Promoting
Schools", with School Health Teams being a central resource.
This thesis has explored several aspects of the epidemiological profile of school
children in rural and urban settings in KwaZulu-Natal. It has established that
school children are exposed to a range of risk factors ranging from nutritional
deficits, parasitic infections, atmospheric lead poisoning and a rising prevalence of
overweight. All of these risk factors may compromise their physical, psychological
and social development. A number of health interventions have been identified, which have the potential to address these problems. Such investments are essential to secure the health of future generations.
Description
Thesis (M.D.)-University of Natal, Durban, 2001.
Keywords
Health status indicators--South Africa., School children--Health and hygiene--South Africa., School health services--South Africa., School hygiene--South Africa., Theses--Public health medicine.