Rural Areas Of Low-income Countries Research Articles

A good egg: An evaluation of a social and behavior change communication campaign to increase egg consumption among children in Rwanda.

Childhood malnutrition, which is endemic in rural areas of low-income countries, leads to a host of deleterious outcomes such as poor cognitive development, low educational attainment and lower lifetime wages. Promoting the consumption of eggs among young children has emerged as a promising strategy to combat childhood malnutrition, though pathways to scale remain unclear. In this paper, we evaluate the impact of a social and behaviour change communication (SBCC) campaign combined with a program in which rural families purchased chickens on credit (poultry + SBCC; n = 769) relative to an arm in which families only received the poultry intervention (poultry only; n = 750), using a difference-in-difference estimation strategy with propensity score matching. The SBCC consisted of radio messages, in-person training, text message reminders and posters. We found a relatively modest but statistically significant increase in the number of times per week respondents in the poultry + SBCC arm reported feeding eggs to children of 0.28 (p = 0.02) compared to the poultry-only arm. The increase in egg feeding, however, was more pronounced for boys (0.42, p < 0.01) than for girls (0.14, p = 0.26). In addition, the campaign increased egg feeding more for those who were already feeding eggs to children (0.63, p < 0.01) than those who were not engaging in those practices at baseline (0.26, p < 0.01). However, the difference in these differences was not statistically significant. Future campaigns should ensure higher saturation of messaging and include specific messaging around the importance of feeding girls as well as boys. Campaigns seeking to scale up egg feeding quickly could potentially target the easier-to-reach segment of caregivers who already occasionally feed eggs to children though these might not be the neediest group.

Sustainability of community-based workers in multisectoral food security programs: a case study of producer leaders, village vaccinators, mother leaders, and community health workers in Burkina Faso

The community-based worker (CBW) model is commonly used by food security projects as an approach to catalyze community-driven development and to enhance long-term sustainability of project impacts in rural areas of low-income countries. However, there is limited follow-up research exploring how CBWs continue to carry out expected activities in the years that follow project exit. This case study examines how four different CBW roles—producer leaders, village vaccinators, community healthcare workers, mother leaders—all trained to contribute to the food security goals of a multi-year initiative in Kaya, Burkina Faso, sustained their respective activities post-project. Two years after the project ended, we collected qualitative data to examine how well these CBWs continued providing the activities that they had been trained to provide as expected by the project. We employ a conceptual framework of sustainability and exit strategies to assess what factors contributed to sustained activities and, where activities ceased, what caused them to stop. We find that where activities were sustained, all four hypothesized factors—sustained capacities, resources, motivation, and linkages—were present. We conclude by discussing key lessons and considerations for using the CBW model: (1) gradually transition to independent operation during project lifetime; (2) integrate CBWs into permanent and functional systems through gradual project exit; (3) professionalize the CBW role (re-think the volunteer approach); (4) what to do about resources and (5) co-develop endogenous definitions and indicators from the project onset.

Delayed cystic fibrosis diagnosis due to presumed celiac disease-A case report from Syria

BackgroundThis case report describes a cystic fibrosis case after 7 years of a presumed diagnosis of celiac disease without confirming laboratory tests and biopsies. Both cystic fibrosis and celiac disease cause malnutrition, malabsorption, and failure to thrive. Also, the occurrence of cystic fibrosis in celiac disease patients is higher than in the normal population. Therefore, the differentiation between the two diseases might be challenging. This article highlights the reason for the confusion between cystic fibrosis and celiac disease and emphasizes the importance of not skipping the necessary investigations no matter how difficult it is to perform them.Case presentationThis report details the case history of a patient presumed to have celiac disease for 7 years without confirming investigations. He developed multiple respiratory infections and weight loss throughout the 7 years but was only diagnosed with cystic fibrosis after hospitalization for gradual abdominal distension and productive cough. Chest CT showed atelectasis in the right upper lobe, tree-in-bud sign on both sides, and right periumbilical mass with several enlargements in the mediastinal nodes. Ascites paracentesis revealed a high SAAG gradient and low-protein fluid. The sweat chloride test resulted in a chloride level of 90 mEq/L, which confirmed the cystic fibrosis diagnosis. Subsequent genetic testing revealed the rare G85E mutation.ConclusionThis report highlights the potential for diagnostic confusion between cystic fibrosis and celiac disease. Also, it reminds physicians about the importance of taking a detailed medical history and performing the essential investigations no matter how difficult it is to do them. Finally, it emphasizes the need to verify the patient’s previous medical history in case there is no official documentation of his case. This should be considered particularly in rural areas in low-income countries where the possibility of medical malpractice should not be forgotten.

Validation of the 24-h perceived exertion recall survey in women in rural Tigray, Ethiopia

BackgroundPhysical activity affects nutritional status and health. Currently, there are few validated survey tools for estimating physical activity in rural areas of low-income countries, including Ethiopia, which limits the ability of researchers to assess how physical activity affects nutritional status. ObjectivesThis study used accelerometry to validate 2 in-person questionnaires, the global physical activity questionnaire (GPAQ) and the 24-h perceived exertion recall survey (PERS). MethodsThis study recruited 180 women aged between 18 and 45 y living in rural Tigray, Ethiopia. Participants had previously participated in an impact evaluation of a public work safety net. They wore an accelerometer for 8 d and responded to perceived exertion questionnaires twice. Data were collected on 89 women during the short rainy period and 91 women during the main rainy season. A survey method was considered valid if the proportion of time spent in moderate or vigorous physical activity (MVPA) levels had a Pearson’s correlation coefficient of >0.40 to the proportion of time spent in MVPA recorded by accelerometry. ResultsThe GPAQ had high reliability, but the overall validity was poorer than accelerometry. The proportion of time spent in MVPA according to the accelerometer was associated with discordance between GPAQ and accelerometry. MVPA levels, as measured by the 24-h PERS, had a fair agreement with accelerometry. The agreement increased to moderate/acceptable when adjusted for season and BMI. ConclusionsThe 24-h PERS is a valid tool for estimating the physical activity of women living in rural highland Ethiopia. It can be used in future research to understand the physical activity demands of living in rural highland Ethiopia, enabling more targeted programs to address undernutrition.

Environmental impacts of corn silage production: influence of wheat residues under contrasting tillage management types

The intensification of specific land management operations (tillage, herbicide, etc.) is increasing land degradation and contributing to ecosystem pollution. Mulches can be a sustainable tool to counter these processes. This is particularly relevant for rural areas in low-income countries where agriculture is a vital sector. In this research, the environmental impact of different rates of wheat residues (no residues, 25, 50, 75, and 100%) in corn silage cultivation was evaluated using the life cycle assessment (LCA) method under conventional tillage (CT) and no-tillage (NT) systems in a semi-arid region in Karaj, Iran. Results showed that in both tillage systems, marine aquatic ecotoxicity (ME) and global warming potential (GWP) had the highest levels of pollution among the environmental impact indicators. In CT systems, the minimum (17,730.70 kg 1,4-dichlorobenzene (DB) eq.) and maximum (33,683.97 kg 1,4-DB eq.) amounts of ME were related to 0 and 100% wheat residue rates, respectively. Also, in the CT system, 0 and 100% wheat residue rates resulted in minimum (176.72 kg CO2 eq.) and maximum (324.95 kg CO2 eq.) amounts of GWP, respectively. However, in the NT system, the 100% wheat residue rate showed the minimum amounts of ME (11,442.39 kg 1,4-DB eq.) and GWP (120.21 kg CO2 eq.). Also, in the NT system, maximum amounts of ME (17,174 kg 1,4-DB eq.) and GWP (175.60 kg CO2 eq.) were observed with a zero wheat residue rate. On-farm emissions and nitrogen fertilizers were the two factors with the highest contribution to the degradation related to environmental parameters at all rates of wheat residues. Moreover, in the CT system, the number of environmental pollutants increased with the addition of a higher wheat residue rate, while in the NT system, increasing residue rates decreased the amount of environmental pollutants. In conclusion, this LCA demonstrates that the NT system with the full retention of wheat residues (100%) is a more environmentally sustainable practice for corn silage production. Therefore, it may be considered one of the most adequate management strategies in this region and similar semi-arid conditions. Further long-term research and considering more environmental impact categories are required to assess the real potential of crop residues and tillage management for sustainable corn silage production.

The effect of poor vision on economic farm performance: Evidence from rural Cambodia

Roughly one-fifth of the global population is affected by poor visual acuity. Despite the fact that inhabitants of rural areas in low-income countries are most distressed by this, no prior research has studied the impact of poor visual acuity on the economic performance of farms. We conduct a standardized eye test with 288 farm managers in rural Cambodia and find that around 30 percent of our sample suffers from poor visual acuity in terms of nearsightedness (myopia). Our analyses indicate a statistically significant and economically meaningful association of poor visual acuity with economic farm performance. Our results show that gross margins for cropping activities per year could be, on average, around 630 USD higher if farm managers were able to correct for poor vision. Our results suggest that poor visual acuity impairs farm managers from tapping the full potential of their business, which in turn decreases their chance to break the vicious cycle of poverty.

Impact of Xpert MTB/RIF in the Diagnosis of Childhood Tuberculosis in Rural Ethiopia.

This study assesses the impact of the Xpert MTB/RIF in the diagnosis of childhood tuberculosis (TB) in a rural hospital in a resource-constrained setting. Retrospective cross-sectional study in children evaluated for presumptive TB from 1 June 2016 to 31 May 2017 at the Gambo General Hospital in rural Southern Ethiopia. Children were evaluated according to a defined protocol based on national guidelines. Samples were submitted for Xpert MTB/RIF assay to the nearest reference laboratory. Of the 201 children assessed for presumptive TB, 46.3% (93/201) were diagnosed with TB. Of these, 49.5% (46/93) were microbiologically confirmed, mostly by Xpert MTB/RIF (only one patient was diagnosed by smear alone). The rest were clinically diagnosed. Microbiologically confirmed patients had a higher mean age, longer duration of fever and cough and lymphadenopathy more frequently than those clinically diagnosed. Gastric aspirates were Xpert MTB/RIF-positive in 18.2% of the samples (26/143); none were smear-positive (0/140). Sputum samples were Xpert MTB/RIF-positive in 27.1% (13/35) of the samples and smear-positive in 8.6% (3/35). There were no HIV-positive patients and just one case of rifampicin-resistant TB. A long delay (median 15 days) was detected in returning the results. Xpert MTB/RIF serves as an important adjunctive test for diagnosing childhood TB in rural settings, with microbiological confirmation in up to half the TB cases. Processes need to be optimized to achieve an early diagnosis. The diagnosis of childhood TB in high-burden countries such as Ethiopia still relies largely upon diagnostic algorithms and the clinician's skills.Lay summaryWorld Health Organization recommends the use of Xpert MTB/RIF to improve the microbiological diagnosis of childhood tuberculosis (TB) since 2014, but the impact of this test under real conditions in rural areas of low-income countries is not clear. We conducted a cross-sectional study in children evaluated for presumptive TB from 1 June 2016 to 31 May 2017 at the Gambo General Hospital in rural Southern Ethiopia. Children were evaluated according to a clinical protocol based on national guidelines and samples were submitted for Xpert MTB/RIF assay to the nearest reference laboratory.Of the 201 children assessed, 46.3% (93/201) were diagnosed with tuberculosis. Of these, 48.4% (45/93) were microbiologically confirmed by Xpert MTB/RIF [smear microscopy only diagnosed the 5.4% (5/93)]. Patients with microbiologically confirmed tuberculosis had a higher mean age, longer duration of fever and cough and had lymphadenopathy more frequently than those clinically diagnosed. A long delay in returning the results (median 15 days) was detected. Xpert MTB/RIF serves as an important test for diagnosing childhood TB in rural settings, with microbiological confirmation in up to half the cases. Processes need to be optimized to achieve an early diagnosis. The diagnosis of childhood TB in high-burden countries still relies largely upon diagnostic algorithms and the clinician's skills.

Can open-defecation free (ODF) communities be sustained? A cross-sectional study in rural Ghana.

Community-led total sanitation (CLTS) is a widely used approach to reduce open defecation in rural areas of low-income countries. Following CLTS programs, communities are designated as open defecation free (ODF) when household-level toilet coverage reaches the threshold specified by national guidelines (e.g., 80% in Ghana). However, because sanitation conditions are rarely monitored after communities are declared ODF, the ability of CLTS to generate lasting reductions in open defecation is poorly understood. In this study, we examined the extent to which levels of toilet ownership and use were sustained in 109 communities in rural Northern Ghana up to two and a half years after they had obtained ODF status. We found that the majority of communities (75%) did not meet Ghana's ODF requirements. Over a third of households had either never owned (16%) or no longer owned (24%) a functional toilet, and 25% reported practicing open defecation regularly. Toilet pit and superstructure collapse were the primary causes of reversion to open defecation. Multivariate regression analysis indicated that communities had higher toilet coverage when they were located further from major roads, were not located on rocky soil, reported having a system of fines to punish open defecation, and when less time had elapsed since ODF status achievement. Households were more likely to own a functional toilet if they were larger, wealthier, had a male household head who had not completed primary education, had no children under the age of five, and benefitted from the national Livelihood Empowerment Against Poverty (LEAP) program. Wealthier households were also more likely to use a toilet for defecation and to rebuild their toilet when it collapsed. Our findings suggest that interventions that address toilet collapse and the difficulty of rebuilding, particularly among the poorest and most vulnerable households, will improve the longevity of CLTS-driven sanitation improvements in rural Ghana.

Information needs and delivery channels: Experimental evidence from Cambodian smallholders

Despite numerous policy interventions, poverty still exists. Those most harshly affected are people living in rural areas of low-income countries, regions that are often characterized by information asymmetries leading to market failure. The widespread growth of information and communications technologies (ICTs) in remote areas across the world holds immense potential for lifting the information barriers of the rural poor. However, there is little evidence of the effectiveness of delivery channels, which might be one reason why digital advice differs in its impact. Seeking to ascertain how smallholders can best be served by ICT, the authors investigated information needs and effective ICT delivery channels. Sociodemographic and ICT-related data was collected and a framed field experiment was conducted with smallholders in Cambodia; they were asked to build an object while using various delivery channels for instruction. Employing different regression techniques and matching algorithms, the experiment reveals that multisensory instructions trump all others.

Trachoma control using water, sanitation, and hygiene

Trachoma remains a neglected tropical disease, causing blindness or visual impairment in 1·9 million people and it is responsible for 1·4% of all blindness, worldwide.1 It affects communities living in poor, rural areas in low-income countries where access to water, sanitation, and hygiene (WASH) is scarce.1–3 Sub-Saharan Africa is the most affected region, where trachoma is hyperendemic in some regions.2,4 The SAFE strategy—which has been mandated by WHO for the elimination of trachoma—outlines measures to manage the disease and has been implemented in trachoma endemic countries since 1998.

Household food insecurity and health in a high-migration area in rural Honduras

Household food insecurity (HFI) is a significant problem in the developing world. Relationships between HFI and nutrition, physical growth, and development have been elucidated; less is known about the non-nutritional impacts among individuals living in rural areas in low-income countries. The aim of this study was to determine if HFI is a risk factor for suboptimal mental health and overall health in rural Honduras. In a population of 24,696 adults with 176 isolated villages in western Honduras, we collected data on household food insecurity and physical and mental health outcome measures. Using logistic regression with and without adjusting for village and household level unobservables invariant across individual respondents, we show that females (OR: 1.11, p <0.01)), indigenous people (OR: 2:00, p < 0.01), and those planning to migrate (OR: 1.24, p <0.01) have higher odds of experiencing food insecurity. The risks of food insecurity and poor health were mitigated among respondents living where they were born and having multi-generations of relatives living in the same village—a measure of the opportunity and availability of social networks. Living in a food insecure compared to a food secure household was associated with 77 percent higher odds of being depressed, 35 percent higher odds of low overall mental health, and 20 percent higher odds for low overall health.

Real-time polymerase chain reaction on filter paper spotted samples: a gateway to molecular diagnosis of invasive bacterial diseases for rural areas in low-income countries.

Bacterial culture is the gold standard for the diagnosis of invasive bacterial diseases (IBDs) but molecular methods are more specific and sensitive. Fresh liquid samples (FLSs) show patent limitations for shipping and storage. We aimed to evaluate the sensitivity and specificity of real-time polymerase chain reaction (PCR) performed on dried sample spots (DSSs) obtained from different biological fluids compared with real-time PCR or culture performed on FLSs. FLSs positive for Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae, Escherichia coli, Streptococcus pyogenes, Staphylococcus aureus, Bordetella pertussis and/or Pseudomonas aeruginosa were spotted on filter paper. Real-time PCR was performed on both FLSs and DSSs and results were compared. The stability of the DSS results over time was evaluated. Real-time PCR performed on 114 DSSs showed a specificity of 99.1% and a sensitivity of 91.2% for IBD diagnosis. A positive correlation was found between FLS cycle threshold (Ct) and DSS Ct (r=0.84; r2=0.71) with the Pearson statistical test and Bland-Altman analysis showing that 95% of the specimens were within agreeable limits. Although we observed a trend towards signal reduction over time in the DSSs, there was no statistical evidence of an increase in Ct values. Real-time PCR on DSSs was 2.2 times more sensitive than culture. Real-time PCR applied to DSSs may be a useful approach in different situations, such as IBD diagnosis, both for rural areas of low-income countries and family practitioners in various settings.

Tuberculosis treatment outcomes in a rural area of Senegal: a decade of experience from 2010 to 2019 by StopTB Italia.

Background: Tuberculosis (TB) unevenly affects individuals across the globe, especially in rural areas of low-income countries. Aim of the study was to assess the impact of social protection to increase TB awareness on treatment outcomes among TB patients in a rural area of Senegal. Materials & methods: The study, conducted in Fimela district (Senegal) from 1 January 2010to 31 December2019 and the intervention started from 31 January2013, includes activities to increase awareness, active case finding, active follow-upand social protection. Results: Overall, 435 subjects - mainly male and young-were included in the analysis. Among TB cases, 94% had pulmonary involvement, 87% had no previous TB history, and 6% resulted positiveHIV. Improved outcome was observed once intervention began (from 71to 91%, p<0.001); whereas mortality decreased (from 15 to 5%; p<0.001), especially for those HIV co-infected for whom TB mortality rate dropped from 70 to 29%. Conclusion: After beginning the cooperation program, TB treatment success increased as a result of the decline of mortality, especially in people living with HIV.

Impacts of improvements in rural roads on household income through the enhancement of market accessibility in rural areas of Cambodia

Rural areas in low-income countries often face severe poverty typically caused by insufficient accessibility to basic facilities. Improvements in rural roads are expected to reduce poverty although the mechanism has not been investigated sufficiently. This study empirically analyzes the impacts of rural road improvements implemented from 2012 to 2014 in Cambodia, highlighting local residents’ accessibility to local markets. This study assumes two causal relationships: rural road improvements have upgraded the accessibility and travel frequency to local markets, and the upgraded accessibility and travel frequency to local markets have led to a growth in local residents’ income. The hypotheses are statistically tested with a dataset developed through a questionnaire survey conducted in three areas in 2016. The dataset contains responses from 400 local residents to questions concerning their social attributes, livelihoods, travel modes, travel frequency, and time/cost of travels to the basic facilities. The quasi-experimental design incorporating a difference-in-differences design and an inverse possibility of treatment weighting approach revealed that the improvements in rural roads did not affect travel time nor travel cost but significantly enhanced travel frequency to local markets, and that an increase in the travel frequency to local markets and travel time savings significantly contributed to the households’ income growth. The results suggest that the improvement of seasonal reliability in accessing local markets through an introduction of all-weather roads could be critical to enhance household income, particularly in areas where agriculture is a leading industry and weather conditions are unstable across seasons.

The Friendship Bench as a brief psychological intervention with peer support in rural Zimbabwean women: a mixed methods pilot evaluation

AbstractBackgroundThere is a large treatment gap for common mental disorders in rural areas of low-income countries. We tested the Friendship Bench as a brief psychological intervention delivered by village health workers (VHWs) in rural Zimbabwe.MethodsRural women identified with depression in a previous trial received weekly home-based problem-solving therapy from VHWs for 6 weeks, and joined a peer-support group. Depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS) and Shona Symptom Questionnaire (SSQ). Acceptability was explored through in-depth interviews and focus group discussions. The proportion of women with depression pre- and post-intervention was compared using McNemar's test.ResultsTen VHWs delivered problem-solving therapy to 27 women of mean age 33 years; 25 completed six sessions. Women valued an established and trustful relationship with their VHW, which ensured confidentiality and prevented gossip, and reported finding individual problem-solving therapy beneficial. Peer-support meetings provided space to share problems, solutions and skills. The proportion of women with depression or suicidal ideation on the EPDS declined from 68% to 12% [difference 56% (95% confidence interval (CI) 27.0–85.0);p= 0.001], and the proportion scoring high (&gt;7) on the SSQ declined from 52% to 4% [difference 48% (95% CI 24.4–71.6);p&lt; 0.001] after the 6-week intervention.ConclusionVHW-delivered problem-solving therapy and peer-support was acceptable and showed promising results in this pilot evaluation, leading to quantitative and qualitative improvements in mental health among rural Zimbabwean women. Scale-up of the Friendship Bench in rural areas would help close the treatment gap for common mental disorders.

Men's nutrition knowledge is important for women's and children's nutrition in Ethiopia.

In an effort to address undernutrition among women and children in rural areas of low‐income countries, nutrition‐sensitive agriculture (NSA) and behaviour change communication (BCC) projects heavily focus on women as an entry point to effect nutritional outcomes. There is limited evidence on the role of men's contribution in improving household diets. In this Agriculture to Nutrition trial (Clinicaltrials.gov identifier: NCT03152227), we explored associations between men's and women's nutritional knowledge on households', children's and women's dietary diversity. At the midline evaluation conducted in July 2017, FAO's nutrition knowledge questionnaire was administered to male and female partners in 1396 households. There was a high degree of agreement (88%) on knowledge about exclusive breastfeeding between parents; however, only 56–66% of the households had agreement when comparing knowledge of dietary sources of vitamin A or iron. Factor analysis of knowledge dimensions resulted in identifying two domains, namely, ‘dietary’ and ‘vitamin’ knowledge. Dietary knowledge had a larger effect on women's and children's dietary diversities than vitamin knowledge. Men's dietary knowledge had strong positive associations with households' dietary diversity scores (0.24, P value = 0.001), children's dietary diversity (0.19, P value = 0.008) and women's dietary diversity (0.18, P value < 0.001). Distance to markets and men's education levels modified the effects of nutrition knowledge on dietary diversity. While previous NSA and BCC interventions predominantly focused on uptake among women, there is a large gap and strong potential for men’s engagement in improving household nutrition. Interventions that expand the role of men in NSA may synergistically improve household nutrition outcomes.

Prevalence, Indications and Complications for Cesarean Sections at District Hospital of Eastern Nepal

Introduction: Cesarean Section (CS) is one of the most common obstetric operative procedures. The procedure of cesarean section is still challenging in hospitals, from rural areas of low-income countries like Nepal, where health resources remain scarce and limited. The aim of this study is to understand the prevalence of cesarean section, clinical indications that prompts CS and maternal complications following CS. Methods: In this descriptive cross-sectional study, all cases of delivery at Ilam District Hospital from Jul 16, 2017 to Jul 15, 2018 were included. Ethical approval was obtained from the institution. Patients attending the hospital were from hilly and remote areas of Ilam, Pachthar and Taplejung districts. The prevalence, clinical indications and outcomes of CS were recorded. Data analysis were conducted using Microsoft Excel. Results: The prevalence of cesarean section was 162(14.70%). The mean maternal age was 24.59 (range 17-39) years. Fetal distress was the leading indication and accounted for 57(35.18%) cases for CS, followed by non-progress of labour 40(24.69%), failed induction 23(14.19%), Cephalopelvic disproportion 17(10.49%) and Breech or malpresentation 11(6.79%). Most of the patients were primigravida 115(70.98%) and mean gestational weeks was 40.21(range 36-44). No major maternal complications were noted. Neonatal mean weight was 3.52(2-5.5) kg and APGAR score of more than 6 at 5th minute were recorded in 158 (97.53%) of newborns. Conclusion: The CS prevalence in our study was within the WHO recommendations of 10-15%. The leading indications for CS were fetal distress and no major complications were seen in mothers or newborns following CS.

Manual Borehole Drilling as a Cost-Effective Solution for Drinking Water Access in Low-Income Contexts

Water access remains a challenge in rural areas of low-income countries. Manual drilling technologies have the potential to enhance water access by providing a low cost drinking water alternative for communities in low and middle income countries. This paper provides an overview of the main successes and challenges experienced by manual boreholes in the last two decades. A review of the existing methods is provided, discussing their advantages and disadvantages and comparing their potential against alternatives such as excavated wells and mechanized boreholes. Manual boreholes are found to be a competitive solution in relatively soft rocks, such as unconsolidated sediments and weathered materials, as well as and in hydrogeological settings characterized by moderately shallow water tables. Ensuring professional workmanship, the development of regulatory frameworks, protection against groundwater pollution and standards for quality assurance rank among the main challenges for the future.

A Garden-Based Intervention to Improve Dietary Diversity in Kenyan School Children: Results from a Natural Experiment

Abstract Objectives School gardens may improve child diet, but little is known about their effectiveness in rural areas in low-income countries. We evaluated the ability of school gardens to improve child diet in rural Kenya. We hypothesized that children in intervention schools would improve their dietary diversity and specifically their produce intake. Methods An non-government organization installed gardens in 2 primary schools. We selected 2 geographically proximal additional schools as comparisons. We conducted baseline assessments in 2013, prior to garden installation, and follow-up assessments a year later in 2014 in all 4 schools. We measured child dietary intake via a single 24-hour recall. We calculated dietary diversity using the women's dietary diversity score (WDDS) (continuous) and also examined each of the 10 food group components defined as adequate ≥15 g (binary). We conducted marginal linear or logistic regression models using a generalized estimating equation and included an exposure x time interaction to assess differences in outcomes between intervention and comparison schools from baseline to follow up. We controlled for child age, gender, and orphan status. Results We assessed 855 children (n = 438 intervention; n = 417 comparison) at baseline and 688 children (n = 383 intervention; n = 305 comparison) at follow up. Children in intervention schools were 51.8% male, compared to 56.5% in comparison schools. Mean (standard deviation) age was 11.6 (2.1) years in intervention and 11.8 (2.3) years in comparison schools. All children's WDDS worsened post-intervention. In adjusted difference in difference analyses, WDDS did not differ in intervention vs. comparison schools pre- to post-intervention (β 0.04, CI −0.19, 0.27). However, we observed less of a decrease in meeting adequate intake for pulses (OR 2.18, CI 1.18, 4.01) and other fruits (OR 1.55, CI 1.00, 2.40) in intervention versus comparison schools. Conversely, children in comparison schools had less of a decrease in meat, poultry, and fish compared to children in intervention schools (OR 0.67, CI 0.45, 0.99). Conclusions Children's WDDS worsened in all 4 schools, likely due to a severe drought that affected the region in 2014. We observed some differences in intervention vs. comparison children, but cannot attribute these improvements to school gardens. Funding Sources Duke Global Health Institute.

Challenges in addressing the knowledge gap on endomyocardial fibrosis through community-based studies.

Endomyocardial fibrosis (EMF) is a poverty-related disease of unknown origin that afflicts predominantly young people of certain rural areas in low-income countries and can be used to expose global disparities in cardiovascular research. Despite affecting predominantly young people and causing high morbidity and mortality, efforts to understand its mechanisms and natural history have been hampered by the incapacity to detect the early stages of the disease in endemic areas. Dietary, environmental and infectious factors seem to combine in susceptible individuals to give rise to an inflammatory process that leads to endomyocardial damage and scar formation. Lack of awareness by health professionals and low access to health care determine late diagnosis, when complications such as chronic heart failure, thromboembolism and arrhythmia are already present. Open-heart surgery to detach the endocardial fibrous tissue and repair the atrioventricular valve, remains the last resource to prolong patients' survival. Community-based research is therefore needed to understand the epidemiology of EMF, detect early disease, uncover its pathogenesis and explore new therapeutic targets. Our research has shown that echocardiographic screening using standard criteria adds sensitivity and precision to the diagnosis, particularly in asymptomatic disease, providing an opportunity for longitudinal community-based research. However, researchers face major constraints in rural settings where EMF is endemic, including socioeconomic, cultural, geographical and administrative barriers. In presenting our experience we aim to describe the challenges and discuss the lessons learned while implementing community-based research in a highly endemic area in southern Mozambique, one of the poorest countries in the world. Additionally, we discuss how recent advances in medicine-such as use of point-of-care diagnostics, heart failure biomarkers and new imaging techniques-may open new possibilities for high quality research through collaborative partnerships and regional initiatives.