Epidemiological and clinical status of South African primary school children : investing in the future.

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.