Non-enrolled Children Research Articles

Endemic status of urogenital schistosomiasis and the efficacy of a single-dose praziquantel treatment in unmapped rural farming communities in Oyo East Local Government Area, Oyo State, Nigeria.

Schistosomiasis is endemic in Nigeria, and the treatment is largely concentrated on children enrolled in schools. Consequently, the coverage of non-enrolled school-aged children is often neglected. Ajagba and Awosan are two communities in Nigeria that have never had any control intervention. Hence, this survey was designed to determine the endemicity of urogenital schistosomiasis and to evaluate the efficacy of a single-dose praziquantel in the communities. Urine sample (10 mL) of each participant from Ajagba and Awosan communities was filtered through 12μm polycarbonate filter. The filter was placed on a microscope slide, and stained with a drop of 1% Lugol iodine solution. The stained slides were examined under the microscope and the numbers of S. haematobium eggs were counted. Water contact sites were searched for snail hosts and the snails collected were shed for Schistosoma cercariae. Data were analyzed using SPSS version 24.0 and the significance level was set at 95%. The overall prevalence of infection in the Ajagba community was 45.6% with a mean intensity of 61.1 ± 144.5 eggs/10 mL of urine, while the prevalence of infection in the Awosan community was 5.7% with a mean intensity of 1.4 ± 6.8 eggs/10 mL of urine. The school-aged children had a prevalence and mean intensity of infection of 73.1% and 111.6 ± 177.9 eggs/10 mL of urine, respectively. Following treatment, women had a higher egg reduction rate than men (p = 0.0283). Bulinus globosus were found in Ajagba but not in Awosan, with 5.7% shedding Schistosoma spp, cercariae. Urogenital schistosomiasis was hyperendemic in the Ajagba community, and hypoendemic in the Awosan community. The presence of Bulinus globosus supported the transmission of the schistosomiasis in the Ajagba community. Communities where schistosomiasis is still actively transmitted in Nigeria should be identified for effective intervention through the MDA programs.

Preventive chemotherapy coverage against soil-transmitted helminth infection among school age children: Implications from coverage validation survey in Ethiopia, 2019.

Soil-transmitted helminth (STH) infections remain the most common neglected tropical diseases among children living mainly in low-resource settings. Preventive chemotherapy (PC) has been implemented as one of the main public health interventions to control and eliminate STH infections. Although data on routine coverage of PC against STH are available at different level of the health system; these data are unreliable as they are subject to errors and manipulation and evidence is lacking on validated treatment coverage. Thus, this study aimed to determine anthelminthic coverage among school age children (SAC) to inform decision made in PC program implementation. We conducted a community-based cross-sectional coverage survey in ten districts of Ethiopia; in April 2019. Sample size was computed automatically using Coverage Survey Builder (CSB) tool in Microsoft excel. Thirty segments were randomly selected per each selected districts. Collected data were cleaned and analysed using SPSS software (IBM, version 25). In all, 8154 SAC participated in the study. The overall anthelminthic coverage was found to be 71% (95%confidence interval (CI) = 70-71.9%). The reported coverage was lower than the surveyed coverage only in Guagusa district. The PC coverage among males (71.9%) was slightly higher than females' coverage (70%); and the coverage in the age group between10 and 14 years (77%) was higher compared with the age group between 5 and 9 years (64.3%). In addition, the PC coverage in school attending children (81.1%) was much higher than coverage in non-enrolled children (28.3%). Moreover, the most frequently mentioned reasons for not swallowing drugs were drug not given (24.75%) and not attending school (19.75%). This study showed that only five out of ten districts met the target threshold (minimum 75%) for effective coverage. Hence, implementations of preventive chemotherapy should be improved in those districts with low coverage data.

Returns to farm child labor in Tanzania

• In Tanzania, 89% of rural working children work on household farm. • One day of child work on farm increases production by US$0.89. • The productivity of older children is much larger. • A conditional cash transfer of $10/month would enroll 27% of working poor children. • In Africa, providing a CCT may not be the most efficient tool to achieve universal enrollment. In developing countries, the opportunity costs of children’s time can significantly hinder universal education. This paper studies one of these opportunity costs: we estimate the agricultural productivity of children aged 10 to 15 years old using the LSMS-ISA panel survey in Tanzania. Since child labor can be endogenous, we exploit the panel structure of the data and instrument child labor with changes in the age composition of the household. One day of child work leads to an increase in production value by roughly US$0.89. Children enrolled in school work 26 fewer days than nonenrolled children. Compensating enrolled children for loss in income can be accomplished with monthly payments of $1.92. However, a complete simulation of a hypothetical conditional cash transfer shows that even $10/month transfers would fail to achieve universal school enrollment of children aged 10 to 15 years old.

Systematic review of community-based, school-based, and combined delivery modes for reaching school-aged children in mass drug administration programs for schistosomiasis.

BackgroundThe mainstay of current schistosomiasis control programs is mass preventive chemotherapy of school-aged children with praziquantel. This treatment is delivered through school-based, community-based, or combined school- and community-based systems. Attaining very high coverage rates for children is essential in mass schistosomiasis treatment programs, as is ensuring that there are no persistently untreated subpopulations, a potential challenge for school-based programs in areas with low school enrollment. This review sought to compare the different treatment delivery methods based both on their coverage of school-aged children overall and on their coverage specifically of non-enrolled children. In addition, qualitative community or programmatic factors associated with high or low coverage rates were identified, with suggestions for overall coverage improvement.Methodology/Principal findingsThis review was registered prospectively with PROSPERO (CRD 42015017656). Five hundred forty-nine publication of potential relevance were identified through database searches, reference lists, and personal communications. Eligible studies included those published before October 2015, written in English or French, containing quantitative or qualitative data about coverage rates for MDA of school-aged children with praziquantel. Among the 22 selected studies, combined community- and school-based programs achieved the highest median coverage rates (89%), followed by community-based programs (72%). School-based programs had both the lowest median coverage of children overall (49%) and the lowest coverage of the non-enrolled subpopulation of children. Qualitatively, major factors affecting program success included fear of side effects, inadequate education about schistosomiasis, lack of incentives for drug distributors, and inequitable distribution to minority groups.Conclusions/SignificanceThis review provides an evidence-based framework for the development of future schistosomiasis control programs. Based on our results, a combined community and school-based delivery system should maximize coverage for both in- and out-of-school children, especially when combined with interventions such as snacks for treated children, educational campaigns, incentives for drug distributors, and active inclusion of marginalized groups.Trial registrationClinicalTrials.gov CRD42015017656

Returns to Farm Child Labor in Tanzania

In developing countries, the opportunity costs of children's time may significantly hinder universal education. This paper studies one of these opportunity costs: we estimate the agricultural productivity of children aged 10 to 15, with the LSMS-ISA panel survey in Tanzania. Since child labor may be endogenous, we use the panel structure of the data and instrument changes in child labor by the change in the number of children of household members of the relevant age range over time. One day of child work leads to an increase in production value by US $1.43-2.45, depending on specifications. Children enrolled in school work 26 days less than non-enrolled children. Compensating them for the loss in income can be done by monthly payments between US $ 3.1-5.3. We find that girls are far less productive than boys on the farm but this may be explained by the fact that they share their day between different activities.

Health insurance and child mortality in rural Burkina Faso

BackgroundMicro health insurance schemes have been implemented across developing countries as a means of facilitating access to modern medical care, with the ultimate aim of improving health. This effect, however, has not been explored sufficiently.ObjectiveWe investigated the effect of enrolment into community-based health insurance on mortality in children under 5 years of age in a health and demographic surveillance system in Nouna, Burkina Faso.DesignWe analysed the effect of health insurance enrolment on child mortality with a Cox regression model. We adjusted for variables that we found to be related to the enrolment in health insurance in a preceding analysis.ResultsBased on the analysis of 33,500 children, the risk of mortality was 46% lower in children enrolled in health insurance as compared to the non-enrolled children (HR=0.54, 95% CI 0.43–0.68) after adjustment for possible confounders. We identified socioeconomic status, father's education, distance to the health facility, year of birth, and insurance status of the mother at time of birth as the major determinants of health insurance enrolment.ConclusionsThe strong effect of health insurance enrolment on child mortality may be explained by increased utilisation of health services by enrolled children; however, other non-observed factors cannot be excluded. Because malaria is a main cause of death in the study area, early consultation of health services in case of infection could prevent many deaths. Concerning the magnitude of the effect, implementation of health insurance could be a major driving factor of reduction in child mortality in the developing world.

AmeriCorps Members increase enrollment in Medicaid/CHIP and preventive care utilization at a community health center.

Uninsured children have less access than others to primary care; Latino children are more likely than non-Latino children to be uninsured. 1. Determine whether case management (CM) by AmeriCorps Members (ACM) increases enrollment of children in Medicaid/CHIP at a federally qualified community health center (FQHC); 2. Identify factors associated with non-enrollment; 3. Compare health care utilization by enrolled and non-enrolled children. Parents of uninsured children at two urban FQHCs serving primarily Latino families were offered CM assistance for enrollment in Medicaid/CHIP at one of the clinics. Application instructions alone were provided at the other clinic. Results. Of 107 children at the CM clinic, 74% were enrolled compared with 26% of the 96 from the non-CM clinic. Non-enrolled children completed fewer preventive care visits than enrolled children despite sliding fees at both FQHCs. Case management by ACM is a low-cost, effective approach to increasing access to care for Latino children.

Responding to Disaster with Alternative Education: A Case Study of a Post-disaster Education Project in Bangladesh

The paper presents a case study and lessons learnt from an alternative education project implemented in two cyclone-devastated districts of Bangladesh as a post-disaster response and recovery initiative after the massive cyclone ‘Sidr' in November 2007. A survey revealed that the shattered financial condition of local families along with other problems in the formal education system was causing dropouts and non-attendance. Based on the needs assessment the NGO Islamic Relief Worldwide implemented an alternative education project named ‘Anondo Biddaloy-Alternative Education for ‘Sidr’ Affected Children’. In an effort of creating access to the formal education for the drop-out and nonenrolled children, the project focused on regaining and augmenting their interest towards education by offering a learner friendly, joyful education scheme that combined life skills and livelihood skills education with health and wellbeing aspects. Implementation of the project resulted into introducing and retaining a significant number i.e. almost 80% of its target group in mainstream education. The project thus brought about a major lesson that education with an alternative nature (to the mainstream) can effectively contribute towards ensuring education for vulnerable target groups in a crisis. With an aim of contributing to the academic and practitioner’s knowledge of the community relevant to providing education in post-disaster situation, the paper has specific purposes of sharing the concept and contents of the particular alternative education initiative as well as lessons learnt from it.

Towards nationwide control of schistosomiasis in Yemen: a pilot project to expand treatment to the whole community

Both the urinary and intestinal forms of schistosomiasis are thought to be widespread in the Republic of Yemen, with estimates of 3 million people infected and 600 000 suffering clinical morbidity. Sub-national control has been ongoing since 2006 via the distribution of praziquantel (PZQ) against schistosomiasis and albendazole (ALB) against soil-transmitted helminths using school-based treatment. In preparation for a 6-year nationwide control programme with the aim of expanding treatment to the wider community, a new programmatic approach of complementing school-based distribution with community-based treatment was trialled in 10 highly endemic districts in three governorates in December 2009. The new approach achieved coverage of 90.1% of non-enrolled children: a 40% increase compared with the same districts in 2008, and coverage of 97.9% of enrolled children: a 2% increase compared to 2008. Coverage of females (children and adults) was 81.8%, and of adults in general was 73.9%. The total cost per person treated was US$0.66 (US$0.79 in 2008), which includes training, health education, social mobilization, distribution and drugs. These results provide hope that a combined school and community-based approach can be successfully implemented on a wider scale during the main control programme in 2010–2015, with approximately 10 million people targeted in the first year alone.

The numbers, educational status and health of enrolled and non-enrolled school-age children in the Allai Valley, Northwest Frontier Province, Pakistan

A cluster survey of the age, sex and enrolment status of all school-age children 5-14 years old was undertaken in 2006 in a remote rural sub-district of the Northwest Frontier Province, Pakistan about a year after a devastating earthquake. Information was collected on the characteristics of children, their households and parents, and on reasons for non-enrolment. The health and nutritional status of a randomly selected child in each household was assessed and enrolled and non-enrolled children were compared by sex. A total of 2032 children were recorded in 925 households, 845 girls and 1187 boys, a sex ratio of 71 girls/100 boys. Half of all girls were not enrolled in school compared with a fifth of all boys. There was no common reason for non-enrolment and they differed between the sexes. The randomly selected children (n = 897) were moderately malnourished: 43% were stunted, 12% were thin and 46% were anaemic. 66% of a sub-sample of children (n = 269) had a low urinary iodine concentration, which could contribute to a low IQ and impaired hearing. There were no statistically significant differences in the nutritional status or health of non-enrolled and enrolled girls. These data contribute towards an understanding of how to improve the education and health of school-age children in a conservative, rural province of Pakistan.

In utero exposure to antiretroviral therapy: feasibility of long-term follow-up

Most uninfected children born to diagnosed HIV-infected women in the United Kingdom (UK) are exposed to antiretroviral therapy (ART) in utero and neonatally, and concerns exist about potential adverse effects of such exposure. We explored the feasibility of using national clinic-based follow-up to investigate the association between ART exposure and adverse health events occurring after the neonatal period. Active surveillance of obstetric and paediatric HIV infection is conducted through the National Study of HIV in Pregnancy and Childhood (NSHPC). Between 2002 and 2005, health professionals enrolled previously notified uninfected children in a consented follow-up study (the CHildren exposed to AntiRetroviral Therapy (CHART) study). Follow-up information was collected opportunistically using a standard questionnaire. Of 2104 eligible uninfected children born in the UK between 1996 and 2004, 704 (33.5%) were enrolled in CHART; parents of 4.8% (100/2104) declined, 2.8% (59/2104) had gone abroad, 21.6% (455/2104) were not contactable, and the remaining 37.3% (786/2104) were not enrolled mainly because of lack of clinic resources or unwillingness of health professionals to approach the families. Demographic characteristics and type of ART exposure for enrolled and non-enrolled children were similar. Latest information on enrolled children was available at a median age of 24 months. Minor childhood ailments were reported in the majority of children, febrile seizures in 1.6% (11/704), and major health problems in 3.8% (27/704). It was reassuring that prevalence of these outcomes was within UK norms, but numbers were small and duration of follow-up was limited. The difficulties encountered in enrolling and retaining children in this study indicate that comprehensive clinic-based follow-up of ART-exposed uninfected children is not practical. Alternative approaches are required; a robust, secure data linkage protocol would provide a more feasible and sustainable system for long-term monitoring of in utero ART exposure.

A rationale for schistosomiasis control in elementary schools of the rainforest zone of pernambuco, Brazil.

BackgroundSince its beginning in 1999, the Schistosomiasis Control Program within the Unified Health System (PCE-SUS) has registered a cumulative coverage of just 20% of the population from the Rainforest Zone of Pernambuco (ZMP), northeast Brazil. This jeopardizes the accomplishment of the minimum goal of the Fifty-Fourth World Health Assembly, resolution WHA54.19, of providing treatment for schistosomiasis and soil-transmitted helminthiases (STH) to 75% of school-aged children at risk, which requires attending at least 166,000 residents in the 7–14 age range by year 2010 in that important endemic area. In the present study, secondary demographic and parasitological data from a representative municipality of the ZMP are analyzed to provide evidence that the current, community-based approach to control schistosomiasis and STH is unlikely to attain the WHA-54.19 minimum goal and to suggest that school-based control actions are also needed.Methodology/Principal FindingsData available on the PCE-SUS activities related to diagnosis and treatment of the population from the study municipality were obtained from the State Secretary of Health of Pernambuco (SES/PE) for 2002–2006, complemented by the Municipal Secretary of Health (SMS) for 2003–2004. Data from a school-based stool survey carried out by the Schistosomiasis Reference Service of the Oswaldo Cruz Foundation (SRE/Fiocruz) in 2004 were used to provide information on infection status variation among school-aged children (7–14 years). According to the SES, from 2004 to 2006, only 2,977 (19.5%) of the estimated 15,288 residents of all ages were examined, of which 396 (13.3%) were positive for Schistosoma mansoni. Among these, only 180 (45.5%) were treated. According to the SMS, of the 1,766 examined in the 2003–2004 population stool survey 570 (32.3%) were children aged 7–14 years. One year later, the SRE/Fiocruz school survey revealed that the infection status among those children remained unchanged at 14%–15% prevalence. By 2006, the school-aged population was estimated at 2,981, of which 2,007 (67.3%) were enrolled as pupils.ConclusionsIt is suggested that in the most troubled municipalities individual diagnosis and treatment should be concentrated in school-aged children rather than the whole population. School-based actions involving teachers and children's families may help the health teams to scale up control actions in order to attain the WHA-54.19 minimum goal. This strategy should involve health and education organs and include both enrolled and non-enrolled children.

Can coverage of schistosomiasis and soil transmitted helminthiasis control programmes targeting school-aged children be improved? New approaches

Control programmes generally use a school-based strategy of mass drug administration to reduce morbidity of schistosomiasis and soil-transmitted helminthiasis (STH) in school-aged populations. The success of school-based programmes depends on treatment coverage. The community-directed treatment (ComDT) approach has been implemented in the control of onchocerciasis and lymphatic filariasis in Africa and improves treatment coverage. This study compared the treatment coverage between the ComDT approach and the school-based treatment approach, where non-enrolled school-aged children were invited for treatment, in the control of schistosomiasis and STH among enrolled and non-enrolled school-aged children. Coverage during the first treatment round among enrolled children was similar for the two approaches (ComDT: 80.3% versus school: 82.1%, P=0.072). However, for the non-enrolled children the ComDT approach achieved a significantly higher coverage than the school-based approach (80.0 versus 59.2%, P<0.001). Similar treatment coverage levels were attained at the second treatment round. Again, equal levels of treatment coverage were found between the two approaches for the enrolled school-aged children, while the ComDT approach achieved a significantly higher coverage in the non-enrolled children. The results of this study showed that the ComDT approach can obtain significantly higher treatment coverage among the non-enrolled school-aged children compared to the school-based treatment approach for the control of schistosomiasis and STH.

COMMUNITY PERCEPTIONS ON THE COMMUNITY-DIRECTED TREATMENT AND SCHOOL-BASED APPROACHES FOR THE CONTROL OF SCHISTOSOMIASIS AND SOIL-TRANSMITTED HELMINTHIASIS AMONG SCHOOL-AGE CHILDREN IN LUSHOTO DISTRICT, TANZANIA

The success of the Community-Directed Treatment (ComDT) approach in the control of onchocerciasis and filariasis has caught the attention of other disease control programmes. In this study the ComDT approach was implemented and compared with the school-based approach for control of schistosomiasis and soil-transmitted helminthiasis among school-age children in Lushoto District, Tanzania. This was a qualitative study, consisting of in-depth interviews with village leaders, community drug distributors (CDDs) and schoolteachers, as well as focus group discussions with separate groups of mothers and fathers to assess the perceptions and experiences of the villagers on the implementation of the two approaches. It was found that the villagers accepted the ComDT approach and took the responsibility of selecting the CDDs, organizing and implementing their own method of distributing drugs to the school-age children in their villages. The ComDT approach was well received and was successfully implemented in the villages. Although the villagers pointed out the limitation in reaching the non-enrolled children in the school-based approach, they also expressed satisfaction with this approach. This study suggests that the ComDT approach is well accepted and can be implemented effectively to ensure better coverage of especially non-enrolled school-age children.

Effects of Enrollment in Medicaid Versus the State Children’s Health Insurance Program on Kindergarten Children’s Untreated Dental Caries

We compared levels of untreated dental caries in children enrolled in public insurance programs with those in nonenrolled children to determine the impact of public dental insurance and the type of plan (Medicaid vs State Children's Health Insurance Program [SCHIP]) on untreated dental caries in children. Dental health outcomes were obtained through a calibrated oral screening of kindergarten children (enrolled in the 2000-2001 school year). We obtained eligibility and claims data for children enrolled in Medicaid and SCHIP who were eligible for dental services during 1999 to 2000. We developed logistic regression models to compare children's likelihood and extent of untreated dental caries according to enrollment. Children enrolled in Medicaid or SCHIP were 1.7 times (95% confidence interval [CI] = 1.65, 1.77) more likely to have untreated dental caries than were nonenrolled children. SCHIP-enrolled children were significantly less likely to have untreated dental caries than were Medicaid-enrolled children (odds ratio [OR]=0.74; 95% CI=0.67, 0.82). According to a 2-part regression model, children enrolled in Medicaid or SCHIP have 17% more untreated dental caries than do nonenrolled children, whereas those in SCHIP had 16% fewer untreated dental caries than did those in Medicaid. Untreated tooth decay continues to be a significant problem for children with public insurance coverage. Children who participated in a separate SCHIP program had fewer untreated dental caries than did children enrolled in Medicaid.

Attaining the minimum target of resolution WHA 54.19 for schistosomiasis control in the Rainforest Zone of the state of Pernambuco, Northeastern Brazil

Resolution 19 of the 54th World Health Assembly (WHA-54.19) urged member nations to promote preventive measures, ensure treatment and mobilize resources for control of schistosomiasis and soil-transmitted helminthiases (STH). The minimum target is to attend 75% of all school-age children at risk by year 2010. The Brazilian Ministry of Health (MoH) recommends biennial surveys of whole communities and treatment of the positives through the Schistosomiasis Control Program within the Unified Health System (PCE-SUS). However, by 2004 the PCE-SUS had covered only 8.4% of the 1.2 million residents in the Rainforest Zone of Pernambuco (ZMP). Six of the 43 municipalities still remained unattended. Only three of the municipalities already surveyed reached coverage of 25% or more. At least 154 thousand children in the 7-14 years old range have to be examined (and treated if positive) within the next five years to attend the minimum target of the WHA 54.19 for the ZMP. To make this target feasible, it is suggested that from 2006 to 2010 the PCE-SUS actions should be complemented with school-based diagnosis and treatment, involving health and educational organs as well as community associations to include both children in schools and non-enrolled school-age children.

A community-based collaboration to assess and improve medical insurance status and access to health care of Latino children.

Despite eligibility for subsidized insurance, low-income Latino children are at high risk of being medically uninsured. The authors sought to understand and improve access to medical insurance for Latino children living in a California community of predominantly low-income immigrant families. During the summer of 1999, trained women from the community conducted interviews in Spanish with 252 randomly selected mothers of 464 children younger than age 19. Mothers provided information about family demographics, children's medical insurance, health care access, and experiences obtaining and maintaining children's insurance. Most children (83.3%) were eligible for subsidized medical insurance (48.4% Medi-Cal eligible; 35.0% Healthy Families eligible). Twenty-eight percent of eligible children were not enrolled. Non-enrolled eligible children were older (median age 7) than enrolled children (median age 4) and more likely to be born outside the U.S. (22.2%) than enrolled children (4.8%). Among children ages 3-18, those not enrolled were less likely to have visited a doctor in the past 12 months (58% compared to 78.7%) and less likely to have a usual source of care (96.3% compared to 99.5%). Mothers of non-enrolled children were more likely than mothers of enrolled children to have less than seven years of education (47.8% compared to 36.4%). Families with non-enrolled children were more likely to report out-of-pocket medical expenses (84.1% compared to 53%). Families with non-enrolled children were more likely to report barriers to the enrollment process, such as problems providing required documents (39.7% compared to 15.1%), problems understanding Spanish forms (19.4% compared to 8.9%), and confusing paperwork (39.7% compared to 24.7%). Most mothers (75.9%) reported that community organizations provided very useful help with children's insurance enrollment. Almost half (48.6%) preferred to receive enrollment assistance from community organizations. Only 43.3% of mothers had heard of the Healthy Families program. To reach the majority of uninsured Latino children, community-based outreach and insurance application assistance are crucial. Most important, the process of applying for and maintaining coverage in Medi-Cal or Healthy Families must be simplified.

School enrollment in Zanzibar linked to children's age and helminth infections.

School health programmes have been identified as a cost-effective strategy to reduce morbidity due to soil-transmitted helminths in the school-age population, but the low rate of school enrollment in developing countries is a major factor limiting their success. The present study was conducted to identify reasons for non-enrollment and to evaluate differences in the occurrence of helminth infection between enrolled and non-enrolled children in Zanzibar, United Republic of Tanzania. A questionnaire was submitted to 520 households to obtain information about enrollment and other socio-economic indicators. In addition, one school-age child was randomly selected in each household and investigated for soil-transmitted helminth infection. Overall, 71% of school-age children were enrolled. Enrollment increased with age. Only 41% of children under 9 years of age were enrolled compared to 91% in children older than 12 years. Enrollment is delayed because of an insufficient number of schools. Among non-enrolled school-age children, the proportion of heavy intensity infections was twice that of enrolled school-age children. Most of the non-enrolled school-age children live together with enrolled siblings in the same household, thereby representing an important opportunity for effective outreach activities. The effectiveness of the school-based helminth control programme in reducing the intensity of infection was confirmed. The significant gains achieved by enrolled school-age children in this study must be viewed as an attainable goal for the important numbers of non-enrolled school-age children in endemic areas. Decision-makers must ensure that outreach activities are included in helminth control programmes targeted to school-age children.

Health and cultural factors associated with enrolment in basic education: a study in rural Ghana

This inter-disciplinary study compares the health status of school-age children in Ghana, both enrolled and non-enrolled, and examines these results within a wider socio-economic and socio-cultural context including kinship and livelihood. Children matched for age and sex who were not enrolled in Primary School were significantly shorter and more stunted than enrolled children were, and 70% of all Primary school-age children were anaemic. Young children from farming communities were significantly more undernourished than children from fishing communities. Adolescent non-enrolled boys were more heavily infected with Schistosoma haematobium, and were more likely to be anaemic than enrolled adolescent boys. The data indicate how health and health related factors may influence and affect enrolment and how socio-economic indicators, livelihood, and kinship may also constrain enrolment and, in turn, affect child health. This study sheds light on the complex factors that may influence enrolment in education and provides novel data on the similarities and differences between the health of enrolled and non-enrolled children in rural Ghana.

A population dynamic approach to evaluating the impact of school attendance on the unit cost and effectiveness of school-based schistosomiasis chemotherapy programmes.

This paper presents a first attempt at modelling the possible cost and effectiveness of reaching non-enrolled children through school-based programmes using empirical data from Egypt. A sex/school-attendance/age-structured population dynamic model was used to predict trends in infection and early disease. Four treatment delivery strategies were compared: school-based (coverage of 85 %) and school-aged targeted (coverage of 25, 50 and 85 %). The school-aged targeted strategies also included the school-based programme. For each alternative strategy, the maximum unit cost was calculated to obtain a cost-effectiveness ratio equal or smaller to the one obtained with the school-based programme (unit cost of US$ 0.60). The analysis showed that, for S. mansoni in Lower Egypt, a programme where only 85% of children attending school were treated would still prevent 77 % of the early disease cases prevented with a programme where 85 % of all school-age children were treated. However, using the school-aged targeted strategy, from US $ 0.06 to US $ 1.03 extra unit costs could be spent to reach non-enrolled children and still be more cost-effective. Treating non-enrolled children is an important consideration in maximizing the effectiveness of treatment programmes while maintaining a cost-effectiveness comparable to school-based delivery.