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1.  Non-Specialist Psychosocial Interventions for Children and Adolescents with Intellectual Disability or Lower-Functioning Autism Spectrum Disorders: A Systematic Review 
PLoS Medicine  2013;10(12):e1001572.
In a systematic review, Brian Reichow and colleagues assess the evidence that non-specialist care providers in community settings can provide effective interventions for children and adolescents with intellectual disabilities or lower-functioning autism spectrum disorders.
Please see later in the article for the Editors' Summary
Background
The development of effective treatments for use by non-specialists is listed among the top research priorities for improving the lives of people with mental illness worldwide. The purpose of this review is to appraise which interventions for children with intellectual disabilities or lower-functioning autism spectrum disorders delivered by non-specialist care providers in community settings produce benefits when compared to either a no-treatment control group or treatment-as-usual comparator.
Methods and Findings
We systematically searched electronic databases through 24 June 2013 to locate prospective controlled studies of psychosocial interventions delivered by non-specialist providers to children with intellectual disabilities or lower-functioning autism spectrum disorders. We screened 234 full papers, of which 34 articles describing 29 studies involving 1,305 participants were included. A majority of the studies included children exclusively with a diagnosis of lower-functioning autism spectrum disorders (15 of 29, 52%). Fifteen of twenty-nine studies (52%) were randomized controlled trials and just under half of all effect sizes (29 of 59, 49%) were greater than 0.50, of which 18 (62%) were statistically significant. For behavior analytic interventions, the best outcomes were shown for development and daily skills; cognitive rehabilitation, training, and support interventions were found to be most effective for improving developmental outcomes, and parent training interventions to be most effective for improving developmental, behavioral, and family outcomes. We also conducted additional subgroup analyses using harvest plots. Limitations include the studies' potential for performance bias and that few were conducted in lower- and middle-income countries.
Conclusions
The findings of this review support the delivery of psychosocial interventions by non-specialist providers to children who have intellectual disabilities or lower-functioning autism spectrum disorders. Given the scarcity of specialists in many low-resource settings, including many lower- and middle-income countries, these findings may provide guidance for scale-up efforts for improving outcomes for children with developmental disorders or lower-functioning autism spectrum disorders.
Protocol Registration
PROSPERO CRD42012002641
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Newborn babies are helpless, but over the first few years of life, they acquire motor (movement) skills, language (communication) skills, cognitive (thinking) skills, and social (interpersonal interaction) skills. Individual aspects of these skills are usually acquired at specific ages, but children with a development disorder such as an autism spectrum disorder (ASD) or intellectual disability (mental retardation) fail to reach these “milestones” because of impaired or delayed brain maturation. Autism, Asperger syndrome, and other ASDs (also called pervasive developmental disorders) affect about 1% of the UK and US populations and are characterized by abnormalities in interactions and communication with other people (reciprocal socio-communicative interactions; for example, some children with autism reject physical affection and fail to develop useful speech) and a restricted, stereotyped, repetitive repertoire of interests (for example, obsessive accumulation of facts about unusual topics). About half of individuals with an ASD also have an intellectual disability—a reduced overall level of intelligence characterized by impairment of the skills that are normally acquired during early life. Such individuals have what is called lower-functioning ASD.
Why Was This Study Done?
Most of the children affected by developmental disorders live in low- and middle-income countries where there are few services available to help them achieve their full potential and where little research has been done to identify the most effective treatments. The development of effective treatments for use by non-specialists (for example, teachers and parents) is necessary to improve the lives of people with mental illnesses worldwide, but particularly in resource-limited settings where psychiatrists, psychologists, and other specialists are scarce. In this systematic review, the researchers investigated which psychosocial interventions for children and adolescents with intellectual disabilities or lower-functioning ASDs delivered by non-specialist providers in community settings produce improvements in development, daily skills, school performance, behavior, or family outcomes when compared to usual care (the control condition). A systematic review identifies all the research on a given topic using predefined criteria; psychosocial interventions are defined as therapy, education, training, or support aimed at improving behavior, overall development, or specific life skills without the use of drugs.
What Did the Researchers Do and Find?
The researchers identified 29 controlled studies (investigations with an intervention group and a control group) that examined the effects of various psychosocial interventions delivered by non-specialist providers to children (under 18 years old) who had a lower-functioning ASD or intellectual disability. The researchers retrieved information on the participants, design and methods, findings, and intervention characteristics for each study, and calculated effect sizes—a measure of the effectiveness of a test intervention relative to a control intervention—for several outcomes for each intervention. Across the studies, three-quarters of the effect size estimates were positive, and nearly half were greater than 0.50; effect sizes of less than 0.2, 0.2–0.5, and greater than 0.5 indicate that an intervention has no, a small, or a medium-to-large effect, respectively. For behavior analytic interventions (which aim to improve socially significant behavior by systematically analyzing behavior), the largest effect sizes were seen for development and daily skills. Cognitive rehabilitation, training, and support (interventions that facilitates the relearning of lost or altered cognitive skills) produced good improvements in developmental outcomes such as standardized IQ tests in children aged 6–11 years old. Finally, parental training interventions (which teach parents how to provide therapy services for their child) had strong effects on developmental, behavioral, and family outcomes.
What Do These Findings Mean?
Because few of the studies included in this systematic review were undertaken in low- and middle-income countries, the review's findings may not be generalizable to children living in resource-limited settings. Moreover, other characteristics of the included studies may limit the accuracy of these findings. Nevertheless, these findings support the delivery of psychosocial interventions by non-specialist providers to children who have intellectual disabilities or a lower-functioning ASD, and indicate which interventions are likely to produce the largest improvements in developmental, behavioral, and family outcomes. Further studies are needed, particularly in low- and middle-income countries, to confirm these findings, but given that specialists are scarce in many resource-limited settings, these findings may help to inform the implementation of programs to improve outcomes for children with intellectual disabilities or lower-functioning ASDs in low- and middle-income countries.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001572.
This study is further discussed in a PLOS Medicine Perspective by Bello-Mojeed and Bakare
The US Centers for Disease Control and Prevention provides information (in English and Spanish) on developmental disabilities, including autism spectrum disorders and intellectual disability
The US National Institute of Mental Health also provides detailed information about autism spectrum disorders, including the publication “A Parent's Guide to Autism Spectrum Disorder”
Autism Speaks, a US non-profit organization, provides information about all aspects of autism spectrum disorders and includes information on the Autism Speaks Global Autism Public Health Initiative
The National Autistic Society, a UK charity, provides information about all aspects of autism spectrum disorders and includes personal stories about living with these conditions
The UK National Health Service Choices website has an interactive guide to child development and information about autism and Asperger syndrome, including personal stories, and about learning disabilities
The UK National Institute for Health and Care Excellence provides clinical guidelines for the management and support of children with autism spectrum disorders
The World Health Organization provides information on its Mental Health Gap Action Programme (mhGAP), which includes recommendations on the management of developmental disorders by non-specialist providers; the mhGAP Evidence Resource Center provides evidence reviews for parent skills training for management of children with intellectual disabilities and pervasive developmental disorders and interventions for management of children with intellectual disabilities
PROSPERO, an international prospective register of systematic reviews, provides more information about this systematic review
doi:10.1371/journal.pmed.1001572
PMCID: PMC3866092  PMID: 24358029
2.  Helminthiasis and Hygiene Conditions of Schools in Ikenne, Ogun State, Nigeria 
Background
A study of the helminth infection status of primary-school children and the hygiene condition of schools in Ikenne Local Government Area of Ogun State, Nigeria was undertaken between November 2004 and February 2005 to help guide the development of a school-based health programme.
Methods and Findings
Three primary schools were randomly selected: two government-owned schools (one urban and the other rural) and one urban private school. No rural private schools existed to survey. A total of 257 schoolchildren aged 4–15 y, of whom 146 (56.8%) were boys and 111 (43.2%) were girls, took part in the survey. A child survey form, which included columns for name, age, sex, and class level, was used in concert with examination of stool samples for eggs of intestinal helminths. A school survey form was used to assess the conditions of water supply, condition of latrines, presence of soap for handwashing, and presence of garbage around the school compound. The demographic data showed that the number of schoolchildren gradually decreased as their ages increased in all three schools. The sex ratio was proportional in the urban school until primary level 3, after which the number of female pupils gradually decreased, whereas in the private school, sexes were proportionally distributed even in higher classes. The prevalence of helminth infection was 54.9% of schoolchildren in the urban government school, 63.5% in the rural government school, and 28.4% in the urban private school. Ascaris lumbricoides was the most prevalent species, followed by Trichuris trichiura, Taenia species, and hookworm in the three schools. Prevalence of infection in the government-owned schools was significantly higher than in the private school (χ2 = 18.85, df = 2, p<0.0005). A survey of hygiene conditions in the three schools indicated that in the two government schools tapwater was unavailable, sanitation of latrines was poor, handwashing soap was unavailable, and garbage was present around school compounds. In the private school, in contrast, all hygiene indices were satisfactory.
Conclusions
These results indicate that burden of parasite infections and poor sanitary conditions are of greater public health importance in government-owned schools than in privately owned schools. School health programmes in government-owned schools, including deworming, health education, and improvement of hygiene conditions are recommended.
Author Summary
We studied intestinal helminth infection status in primary-school children and the hygiene conditions of primary schools in Ikenne Local Government Area of Ogun State, Nigeria in order to help guide the development of school-based health programmes. Two government-owned schools (one urban and the other rural) plus one privately owned school participated in the study. Demographic data from 257 children showed that the number of schoolchildren gradually decreased as their ages increased in all the three schools. The sex ratio was proportional in the urban school until primary level three, after which the number of female pupils gradually decreased, whereas in the private school, sexes were proportionally distributed even in higher classes. The prevalence of helminth infection in 232 of the children, however, was 54.9%, 63.5%, and 28.4% in the urban government, rural government, and private school, respectively. Ascaris lumbricoides was the most common parasite, followed by Trichuris trichiura, Taenia species, and hookworm in the three schools. Infection in the government-owned schools was significantly higher than in the private school (p<0.0005). The hygiene condition in the three schools indicated that water supply and sanitation were poorer in government schools than in the private school. We therefore propose that school health programmes such as deworming, health education, and improvement of hygiene conditions, be undertaken in government-owned schools.
doi:10.1371/journal.pntd.0000146
PMCID: PMC2270794  PMID: 18357338
3.  Gestational Age at Delivery and Special Educational Need: Retrospective Cohort Study of 407,503 Schoolchildren 
PLoS Medicine  2010;7(6):e1000289.
A retrospective cohort study of 407,503 schoolchildren by Jill Pell and colleagues finds that gestational age at delivery has a dose-dependent relationship with the risk of special educational needs that extends across the full gestational range.
Background
Previous studies have demonstrated an association between preterm delivery and increased risk of special educational need (SEN). The aim of our study was to examine the risk of SEN across the full range of gestation.
Methods and Findings
We conducted a population-based, retrospective study by linking school census data on the 407,503 eligible school-aged children resident in 19 Scottish Local Authority areas (total population 3.8 million) to their routine birth data. SEN was recorded in 17,784 (4.9%) children; 1,565 (8.4%) of those born preterm and 16,219 (4.7%) of those born at term. The risk of SEN increased across the whole range of gestation from 40 to 24 wk: 37–39 wk adjusted odds ratio (OR) 1.16, 95% confidence interval (CI) 1.12–1.20; 33–36 wk adjusted OR 1.53, 95% CI 1.43–1.63; 28–32 wk adjusted OR 2.66, 95% CI 2.38–2.97; 24–27 wk adjusted OR 6.92, 95% CI 5.58–8.58. There was no interaction between elective versus spontaneous delivery. Overall, gestation at delivery accounted for 10% of the adjusted population attributable fraction of SEN. Because of their high frequency, early term deliveries (37–39 wk) accounted for 5.5% of cases of SEN compared with preterm deliveries (<37 wk), which accounted for only 3.6% of cases.
Conclusions
Gestation at delivery had a strong, dose-dependent relationship with SEN that was apparent across the whole range of gestation. Because early term delivery is more common than preterm delivery, the former accounts for a higher percentage of SEN cases. Our findings have important implications for clinical practice in relation to the timing of elective delivery.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Most pregnancies last around 40 weeks, but the number of babies who are born early is increasing. In the US, for example, more than half a million babies a year are now born before 37 weeks of gestation (gestation is the period during which a baby develops in its mother). Sadly, babies born this early (premature babies) are more likely to die than babies delivered between 37 and 42 weeks of gestation (term babies) and many have short- and/or long-term health problems. They are also more likely to have a “special educational need” (SEN) as children, a learning difficulty (for example, dyslexia or autism), or a physical difficulty such as deafness or poor vision that requires special educational help, than term babies. The severity of all the problems associated with being born early depends on the degree of prematurity. Thus, the risk of SEN associated with prematurity declines steadily with advancing gestational age up to 36 weeks. That is, a baby born at 24 weeks of gestation is more likely to have an SEN later in life than one born at 36 weeks of gestation.
Why Was This Study Done?
Early term births (between 37 and 39 weeks of gestation) are also becoming more common, because more mothers are electing to be delivered early for nonmedical reasons (so-called birth scheduling). Unfortunately, it is not known whether early term babies have an increased risk of SEN compared with babies born at 40 weeks, because few studies have looked at SEN in children born between 37 and 39 weeks of gestation. In this retrospective cohort study, the researchers investigate the risk of SEN across the whole spectrum of gestational age at delivery and use their results to calculate the fraction of SEN associated with delivery at different gestational ages—the “population attributable risk.” In a retrospective cohort study, researchers examine the medical records of groups of people who differ in a specific characteristic (in this case, having an SEN) for a particular outcome (in this case, gestational age at birth).
What Did the Researchers Do and Find?
The researchers linked 2005 School Census data (which includes a record of all children with an SEN) for more than 400,000 school-aged children in 19 Scottish Local Authority areas (covering three-quarters of the Scottish population) with routine birth data held in the Scottish Morbidity Record. SEN was recorded for nearly 18,000 children (4.9% of the children). 8.4% of the children who were born preterm and 4.7% of those born at term were recorded as having an SEN. The risk of SEN increased across the gestation range from 40 to 24 weeks. Thus, compared to children born at 40 weeks, children born at 37–39 weeks of gestation were 1.16 times as likely to have an SEN—an odds ratio of 1.16. Children born at 33–36, 28–32, and 24–27 weeks were 1.53, 2.66, and 6.92 times as likely to have an SEN, respectively, as children born at 40 weeks. Although the risk of SEN was much higher in preterm than in early term babies, because many more children were born between 37 and 39 weeks (about a third of babies) than before 37 weeks (one in 20 babies), early term births accounted for 5.5% of cases of SEN, whereas preterm deliveries accounted for only 3.6% of cases.
What Do These Findings Mean?
These findings show that gestational age at delivery strongly affects a child's subsequent risk of having an SEN in a dose-dependent manner across the whole range of gestational age. Furthermore, because early term delivery is much more common than preterm delivery, these findings show that early term delivery is responsible for more cases of SEN than preterm delivery. These findings, which are likely to be accurate because of the large size of the study and its design, have important implications for the timing of elective delivery. They suggest that deliveries should ideally wait until 40 weeks of gestation because even a baby born at 39 weeks—the normal timing for elective deliveries these days—has an increased risk of SEN compared with a baby born a week later.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000289.
The March of Dimes, a nonprofit organization for pregnancy and baby health, provides information on preterm birth and an article on why the last weeks of pregnancy count (in English and Spanish)
The US National Institute of Child Health and Human Development has information on preterm labor and birth and on learning disabilities
The UK Government provides information for parents on special educational needs
Medline Plus has links to further information on both premature birth and learning disabilities (in English and Spanish)
doi:10.1371/journal.pmed.1000289
PMCID: PMC2882432  PMID: 20543995
4.  Mental Health Services Use among School-Aged Children with Disabilities: The Role of Sociodemographics, Functional Limitations, Family Burdens, and Care Coordination 
Health Services Research  2003;38(6 Pt 1):1441-1466.
Objective
To examine the use of mental health services and correlates of receiving services among community-dwelling children with disabilities, ages 6 to 17 years.
Study Design
Data are from the 1994 and 1995 National Health Interview Survey Disability Supplements (NHIS-D), conducted by the National Center for Health Statistics. The study sample is 4,939 children with disabilities, representing an estimated eight million children with disabilities nationwide. Parents of children under 16 years of age reported (17-year-olds self-reported) on health, emotional and behavioral problems, mental health services use, and who, if anyone, coordinated the child's health care.
Principal Findings
Among disabled children with poor psychosocial adjustment (11.5 percent), only 41.8 percent received mental health services in the past year. Multivariate logistic regression analysis showed service use was associated with poor psychosocial adjustment; communication, social, and learning-related functional impairments; public health insurance; and financial family burdens. Younger and black disabled children were less likely to receive mental health services. The odds of service use were greater with the involvement of a health professional in coordinating care, in contrast to no one or family only. Moreover, children with disabilities were more likely to use outpatient mental health services if their care was jointly coordinated by a family member and a health professional, compared to a health professional working alone. In contrast to inpatient and outpatient care, race and family burden were not associated with the likelihood of mental health counseling in special education school settings.
Conclusions
Findings indicate that only two in five disabled children with poor psychosocial adjustment receive mental health services. Differences by age, race, and insurance coverage suggest that inequalities to access exist. However, the school setting may be one in which some barriers to mental health services for disabled children are reduced. The study also shows that the involvement of health professionals in care coordination is associated with greater access to mental health care for disabled children. These findings underscore the importance of engaging both health care professionals and the family in the care process.
doi:10.1111/j.1475-6773.2003.00187.x
PMCID: PMC1360958  PMID: 14727782
Children; disabilities; utilization; mental health services; care coordination; family burden
5.  Hand Sanitiser Provision for Reducing Illness Absences in Primary School Children: A Cluster Randomised Trial 
PLoS Medicine  2014;11(8):e1001700.
In a cluster randomized trial, Patricia Priest and colleagues find that providing hand sanitizer along with hand hygiene education in primary school classrooms, compared with hand hygiene alone, does not reduce school absences.
Please see later in the article for the Editors' Summary
Background
The potential for transmission of infectious diseases offered by the school environment are likely to be an important contributor to the rates of infectious disease experienced by children. This study aimed to test whether the addition of hand sanitiser in primary school classrooms compared with usual hand hygiene would reduce illness absences in primary school children in New Zealand.
Methods and Findings
This parallel-group cluster randomised trial took place in 68 primary schools, where schools were allocated using restricted randomisation (1∶1 ratio) to the intervention or control group. All children (aged 5 to 11 y) in attendance at participating schools received an in-class hand hygiene education session. Schools in the intervention group were provided with alcohol-based hand sanitiser dispensers in classrooms for the winter school terms (27 April to 25 September 2009). Control schools received only the hand hygiene education session. The primary outcome was the number of absence episodes due to any illness among 2,443 follow-up children whose caregivers were telephoned after each absence from school. Secondary outcomes measured among follow-up children were the number of absence episodes due to specific illness (respiratory or gastrointestinal), length of illness and illness absence episodes, and number of episodes where at least one other member of the household became ill subsequently (child or adult). We also examined whether provision of sanitiser was associated with experience of a skin reaction. The number of absences for any reason and the length of the absence episode were measured in all primary school children enrolled at the schools. Children, school administrative staff, and the school liaison research assistants were not blind to group allocation. Outcome assessors of follow-up children were blind to group allocation. Of the 1,301 and 1,142 follow-up children in the hand sanitiser and control groups, respectively, the rate of absence episodes due to illness per 100 child-days was similar (1.21 and 1.16, respectively, incidence rate ratio 1.06, 95% CI 0.94 to 1.18). The provision of an alcohol-based hand sanitiser dispenser in classrooms was not effective in reducing rates of absence episodes due to respiratory or gastrointestinal illness, the length of illness or illness absence episodes, or the rate of subsequent infection for other members of the household in these children. The percentage of children experiencing a skin reaction was similar (10.4% hand sanitiser versus 10.3% control, risk ratio 1.01, 95% CI 0.78 to 1.30). The rate or length of absence episodes for any reason measured for all children also did not differ between groups. Limitations of the study include that the study was conducted during an influenza pandemic, with associated public health messaging about hand hygiene, which may have increased hand hygiene among all children and thereby reduced any additional effectiveness of sanitiser provision. We did not quite achieve the planned sample size of 1,350 follow-up children per group, although we still obtained precise estimates of the intervention effects. Also, it is possible that follow-up children were healthier than non-participating eligible children, with therefore less to gain from improved hand hygiene. However, lack of effectiveness of hand sanitiser provision on the rate of absences among all children suggests that this may not be the explanation.
Conclusions
The provision of hand sanitiser in addition to usual hand hygiene in primary schools in New Zealand did not prevent disease of severity sufficient to cause school absence.
Trial registration
Australian New Zealand Clinical Trials Registry ACTRN12609000478213
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Throughout human history, infectious diseases have been major killers. In the 1300 s, for example, the black death killed a third of the European population. Other diseases such as smallpox and cholera have also devastated human populations. Now, though, a better understanding of the bacteria, viruses, and other microbes that cause infectious diseases and the availability of effective vaccines and antibiotics mean that, for the first time in human history, non-communicable (chronic) diseases such as heart attacks and strokes are killing and disabling more people around the world than infectious diseases. But this does not mean that we can be complacent about infectious diseases. The control of infectious diseases remains important, even in high-income countries, because of the contribution of infectious diseases to ill-health and because we need to manage the risk of epidemics and pandemics (disease outbreaks that affect a large proportion of the population of a country or the world, respectively) of influenza and other diseases.
Why Was This Study Done?
The control of infectious disease transmission in children is a particularly important component of disease control because children tend to have high rates of infectious disease and to have more physical contact with peers and with adults than other age groups, particularly in the school environment. It might be possible, therefore, to reduce the occurrence of many infectious respiratory and gastrointestinal diseases in communities by interrupting the transmission of infectious diseases between children at school, but how can this be achieved? In health care settings, good hand hygiene is a key component of infectious disease control, so, here, the researchers undertake a cluster randomized trial among primary school children in New Zealand to investigate whether the promotion of extra hand cleaning through the provision of alcohol-based hand sanitizer in classrooms can reduce illness absences among school children compared with normal hand hygiene (washing with soap and water, mainly in school bathrooms). A cluster randomized trial compares the outcomes of groups of participants (in this case, schools) chosen randomly to receive different interventions.
What Did the Researchers Do and Find?
The researchers randomly assigned 68 city primary schools to the intervention or control group. All the children (aged 5–11 years) attending the participating schools received a thirty-minute in-class hand hygiene education session. Alcohol-based hand sanitizer dispensers were installed in the classrooms of the intervention schools during the winter term, and the children were asked to use the dispensers after coughing or sneezing and on the way out of the classroom for morning break and lunch. The researchers report that the trial's primary outcome—the rate of absence episodes per 100 child-days due to any illness among “follow-up” children, individuals whose caregivers agreed to be asked about the reason for any absence—was similar in the intervention and control groups. Moreover, among the follow-up children, the provision of hand sanitizer did not reduce the number of absences due to a specific illness (respiratory or gastrointestinal), the length of illness and length of absence from school, or the number of episodes in which at least one other family member became ill. Finally, the number of absences for any reason, and length of absence episodes, in all the children enrolled at the participating schools did not differ between the intervention and control groups.
What Do These Findings Mean?
These findings suggest that the provision of hand sanitizer in addition to usual hand hygiene in primary schools in New Zealand did not prevent any infectious diseases severe enough to warrant school absence. Because the trial was undertaken during an influenza epidemic, influenza-related public health messages about good hand hygiene may have increased hand hygiene among all the children in the study and lessened the intervention's effectiveness. Other study limitations—including that only a third of caregivers agreed to be contacted about their child's absences, and these may have been caregivers who had already taught their children good hand hygiene—may also affect the accuracy of these findings and their generalizability to other high-income countries. However, these findings suggest that, in high-income countries where clean water for hand washing is readily available, putting resources into extra hand hygiene by providing hand sanitizer in classrooms may not be an effective way to break the child-to-child transmission of infectious diseases.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001700.
The US Centers for Disease Control and Prevention has information about hand-washing, when and how to wash your hands and use sanitizer, and hand-washing as a family activity; it also provides information about the importance of hand hygiene in health care settings
Public Health England provides information about hand-washing; its webpage about hand-washing in primary schools contains links to lesson plans about hand-washing for children aged 5–7 years and to e-Bug, a web-based student resource about infectious diseases and their prevention for children aged 7–14 years
Kidshealth, a US-based not-for-profit organization, also provides information about the importance of hand-washing for parents, kids, and teens (in English and Spanish)
doi:10.1371/journal.pmed.1001700
PMCID: PMC4130492  PMID: 25117155
6.  Visual acuity and visual skills in Malaysian children with learning disabilities 
Background:
There is limited data in the literature concerning the visual status and skills in children with learning disabilities, particularly within the Asian population. This study is aimed to determine visual acuity and visual skills in children with learning disabilities in primary schools within the suburban Kota Bharu district in Malaysia.
Methods:
We examined 1010 children with learning disabilities aged between 8–12 years from 40 primary schools in the Kota Bharu district, Malaysia from January 2009 to March 2010. These children were identified based on their performance in a screening test known as the Early Intervention Class for Reading and Writing Screening Test conducted by the Ministry of Education, Malaysia. Complete ocular examinations and visual skills assessment included near point of convergence, amplitude of accommodation, accommodative facility, convergence break and recovery, divergence break and recovery, and developmental eye movement tests for all subjects.
Results:
A total of 4.8% of students had visual acuity worse than 6/12 (20/40), 14.0% had convergence insufficiency, 28.3% displayed poor accommodative amplitude, and 26.0% showed signs of accommodative infacility. A total of 12.1% of the students had poor convergence break, 45.7% displayed poor convergence recovery, 37.4% showed poor divergence break, and 66.3% were noted to have poor divergence recovery. The mean horizontal developmental eye movement was significantly prolonged.
Conclusion:
Although their visual acuity was satisfactory, nearly 30% of the children displayed accommodation problems including convergence insufficiency, poor accommodation, and accommodative infacility. Convergence and divergence recovery are the most affected visual skills in children with learning disabilities in Malaysia.
doi:10.2147/OPTH.S33270
PMCID: PMC3460699  PMID: 23055674
Learning disabilities; Malaysian children; visual acuity; visual skills
7.  Impact of Intermittent Screening and Treatment for Malaria among School Children in Kenya: A Cluster Randomised Trial 
PLoS Medicine  2014;11(1):e1001594.
Katherine Halliday and colleagues conducted a cluster randomized controlled trial in Kenyan school children in an area of low to moderate malaria transmission to investigate the effect of intermittent screening and treatment of malaria on health and education.
Please see later in the article for the Editors' Summary
Background
Improving the health of school-aged children can yield substantial benefits for cognitive development and educational achievement. However, there is limited experimental evidence of the benefits of alternative school-based malaria interventions or how the impacts of interventions vary according to intensity of malaria transmission. We investigated the effect of intermittent screening and treatment (IST) for malaria on the health and education of school children in an area of low to moderate malaria transmission.
Methods and Findings
A cluster randomised trial was implemented with 5,233 children in 101 government primary schools on the south coast of Kenya in 2010–2012. The intervention was delivered to children randomly selected from classes 1 and 5 who were followed up for 24 months. Once a school term, children were screened by public health workers using malaria rapid diagnostic tests (RDTs), and children (with or without malaria symptoms) found to be RDT-positive were treated with a six dose regimen of artemether-lumefantrine (AL). Given the nature of the intervention, the trial was not blinded. The primary outcomes were anaemia and sustained attention. Secondary outcomes were malaria parasitaemia and educational achievement. Data were analysed on an intention-to-treat basis.
During the intervention period, an average of 88.3% children in intervention schools were screened at each round, of whom 17.5% were RDT-positive. 80.3% of children in the control and 80.2% in the intervention group were followed-up at 24 months. No impact of the malaria IST intervention was observed for prevalence of anaemia at either 12 or 24 months (adjusted risk ratio [Adj.RR]: 1.03, 95% CI 0.93–1.13, p = 0.621 and Adj.RR: 1.00, 95% CI 0.90–1.11, p = 0.953) respectively, or on prevalence of P. falciparum infection or scores of classroom attention. No effect of IST was observed on educational achievement in the older class, but an apparent negative effect was seen on spelling scores in the younger class at 9 and 24 months and on arithmetic scores at 24 months.
Conclusion
In this setting in Kenya, IST as implemented in this study is not effective in improving the health or education of school children. Possible reasons for the absence of an impact are the marked geographical heterogeneity in transmission, the rapid rate of reinfection following AL treatment, the variable reliability of RDTs, and the relative contribution of malaria to the aetiology of anaemia in this setting.
Trial registration
www.ClinicalTrials.gov NCT00878007
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, more than 200 million cases of malaria occur worldwide and more than 600,000 people, mostly children living in sub-Saharan Africa, die from this mosquito-borne parasitic infection. Malaria can be prevented by controlling the night-biting mosquitoes that transmit Plasmodium parasites and by sleeping under insecticide-treated nets to avoid mosquito bites. Infection with malaria parasites causes recurring flu-like symptoms and needs to be treated promptly with antimalarial drugs to prevent the development of anaemia (a reduction in red blood cell numbers) and potentially fatal damage to the brain and other organs. Treatment also reduces malaria transmission. In 1998, the World Health Organization and several other international bodies established the Roll Back Malaria Partnership to provide a coordinated global approach to fighting malaria. In 2008, the Partnership launched its Global Malaria Action Plan, which aims to control malaria to reduce the current burden, to eliminate malaria over time country by country, and, ultimately, to eradicate malaria.
Why Was This Study Done?
In recent years, many malaria-endemic countries (countries where malaria is always present) have implemented successful malaria control programs and reduced malaria transmission levels. In these countries, immunity to malaria is now acquired more slowly than in the past, the burden of clinical malaria is shifting from very young children to older children, and infection rates with malaria parasites are now highest among school-aged children. Chronic untreated Plasmodium infection, even when it does not cause symptoms, can negatively affect children's health, cognitive development (the acquisition of thinking skills), and educational achievement. However, little is known about how school-based malaria interventions affect the health of children or their educational outcomes. In this cluster randomized trial, the researchers investigate the effect of intermittent screening and treatment (IST) of malaria on the health and education of school children in a rural area of southern Kenya with low-to-moderate malaria transmission. Cluster randomized trials compare the outcomes of groups (“clusters”) of people randomly assigned to receive alternative interventions. IST of malaria involves periodical screening of individuals for Plasmodium infection followed by treatment of everyone who is infected, including people without symptoms, with antimalarial drugs.
What Did the Researchers Do and Find?
The researchers enrolled more than 5,000 children aged between 5 and 20 years from 101 government primary schools in Kenya into their 24-month study. Half the schools were randomly selected to receive the IST intervention (screening once a school term for infection with a malaria parasite with a rapid diagnostic test [RDT] and treatment of all RDT-positive children, with or without malaria symptoms, with six doses of artemether-lumefantrine), which was delivered to randomly selected children from classes 1 and 5 (which contained younger and older children, respectively). During the study, 17.5% of the children in the intervention schools were RDT-positive at screening on average. The prevalences of anaemia and parasitemia (the proportion of children with anaemia and the proportion who were RDT-positive, respectively) were similar in the intervention and control groups at the 12-month and 24-month follow-up and there was no difference between the two groups in classroom attention scores at the 9-month and 24-month follow-up. The IST intervention also had no effect on educational achievement in the older class but, unexpectedly, appeared to have a negative effect on spelling and arithmetic scores in the younger class.
What Do These Findings Mean?
These findings indicate that, in this setting in Kenya, IST as implemented in this study provided no health or education benefits to school children. The finding that the educational achievement of younger children was lower in the intervention group than in the control group may be a chance finding or may indicate that apprehension about the finger prick needed to take blood for the RDT had a negative effect on the performance of younger children during educational tests. The researchers suggest that their failure to demonstrate that the school-based IST intervention they tested had any long-lasting health or education benefits may be because, in a low-to-moderate malaria transmission setting, most of the children screened did not require treatment and those who did lived in focal high transmission regions, where rapid re-infection occurred between screening rounds. Importantly, however, these findings suggest that school screening using RDT could be an efficient way to identify transmission hotspots in communities that should be targeted for malaria control interventions.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001594.
This study is further discussed in a PLOS Medicine Perspective by Lorenz von Seidlein
Information is available fro m the World Health Organization on malaria (in several languages); the 2012 World Malaria Report provides details of the current global malaria situation
The US Centers for Disease Control and Prevention provide information on malaria (in English and Spanish), including a selection of personal stories about children with malaria
Information is available from the Roll Back Malaria Partnership on the global control of malaria and on the Global Malaria Action Plan (in English and French); its website includes a fact sheet about malaria in Kenya
MedlinePlus provides links to additional information on malaria (in English and Spanish)
More information about this trial is available
More information about malaria control in schools is provided in the toolkit
doi:10.1371/journal.pmed.1001594
PMCID: PMC3904819  PMID: 24492859
8.  Effectiveness of a Pre-treatment Snack on the Uptake of Mass Treatment for Schistosomiasis in Uganda: A Cluster Randomized Trial 
PLoS Medicine  2014;11(5):e1001640.
In a cluster randomized trial, Simon Muhumuza and colleagues examine the effectiveness of a pre-treament snack given to school-aged children on the uptake of mass treatment for schistosomiasis in Uganda.
Please see later in the article for the Editors' Summary
Background
School-based mass treatment with praziquantel is the cornerstone for schistosomiasis control in school-aged children. However, uptake of treatment among school-age children in Uganda is low in some areas. The objective of the study was to examine the effectiveness of a pre-treatment snack on uptake of mass treatment.
Methods and Findings
In a cluster randomized trial carried out in Jinja district, Uganda, 12 primary schools were randomized into two groups; one received education messages for schistosomiasis prevention for two months prior to mass treatment, while the other, in addition to the education messages, received a pre-treatment snack shortly before mass treatment. Four weeks after mass treatment, uptake of praziquantel was assessed among a random sample of 595 children in the snack schools and 689 children in the non-snack schools as the primary outcome. The occurrence of side effects and the prevalence and mean intensity of Schistosoma mansoni infection were determined as the secondary outcomes. Uptake of praziquantel was higher in the snack schools, 93.9% (95% CI 91.7%–95.7%), compared to that in the non-snack schools, 78.7% (95% CI 75.4%–81.7%) (p = 0.002). The occurrence of side effects was lower in the snack schools, 34.4% (95% CI 31.5%–39.8%), compared to that in the non-snack schools, 46.9% (95% CI 42.2%–50.7%) (p = 0.041). Prevalence and mean intensity of S. mansoni infection was lower in the snack schools, 1.3% (95% CI 0.6%–2.6%) and 38.3 eggs per gram of stool (epg) (95% CI 21.8–67.2), compared to that in the non-snack schools, 14.1% (95% CI 11.6%–16.9%) (p = 0.001) and 78.4 epg (95% CI 60.6–101.5) (p = 0.001), respectively.
Conclusions
Our results suggest that provision of a pre-treatment snack combined with education messages achieves a higher uptake compared to the education messages alone. The use a pre-treatment snack was associated with reduced side effects as well as decreased prevalence and intensity of S. mansoni infection.
Trial registration
www.ClinicalTrials.gov NCT01869465
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Globally, more than 240 million people are infected with schistosomes, a parasitic worm found in tropical and sub-tropical fresh water. Schistosomes reproduce in snails, which release free-swimming infectious parasites that burrow into the skin of people when they wash or swim in contaminated water. Once inside a person, the parasites turn into larvae and migrate to the liver, where they become juvenile worms. These mature into 10–20 mm long adult worms and take up residence in the veins draining the gut or bladder where they mate and release eggs, some of which pass into the feces and go back into water where they hatch and infect fresh snails. Most people have no symptoms when they are first infected with schistosomes but some develop a rash or itchy skin. Later symptoms include fever, chills, cough, and muscle aches. Without treatment, schistosomiasis can persist for years, eventually causing liver, gut, bladder, and spleen damage. In Africa alone, schistosomiasis kills about 280,000 people annually.
Why Was This Study Done?
Strategies for the control of schistosomiasis include the provision of clean water and adequate sanitation, and education. However, the cornerstone of control is the reduction of disease through periodic, targeted treatment with the anti-schistosomal drug praziquantel. One group that is targeted for treatment in countries affected by schistosomiasis is school-aged children. For this approach to be successful, experts recommend regular treatment of at least 75% of school-age children at risk of infection. Unfortunately, the uptake of the intervention is often low, partly because children fear praziquantel's side effects, which include diarrhea, and vomiting. The risk of developing side effects can be reduced by eating food just before taking the drug. In this cluster randomized trial (a study that compares outcomes in groups of people randomly assigned to receive different treatments), the researchers investigate whether the provision of a pre-treatment snack improves the uptake of praziquantel among school children in Jinja district of Uganda, a country that has adopted school-based mass drug administration as part of its national schistosomiasis control program. The researchers also investigated whether this intervention reduces the occurrence of side effects attributable to praziquantel, the prevalence of schistosomiasis (the proportion of the population that is infected), and the infection intensity (indicated by the density of eggs in stool).
What Did the Researchers Do and Find?
The researchers randomly assigned 12 primary schools to receive education messages for 2 months before mass treatment with praziquantel or the same education messages plus a mango juice and donut snack just before treatment. The education messages included information about the dangers of schistosome infection, the importance of preventative treatment with praziquantel, and information about taking the drug with food to avoid side effects. Four weeks after mass treatment, praziquantel uptake was assessed by self report in 595 children chosen randomly from the snack schools and 689 children from the no-snack schools. Uptake of praziquantel in the snack and no-snack schools was 93.9% and 78.7%, respectively, a significant difference in outcomes that is unlikely to be a chance event. The occurrence of self-reported side effects, the prevalence of schistosome infection, and the average intensity of infection were all significantly lower in the snack schools than in the no-snack schools.
What Do These Findings Mean?
These findings suggest that the provision of a pre-treatment snack combined with education messages improved uptake of mass treatment for schistosomiasis among school children in Uganda compared to education messages alone. The intervention also reduced the occurrence of side effects, the prevalence of infection, and the infection intensity. Because uptake and the occurrence of side effects were determined by self-report, some children may have provided socially desirable answers. That is, they may have said they took the drug when they didn't because they knew that is what the researchers wanted to hear. However, the infection prevalence and intensity findings validate the self-reported uptake. The researchers conclude that the provision of a snack to mitigate the side effects of praziquantel could have motivated the children to take the treatment. If future trials show that the intervention is cost-effective, the researchers suggest that the provision of pre-treatment food should be integrated into school-based mass treatment programs for schistosomiasis control at the national level in Uganda and in similar settings elsewhere in sub-Saharan Africa.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001640.
The World Health Organization provides detailed information about schistosomiasis (in several languages)
The US Centers for Disease Control and Prevention provides information for the public and for health professionals about all aspects of schistosomiasis (in English and Spanish)
The UK National Health Service Choices website also provides information about schistosomiasis
More information about the Evaluation of Strategies for Improved Uptake of Preventive Treatment for Intestinal Schistosomiasis trial is available
The End Fund, a US not-for-profit organization that aims to tackle schistosomiasis and other neglected tropical diseases, has a personal story about dealing with schistosomiasis
doi:10.1371/journal.pmed.1001640
PMCID: PMC4019501  PMID: 24824051
9.  Disability Transitions and Health Expectancies among Adults 45 Years and Older in Malawi: A Cohort-Based Model 
PLoS Medicine  2013;10(5):e1001435.
Collin Payne and colleagues investigated development of disabilities and years expected to live with disabilities in participants 45 years and older participating in the Malawi Longitudinal Survey of Families and Health.
Please see later in the article for the Editors' Summary
Background
Falling fertility and increasing life expectancy contribute to a growing elderly population in sub-Saharan Africa (SSA); by 2060, persons aged 45 y and older are projected to be 25% of SSA's population, up from 10% in 2010. Aging in SSA is associated with unique challenges because of poverty and inadequate social supports. However, despite its importance for understanding the consequences of population aging, the evidence about the prevalence of disabilities and functional limitations due to poor physical health among older adults in SSA continues to be very limited.
Methods and Findings
Participants came from 2006, 2008, and 2010 waves of the Malawi Longitudinal Survey of Families and Health, a study of the rural population in Malawi. We investigate how poor physical health results in functional limitations that limit the day-to-day activities of individuals in domains relevant to this subsistence-agriculture context. These disabilities were parameterized based on questions from the SF-12 questionnaire about limitations in daily living activities. We estimated age-specific patterns of functional limitations and the transitions over time between different disability states using a discrete-time hazard model. The estimated transition rates were then used to calculate the first (to our knowledge) microdata-based health expectancies calculated for SSA. The risks of experiencing functional limitations due to poor physical health are high in this population, and the onset of disabilities happens early in life. Our analyses show that 45-y-old women can expect to spend 58% (95% CI, 55%–64%) of their remaining 28 y of life (95% CI, 25.7–33.5) with functional limitations; 45-y-old men can expect to live 41% (95% CI, 35%–46%) of their remaining 25.4 y (95% CI, 23.3–28.8) with such limitations. Disabilities related to functional limitations are shown to have a substantial negative effect on individuals' labor activities, and are negatively related to subjective well-being.
Conclusions
Individuals in this population experience a lengthy struggle with disabling conditions in adulthood, with high probabilities of remitting and relapsing between states of functional limitation. Given the strong association of disabilities with work efforts and subjective well-being, this research suggests that current national health policies and international donor-funded health programs in SSA inadequately target the physical health of mature and older adults.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
The population of the world is getting older. In almost every country, the over-60 age group is growing faster than any other age group. In 2000, globally, there were about 605 million people aged 60 years or more; by 2050, 2 billion people will be in this age group. Much of this increase in the elderly population will be in low-income countries. In sub-Saharan Africa, for example, 10% of the population is currently aged 45 years or more, but by 2060, a quarter of the population will be so-called mature adults. In all countries, population aging is the result of women having fewer children (falling fertility) and people living longer (increasing life expectancy). Thus, population aging is a demographic transition, a change in birth and death rates. In low- and middle-income countries, population aging is occurring in parallel with an “epidemiological transition,” a shift from communicable (infectious) diseases to non-communicable diseases (for example, heart disease) as the primary causes of illness and death.
Why Was This Study Done?
Both the demographic and the epidemiological transition have public health implications for low-income countries. Good health is important for the independence and economic productivity of older people. Productive older people can help younger populations financially and physically, and help compensate for the limitations experienced by younger populations infected with HIV. Also, low-income countries lack social safety nets, so disabled older adults can be a burden on younger populations. Thus, the health of older individuals is important to the well-being of people of all ages. As populations age, low-income countries will need to invest in health care for mature and elderly adults and in disease prevention programs to prevent or delay the onset of non-communicable diseases, which can limit normal daily activities by causing disabilities. Before providing these services, national policy makers need to know the proportion of their population with disabilities, the functional limitations caused by poor physical health, and the health expectancies (the number of years a person can expect to be in good health) of older people in their country. In this cohort modeling study, the researchers estimate health expectancies and transition rates between different levels of disability among mature adults in Malawi, one of the world's poorest countries, using data collected by the Malawi Longitudinal Survey of Families and Health (MLSFH) on economic, social, and health conditions in a rural population. Because Malawi has shorter life expectancies and earlier onset of disability than wealthier countries, the authors considered individuals aged 45 and older as mature adults at risk for disability.
What Did the Researchers Do and Find?
The researchers categorized the participants in the 2006, 2008, and 2010 waves of the MLSFH into three levels of functional limitation (healthy, moderately limited, and severely limited) based on answers to questions in the SF-12 health survey questionnaire that ask about disabilities that limit daily activities that rural Malawians perform. The researchers estimated age–gender patterns of functional limitations and transition rates between different disability states using a discrete-time hazard model, and health expectancies by running a microsimulation to model the aging of synthetic cohorts with various starting ages but the same gender and functional limitation distributions as the study population. These analyses show that the chance of becoming physically disabled rises sharply with age, with 45-year-old women in rural Malawi expected to spend 58% of their estimated remaining 28 years with functional limitations, and 45-year-old men expected to live 41% of their remaining 25.4 years with functional limitations. Also, on average, a 45-year-old woman will spend 2.7 years with moderate functional limitation and 0.6 years with severe functional limitation before she reaches 55; for men the corresponding values are 1.6 and 0.4 years. Around 50% of moderately and 60%–80% of severely limited individuals stated that pain interfered quite a bit or extremely with their normal work during the past four weeks, suggesting that pain treatment may help reduce disability.
What Do These Findings Mean?
These findings suggest that mature adults in rural Malawi will have some degree of disability during much of their remaining lifetime. The risks of experiencing functional limitations are higher and the onset of persistent disabilities happens earlier in Malawi than in more developed contexts—the proportions of remaining life spent with severe limitations at age 45 in Malawi are comparable to those of 80-year-olds in the US. The accuracy of these findings is likely to be affected by assumptions made during modeling and by the quality of the data fed into the models. Nevertheless, these findings suggest that functional limitations, which have a negative effect on the labor activity of individuals, will become more prominent in Malawi (and probably other sub-Saharan countries) as the age composition of populations shifts over the coming years. Older populations in sub-Saharan Africa are not targeted well by health policies and programs at present. Consequently, these findings suggest that policy makers will need to ensure that additional financial resources are provided to improve health-care provision for aging individuals and to lessen the high rates of functional limitation and associated disabilities.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001435.
This study is further discussed in a PLoS Medicine Perspective by Andreas Stuck, et al.
The World Health Organization provides information on many aspects of aging (in several languages); the WHO Study on Global Ageing and Adult Health (SAGE) is compiling longitudinal information on the health and well-being of adult populations and the aging process
The United Nations Population Fund and HelpAge International publication Ageing in the Twenty-First Century is available
HelpAge International is an international nongovernmental organization that helps older people claim their rights, challenge discrimination, and overcome poverty, so that they can lead dignified, secure, and healthy lives
More information on the Malawi Longitudinal Study of Families and Health is available
doi:10.1371/journal.pmed.1001435
PMCID: PMC3646719  PMID: 23667343
10.  Do extra compulsory physical education lessons mean more physically active children - findings from the childhood health, activity, and motor performance school study Denmark (The CHAMPS-study DK) 
Background
Primarily, this study aims to examine whether children attending sports schools are more active than their counterpart attending normal schools. Secondary, the study aims to examine if physical activity (PA) levels in specific domains differ across school types. Finally, potential modifications by status of overweight/obesity and poor cardio-respiratory fitness are examined.
Methods
Participants were from the first part of the CHAMPS-study DK, which included approximately 1200 children attending the 0th – 6th grade. At the sports schools, the mandatory physical education (PE) program was increased from 2 to 6 weekly lessons over a 3-year period. Children attending normal schools were offered the standard 2 PE lessons. PA was assessed at two different occasions with the GT3X ActiGraph accelerometer, once during winter in 2009/10 and once during summer/fall in 2010. Leisure time organized sports participation was quantified by SMS track. Based on baseline values in 2008, we generated a high-BMI and a low-cardio-respiratory fitness for age and sex group variable.
Results
There were no significant differences in PA levels during total time, PE, or recess between children attending sports schools and normal schools, respectively. However, children, especially boys, attending sports schools were more active during school time than children attending normal schools (girls: β=51, p=0.065; boys: β=113, p<0.001). However, in the leisure time during weekdays children who attended sports schools were less active (girls: β=-41, p=0.004; boys: β=-72, p<0.001) and less involved in leisure time organized sports participation (girls: β=-0.4, p=0.016; boys: β=-0.2, p=0.236) than children who attended normal schools. Examination of modification by baseline status of overweight/obesity and low cardio-respiratory fitness indicated that during PE low fit girls in particular were more active at sports schools.
Conclusion
No differences were revealed in overall PA levels between children attending sports schools and normal schools. Sports schools children were more active than normal schools children during school time, but less active during leisure time. In girls, less organized sports participation at least partly explained the observed differences in PA levels during leisure time across school types. Baseline status of cardio-respiratory fitness modified school type differences in PA levels during PE in girls.
Electronic supplementary material
The online version of this article (doi:10.1186/s12966-014-0121-0) contains supplementary material, which is available to authorized users.
doi:10.1186/s12966-014-0121-0
PMCID: PMC4180151  PMID: 25248973
Physical activity; Physical education; School-based; Organized sports; Children; Objective monitoring; Accelerometry; CHAMPS-study DK
11.  School Playground Surfacing and Arm Fractures in Children: A Cluster Randomized Trial Comparing Sand to Wood Chip Surfaces 
PLoS Medicine  2009;6(12):e1000195.
In a randomized trial of elementary schools in Toronto, Andrew Howard and colleagues show that granitic sand playground surfaces reduce the risk of arm fractures from playground falls when compared with wood fiber surfaces.
Background
The risk of playground injuries, especially fractures, is prevalent in children, and can result in emergency room treatment and hospital admissions. Fall height and surface area are major determinants of playground fall injury risk. The primary objective was to determine if there was a difference in playground upper extremity fracture rates in school playgrounds with wood fibre surfacing versus granite sand surfacing. Secondary objectives were to determine if there were differences in overall playground injury rates or in head injury rates in school playgrounds with wood fibre surfacing compared to school playgrounds with granite sand surfacing.
Methods and Findings
The cluster randomized trial comprised 37 elementary schools in the Toronto District School Board in Toronto, Canada with a total of 15,074 students. Each school received qualified funding for installation of new playground equipment and surfacing. The risk of arm fracture from playground falls onto granitic sand versus onto engineered wood fibre surfaces was compared, with an outcome measure of estimated arm fracture rate per 100,000 student-months. Schools were randomly assigned by computer generated list to receive either a granitic sand or an engineered wood fibre playground surface (Fibar), and were not blinded. Schools were visited to ascertain details of the playground and surface actually installed and to observe the exposure to play and to periodically monitor the depth of the surfacing material. Injury data, including details of circumstance and diagnosis, were collected at each school by a prospective surveillance system with confirmation of injury details through a validated telephone interview with parents and also through collection (with consent) of medical reports regarding treated injuries. All schools were recruited together at the beginning of the trial, which is now closed after 2.5 years of injury data collection. Compliant schools included 12 schools randomized to Fibar that installed Fibar and seven schools randomized to sand that installed sand. Noncompliant schools were added to the analysis to complete a cohort type analysis by treatment received (two schools that were randomized to Fibar but installed sand and seven schools that were randomized to sand but installed Fibar). Among compliant schools, an arm fracture rate of 1.9 (95% confidence interval [CI] 0.04–6.9) per 100,000 student-months was observed for falls into sand, compared with an arm fracture rate of 9.4 (95% CI 3.7–21.4) for falls onto Fibar surfaces (p≤0.04905). Among all schools, the arm fracture rate was 4.5 (95% CI 0.26–15.9) per 100,000 student-months for falls into sand compared with 12.9 (95% CI 5.1–30.1) for falls onto Fibar surfaces. No serious head injuries and no fatalities were observed in either group.
Conclusions
Granitic sand playground surfaces reduce the risk of arm fractures from playground falls when compared with engineered wood fibre surfaces. Upgrading playground surfacing standards to reflect this information will prevent arm fractures.
Trial Registration
Current Controlled Trials ISRCTN02647424
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Playgrounds and outdoor play equipment provide children with a place to let steam off, play creatively, socialize, and learn new skills. And, in a world where childhood obesity is a burgeoning problem, playgrounds provide a place where children can be encouraged to exercise. But playgrounds are not without hazards. Even in well-maintained and well-run facilities, children can hurt themselves by falling off climbing frames, monkey bars, and other equipment or by falling from standing height during playground games such as tag. In the US alone, more than 200,000 children are treated in emergency departments for injuries sustained in playgrounds every year and about 6,400 children are admitted to hospitals because of playground injuries, most of which are bone fractures (broken bones). In fact, playground injuries in the US are more severe and have a higher hospital admission rate than any other sort of child injury except those involving vehicles.
Why Was This Study Done?
Children who fall off playground equipment are nearly four times as likely to break a bone (often in an arm) as children who fall from standing height. To reduce the number of fractures that occur in playgrounds, some governments have limited the height of playground equipment. Some have also set standards for the type of surfaces installed in playgrounds and for the depth of sand or engineered wood fiber in loose fill surfaces. These standards are based on laboratory tests in which headforms (artificial heads) are dropped onto surfaces. However, these tests provide no information about the ability of different surfaces to prevent broken arms and other specific injuries in the real world. In this cluster randomized trial (a study in which groups of people are randomly assigned to receive different interventions), the researchers compare the rates of arm fractures in elementary (primary) school playgrounds in Toronto (Canada) that have wood fiber surfacing with the rates in playgrounds that have granite sand surfacing.
What Did the Researchers Do and Find?
The researchers randomly assigned 37 elementary schools that had qualified for school board funding for replacement playground equipment to receive either wood fiber (19 schools) or granite sand surfacing (18 schools) in their playgrounds. 19 of the schools complied with their randomization (12 installed fiber and seven installed sand); two schools installed sand although they were randomized to install fiber and seven schools installed fiber instead of sand. The researchers evaluated the playgrounds and their surfaces several times during the 2.5-year study and collected data on how playground injuries happened and types of injuries from the schools, parents, and medical reports. Among the schools that complied with randomization, falls from height into sand resulted in 1.9 arm fractures per 100,000 student-months whereas falls into fiber resulted in 9.4 arm fractures per 100,000 student-months. Arm fracture rates and other injury rates were also higher for falls from height into fiber than into sand when all the schools that had installed new surfaces were considered. However, the rates of arm fracture and other injuries that did not involve a fall from height did not vary between surfaces.
What Do These Findings Mean?
The accuracy of these findings is limited by the small number of arm fractures that occurred during the trial—only 20 children who fell into fiber and two who fell into sand broke an arm. The accuracy of the findings may also be limited by the failure of many schools to comply with randomization although the researchers found no obvious differences between the schools that did and did not comply with randomization that might have affected the trial's outcome. However, even with these limitations, the findings of this real-world study indicate that granitic sand surfaces substantially reduce the risk of arm fractures and other injuries caused by falls from playground equipment when compared with wood fiber surfaces. Thus, because falls from playground equipment are more likely to cause a fracture than falls from standing height, if playground surfacing standards are adjusted to reflect the findings of this study (that is, if sand surfaces are recommended in preference to wood fiber surfaces), many arm fractures in children should be prevented.
Additional Information
Please access these Web sites via the online version of this summary at ttp://dx.doi.org/10.1371/journal.pmed.1000195.
Safe Kids Canada provides information about playground safety and other aspects of childhood safety (in English and French)
Safe Kids Worldwide is a global network of organizations whose mission is to prevent accidental childhood injury (in English and Spanish)
The Nemours Foundation, a nonprofit organization for child health, provides information for parents on playground safety
The Royal Society for the Prevention of Accidents provides information on the safety of indoor and outdoor play areas
The US Centers for Disease Control and Prevention provides fact sheets on playground injuries
The US Consumer Product Safety Commission also has information on playground safety, including resources designed for children such as The Further Adventures of Kidd Safety and Little Big Kids, a booklet on play safety written by children for children
doi:10.1371/journal.pmed.1000195
PMCID: PMC2784292  PMID: 20016688
12.  HIV and Childhood Disability: A Case-Controlled Study at a Paediatric Antiretroviral Therapy Centre in Lilongwe, Malawi 
PLoS ONE  2013;8(12):e84024.
Background
As paediatric antiretroviral therapy (ART) is rapidly scaled up in Southern Africa, Human Immunodeficiency Virus (HIV) infection is becoming a chronic illness. Children growing up with HIV may begin to encounter disabilities. The relationship between HIV, disability and the need for rehabilitation has added an additional element that needs to be addressed by paediatric HIV treatment programmes.
Study Objectives
1) Estimate the prevalence of disabilities in HIV-infected and HIV-uninfected children in Lilongwe, Malawi. 2) Examine types of disability and associated clinical and socio-demographic factors. 3) Identify needs, opportunities and barriers for rehabilitation in Malawi.
Methods
A case-controlled study of 296 HIV-infected children aged 2–9 years attending an ART centre in Lilongwe (cases) and their uninfected siblings (controls) was conducted. Disability was assessed using the WHO Ten Question Screen (TQS). Socio-demographic and clinical data were collected using a parent-proxy questionnaire and medical records.
Results
Of 296 case and control pairs recruited, 33% (98) versus 7% (20) screened positive for a disability (OR 8.4, 4.4–15.7) respectively. Of these 98 HIV-infected cases, 6%, 36%, 33%, 53%, 46% and 6% had a vision, hearing; physical, learning/comprehension, speech or seizure-related disability respectively and 51% had multiple coexisting disabilities. HIV-infected cases with a disability were more likely to be WHO stage III or IV at enrolment (71% vs. 52%, OR 2.7, 1.5–4.2), to have had TB (58% vs. 39%, OR 2.3, 1.4–3.8) and to have below-average school grades (18% vs. 2%, OR 11.1, 2.2–54.6) than those without. Sixty-seven percent of cases with a disability had never attended any rehabilitative service. Twenty-nine percent of caregivers reported facing stigma and discrimination because of the child’s disability.
Conclusion
This study reveals the magnitude of disability among HIV-infected children and the large unmet need for rehabilitation services. This expanding issue demands further investigation to provide an evidence base for holistic care for disabled children living with HIV.
doi:10.1371/journal.pone.0084024
PMCID: PMC3877142  PMID: 24391869
13.  Oral health and the impact of socio-behavioural factors in a cross sectional survey of 12-year old school children in Laos 
BMC Oral Health  2009;9:29.
Background
In recent decades low-income countries experienced an increasing trend in dental caries among children, particularly recorded in 12-year olds, which is the principal WHO indicator age group for children. This increases the risks of negative affects on children's life. Some data exist on the oral health status of children in low-income countries of Southeast Asia. However, information on how oral health is associated with socio-behavioural factors is almost not available. The aims of this study were to: assess the level of oral health of Lao 12-year-olds in urban and semi-urban settings; study the impact of poor oral health on quality of life; analyse the association between oral health and socio-behavioural factors; investigate the relation between obesity and oral health.
Methods
A cross sectional study of 12-year old schoolchildren chosen by multistage random sampling in Vientiane, Lao P.D.R (hereafter Laos). The final study population comprised 621 children. The study consisted of: clinical registration of caries and periodontal status, and scores for dental trauma according to WHO; structured questionnaire; measurement of anthropometric data. Frequency distributions for bi-variate analysis and logistic regression for multivariate analysis were used for assessment of statistical association between variables.
Results
Mean DMFT was 1.8 (SEM = 0.09) while caries prevalence was 56% (CI95 = 52-60). Prevalence of gingival bleeding was 99% (CI95 = 98-100) with 47% (CI95 = 45-49) of present teeth affected. Trauma was observed in 7% (CI95 = 5-9) of the children. High decay was seen in children with dental visits and frequent consumption of sweet drinks. Missed school classes, tooth ache and several impairments of daily life activities were associated with a high dD-component. No associations were found between Body Mass Index (BMI) and oral health or common risk factors. The multivariate analyses revealed high risk for caries for children with low or moderate attitude towards health, a history of dental visits and a preference for drinking sugary drinks during school hours. Low risk was found for children with good or average perception of own oral health. High risk for gingival bleeding was seen in semi-urban children and boys.
Conclusion
Although the caries level is low it causes considerable negative impact on daily life. School based health promotion should be implemented focussing on skills based learning and attitudes towards health.
doi:10.1186/1472-6831-9-29
PMCID: PMC2781791  PMID: 19917089
14.  Increased Cerebral Blood Flow Velocity in Children with Mild Sleep-Disordered Breathing 
Pediatrics  2006;118(4):e1100-e1108.
Objective
Sleep-disordered breathing describes a spectrum of upper airway obstruction in sleep from simple primary snoring, estimated to affect 10% of preschool children, to the syndrome of obstructive sleep apnea. Emerging evidence has challenged previous assumptions that primary snoring is benign. A recent report identified reduced attention and higher levels of social problems and anxiety/depressive symptoms in snoring children compared with controls. Uncertainty persists regarding clinical thresholds for medical or surgical intervention in sleep-disordered breathing, underlining the need to better understand the pathophysiology of this condition. Adults with sleep-disordered breathing have an increased risk of cerebrovascular disease independent of atherosclerotic risk factors. There has been little focus on cerebrovascular function in children with sleep-disordered breathing, although this would seem an important line of investigation, because studies have identified abnormalities of the systemic vasculature. Raised cerebral blood flow velocities on transcranial Doppler, compatible with raised blood flow and/or vascular narrowing, are associated with neuropsychological deficits in children with sickle cell disease, a condition in which sleep-disordered breathing is common. We hypothesized that there would be cerebral blood flow velocity differences in sleep-disordered breathing children without sickle cell disease that might contribute to the association with neuropsychological deficits.
Design
Thirty-one snoring children aged 3 to 7 years were recruited from adenotonsillectomy waiting lists, and 17 control children were identified through a local Sunday school or as siblings of cases. Children with craniofacial abnormalities, neuromuscular disorders, moderate or severe learning disabilities, chronic respiratory/cardiac conditions, or allergic rhinitis were excluded. Severity of sleep-disordered breathing in snoring children was categorized by attended polysomnography. Weight, height, and head circumference were measured in all of the children. BMI and occipitofrontal circumference z scores were computed. Resting systolic and diastolic blood pressure were obtained. Both sleep-disordered breathing children and the age- and BMI-similar controls were assessed using the Behavior Rating Inventory of Executive Function (BRIEF), Neuropsychological Test Battery for Children (NEPSY) visual attention and visuomotor integration, and IQ assessment (Wechsler Preschool and Primary Scale of Intelligence Version III). Transcranial Doppler was performed using a TL2-64b 2-MHz pulsed Doppler device between 2 PM and 7 PM in all of the patients and the majority of controls while awake. Time-averaged mean of the maximal cerebral blood flow velocities was measured in the left and right middle cerebral artery and the higher used for analysis.
Results
Twenty-one snoring children had an apnea/hypopnea index <5, consistent with mild sleep-disordered breathing below the conventional threshold for surgical intervention. Compared with 17 nonsnoring controls, these children had significantly raised middle cerebral artery blood flow velocities. There was no correlation between cerebral blood flow velocities and BMI or systolic or diastolic blood pressure indices. Exploratory analyses did not reveal any significant associations with apnea/hypopnea index, apnea index, hypopnea index, mean pulse oxygen saturation, lowest pulse oxygen saturation, accumulated time at pulse oxygen saturation <90%, or respiratory arousals when examined in separate bivariate correlations or in aggregate when entered simultaneously. Similarly, there was no significant association between cerebral blood flow velocities and parental estimation of child’s exposure to sleep-disordered breathing. However, it is important to note that whereas the sleep-disordered breathing group did not exhibit significant hypoxia at the time of study, it was unclear to what extent this may have been a feature of their sleep-disordered breathing in the past. IQ measures were in the average range and comparable between groups. Measures of processing speed and visual attention were significantly lower in sleep-disordered breathing children compared with controls, although within the average range. There were similar group differences in parental-reported executive function behavior. Although there were no direct correlations, adjusting for cerebral blood flow velocities eliminated significant group differences between processing speed and visual attention and decreased the significance of differences in Behavior Rating Inventory of Executive Function scores, suggesting that cerebral hemodynamic factors contribute to the relationship between mild sleep-disordered breathing and these outcome measures.
Conclusions
Cerebral blood flow velocities measured by noninvasive transcranial Doppler provide evidence for increased cerebral blood flow and/or vascular narrowing in childhood sleep-disordered breathing; the relationship with neuropsychological deficits requires further exploration. A number of physiologic changes might alter cerebral blood flow and/or vessel diameter and, therefore, affect cerebral blood flow velocities. We were able to explore potential confounding influences of obesity and hypertension, neither of which explained our findings. Second, although cerebral blood flow velocities increase with increasing partial pressure of carbon dioxide and hypoxia, it is unlikely that the observed differences could be accounted for by arterial blood gas tensions, because all of the children in the study were healthy, with no cardiorespiratory disease, other than sleep-disordered breathing in the snoring group. Although arterial partial pressure of oxygen and partial pressure of carbon dioxide were not monitored during cerebral blood flow velocity measurement, assessment was undertaken during the afternoon/early evening when the child was awake, and all of the sleep-disordered breathing children had normal resting oxyhemoglobin saturation at the outset of their subsequent sleep studies that day. Finally, there is an inverse linear relationship between cerebral blood flow and hematocrit in adults, and it is known that iron-deficient erythropoiesis is associated with chronic infection, such as recurrent tonsillitis, a clinical feature of many of the snoring children in the study. Preoperative full blood counts were not performed routinely in these children, and, therefore, it was not possible to exclude anemia as a cause of increased cerebral blood flow velocity in the sleep-disordered breathing group. However, hemoglobin levels were obtained in 4 children, 2 of whom had borderline low levels (10.9 and 10.2 g/dL). Although there was no apparent relationship with cerebral blood flow velocity in these children (cerebral blood flow velocity values of 131 and 130 cm/second compared with 130 and 137 cm/second in the 2 children with normal hemoglobin levels), this requires verification. It is of particular interest that our data suggest a relationship among snoring, increased cerebral blood flow velocities and indices of cognition (processing speed and visual attention) and perhaps behavioral (Behavior Rating Inventory of Executive Function) function. This finding is preliminary: a causal relationship is not established, and the physiologic mechanisms underlying such a relationship are not clear. Prospective studies that quantify cumulative exposure to the physiologic consequences of sleep-disordered breathing, such as hypoxia, would be informative.
doi:10.1542/peds.2006-0092
PMCID: PMC1995426  PMID: 17015501
sleep disordered breathing; cerebral blood flow; transcranial Doppler; executive function; neuropsychological function
15.  Unidentified Chronic Fatigue Syndrome/myalgic encephalomyelitis (CFS/ME) is a major cause of school absence: surveillance outcomes from school-based clinics 
BMJ Open  2011;1(2):e000252.
Objective
To investigate the feasibility of conducting clinics for chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) in schools.
Design
School-based clinical project.
Participants
Children aged 11–16 years were enrolled in three state secondary schools in England.
Main outcome measures
Number of children newly diagnosed as having CFS/ME.
Methods
Attendance officers identified children missing ≥20% of school in a 6-week term without a known cause, excluding those with a single episode off school, a known medical illness explaining the absence or known to be truanting. Children with fatigue were referred to a specialist CFS/ME service for further assessment. The authors compared children with CFS/ME identified through school-based clinics with those referred via health services. Outcomes of CFS/ME were evaluated at 6 weeks and 6 months.
Results
461 of the 2855 enrolled children had missed ≥20% school over a 6-week period. In 315, of whom three had CFS/ME, the reason for absence was known. 112 of the 146 children with unexplained absence attended clinical review at school; two had been previously diagnosed as having CFS/ME and 42 were referred on to a specialist clinic, where 23 were newly diagnosed as having CFS/ME. Therefore, 28 of the 2855 (1.0%) children had CFS/ME. Children with CFS/ME identified through surveillance had been ill for an amount of time comparable to those referred via health services but had less fatigue (mean difference 4.4, 95% CI 2.2 to 6.6), less disability (mean difference −5.7, 95% CI −7.9 to −3.5) and fewer symptoms (mean difference 1.86, 95% CI 0.8 to 2.93). Of 19 children followed up, six had fully recovered at 6 weeks and a further six at 6 months.
Conclusions
Chronic fatigue is an important cause of unexplained absence from school. Children diagnosed through school-based clinics are less severely affected than those referred to specialist services and appear to make rapid progress when they access treatment.
Article summary
Article focus
Hypothesis: many children with CFS/ME remain undiagnosed and untreated, despite evidence that treatment is effective in children.
Research question: are school-based clinics a feasible way to identify children with CFS/ME and offer treatment?
Key messages
1.0% of enrolled children missed ≥20% of school because of CFS/ME.
Fewer than one in five children with CFS/ME had received a diagnosis and been offered treatment.
Children with CFS/ME who were detected through school-based clinics were less severely affected than children referred via health services and appeared to do well once treated.
Strengths and limitations of this study
Children were offered assessment regardless of how their absence had been classified.
All children given a diagnosis of CFS/ME were screened for other medical and emotional causes of fatigue and were prospectively characterised and followed up.
School clinics were conducted in three schools in the south west, which has a well-established specialist CFS/ME service. Results may not be generalisable to regions without a CFS/ME service or to regions with different socioeconomic factors that impact on school attendance.
doi:10.1136/bmjopen-2011-000252
PMCID: PMC3244656  PMID: 22155938
16.  Chaotic homes and school achievement: a twin study 
Background
Chaotic homes predict poor school performance. Given that it is known that genes affect both children's experience of household chaos and their school achievement, to what extent is the relationship between high levels of noise and environmental confusion in the home, and children's school performance, mediated by heritable child effects? This is the first study to explore the genetic and environmental pathways between household chaos and academic performance.
Method
Children's perceptions of family chaos at ages 9 and 12 and their school performance at age 12 were assessed in more than 2,300 twin pairs. The use of child-specific measures in a multivariate genetic analysis made it possible to investigate the genetic and environmental origins of the covariation between children's experience of chaos in the home and their school achievement.
Results
Children's experience of family chaos and their school achievement were significantly correlated in the expected negative direction (r = −.26). As expected, shared environmental factors explained a large proportion (63%) of the association. However, genetic factors accounted for a significant proportion (37%) of the association between children's experience of household chaos and their school performance.
Conclusions
The association between chaotic homes and poor performance in school, previously assumed to be entirely environmental in origin, is in fact partly genetic. How children's home environment affects their academic achievement is not simply in the direction environment → child → outcome. Instead, genetic factors that influence children's experience of the disordered home environment also affect how well they do at school. The relationship between the child, their environment and their performance at school is complex: both genetic and environmental factors play a role.
doi:10.1111/j.1469-7610.2011.02421.x
PMCID: PMC3175268  PMID: 21675992
Gene–environment correlation; household chaos; environmental confusion; home environment; school achievement; twin studies; behavioural genetics
17.  Chaotic homes and school achievement: A twin study 
Background
Chaotic homes predict poor school performance. Given that it is known that genes affect both children's experience of household chaos and their school achievement, to what extent is the relationship between high levels of noise and environmental confusion in the home, and children's school performance, mediated by heritable child effects? This is the first study to explore the genetic and environmental pathways between household chaos and academic performance.
Method
Children's perceptions of family chaos at ages 9 and 12 and their school performance at age 12 were assessed in more than 2300 twin pairs. The use of child-specific measures in a multivariate genetic analysis made it possible to investigate the genetic and environmental origins of the covariation between children's experience of chaos in the home and their school achievement.
Results
Children's experience of family chaos and their school achievement were significantly correlated in the expected negative direction (r = −0.26). As expected, shared environmental factors explained a large proportion (63%) of the association. However, genetic factors accounted for a significant proportion (37%) of the association between children's experience of household chaos and their school performance.
Conclusions
The association between chaotic homes and poor performance in school, previously assumed to be entirely environmental in origin, is in fact partly genetic. How children's home environment affects their academic achievement is not simply in the direction: environment → child → outcome. Instead, genetic factors that influence children's experience of the disordered home environment also affect how well they do at school. The relationship between the child, their environment, and their performance at school is complex: both genetic and environmental factors play a role.
doi:10.1111/j.1469-7610.2011.02421.x
PMCID: PMC3175268  PMID: 21675992
gene–environment correlation; household chaos; environmental confusion; home environment; school achievement; twin studies; behavioral genetics
18.  Anaemia among Students of Rural China's Elementary Schools: Prevalence and Correlates in Ningxia and Qinghai's Poor Counties 
Although the past few decades have seen rising incomes and increased government attention to rural development, many children in rural China still lack regular access to micronutrient-rich diets. Insufficient diets and poor knowledge of nutrition among the poor result in nutritional problems, including iron-deficiency anaemia, which adversely affect attention and learning of students in school. Little research has been conducted in China documenting the prevalence of nutritional problems among vulnerable populations, such as school-age children, in rural areas. The absence of programmes to combat anaemia among students might be interpreted as a sign that the Government does not recognize its severity. The goals of this paper were to measure the prevalence of anaemia among school-age children in poor regions of Qinghai and Ningxia, to identify individual-, householdand school-based factors that correlate with anaemia in this region, and to report on the correlation between the anaemic status and the physical, psychological and cognitive outcomes. The results of a cross-sectional survey are reported here. The survey involved over 4,000 fourth and fifth grade students from 76 randomly-selected elementary schools in 10 poor counties in rural Qinghai province and Ningxia Hui Autonomous Region, located in the northwest region of China. Data were collected using a structured questionnaire and standardized tests. Trained professional nurses administered haemoglobin (Hb) tests (using Hemocue finger prick kits) and measured heights and weights of children. The baseline data showed that the overall anaemia rate was 24.9%, using the World Health Organization's blood Hb cut-offs of 120 g/L for children aged 12 years and older and 115 g/L for children aged 11 years and under. Children who lived and ate at school had higher rates of anaemia, as did children whose parents worked in farms or were away from home. Children with parents who had lower levels of education were more likely to be anaemic. The anaemic status correlated with the adverse physical, cognitive and psychological outcomes among the students. Such findings are consistent with findings of other recent studies in poor, northwest areas of China and led to conclude that anaemia remains a serious health problem among children in parts of China.
PMCID: PMC3225109  PMID: 22106753
Anaemia; Anaemia, Iron-deficiency; Cross-sectional studies; Educational performance; Primary school students; China
19.  The Long-Term Effects of a Peer-Led Sex Education Programme (RIPPLE): A Cluster Randomised Trial in Schools in England 
PLoS Medicine  2008;5(11):e224.
Background
Peer-led sex education is widely believed to be an effective approach to reducing unsafe sex among young people, but reliable evidence from long-term studies is lacking. To assess the effectiveness of one form of school-based peer-led sex education in reducing unintended teenage pregnancy, we did a cluster (school) randomised trial with 7 y of follow-up.
Methods and Findings
Twenty-seven representative schools in England, with over 9,000 pupils aged 13–14 y at baseline, took part in the trial. Schools were randomised to either peer-led sex education (intervention) or to continue their usual teacher-led sex education (control). Peer educators, aged 16–17 y, were trained to deliver three 1-h classroom sessions of sex education to 13- to 14-y-old pupils from the same schools. The sessions used participatory learning methods designed to improve the younger pupils' skills in sexual communication and condom use and their knowledge about pregnancy, sexually transmitted infections (STIs), contraception, and local sexual health services. Main outcome measures were abortion and live births by age 20 y, determined by anonymised linkage of girls to routine (statutory) data. Assessment of these outcomes was blind to sex education allocation. The proportion of girls who had one or more abortions before age 20 y was the same in each arm (intervention, 5.0% [95% confidence interval (CI) 4.0%–6.3%]; control, 5.0% [95% CI 4.0%–6.4%]). The odds ratio (OR) adjusted for randomisation strata was 1.07 (95% CI 0.80–1.42, p = 0.64, intervention versus control). The proportion of girls with one or more live births by 20.5 y was 7.5% (95% CI 5.9%–9.6%) in the intervention arm and 10.6% (95% CI 6.8%–16.1%) in the control arm, adjusted OR 0.77 (0.51–1.15). Fewer girls in the peer-led arm self-reported a pregnancy by age 18 y (7.2% intervention versus 11.2% control, adjusted OR 0.62 [95% CI 0.42–0.91], weighted for non-response; response rate 61% intervention, 45% control). There were no significant differences for girls or boys in self-reported unprotected first sex, regretted or pressured sex, quality of current sexual relationship, diagnosed sexually transmitted diseases, or ability to identify local sexual health services.
Conclusion
Compared with conventional school sex education at age 13–14 y, this form of peer-led sex education was not associated with change in teenage abortions, but may have led to fewer teenage births and was popular with pupils. It merits consideration within broader teenage pregnancy prevention strategies.
Trial registration:
ISRCTN (ISRCTN94255362).
Judith Stephenson and colleagues report on a cluster randomized trial in London of school-based peer-led sex education and whether it reduced unintended teenage pregnancy.
Editors' Summary
Background.
Teenage pregnancies are fraught with problems. Children born to teenage mothers are often underweight, which can affect their long-term health; young mothers have a high risk of poor mental health after the birth; and teenage parents and their children are at increased risk of living in poverty. Little wonder, then, that faced with one of the highest teenage pregnancy rates in Western Europe, the Department of Health in England launched a national Teenage Pregnancy Strategy in 2000 to reduce teenage pregnancies. The main goal of the strategy is to halve the 1998 under-18 pregnancy rate—there were 46.6 pregnancies for every 1,000 young women in this age group in that year—by 2010. Approaches recommended in the strategy to achieve this goal include the provision of effective sexual health advice services for young people, active engagement of health, social, youth support, and other services in the reduction of teenage pregnancies, and the improvement of sex and relationships education (SRE).
Why Was This Study Done?
Although the annual under-18 pregnancy rate in England is falling, it is still very high, and it is extremely unlikely that the main goal of the Teenage Pregnancy Strategy will be achieved. Experts are, therefore, looking for better ways to reduce both teenage pregnancy rates and the high rates of sexual transmitted diseases among teenagers. Many believe that peer-led SRE—the teaching (sharing) of sexual health information, values, and behaviours by people of a similar age or status group—might be a good approach to try. Peers, they suggest, might convey information about sexual health and relationships better than teachers. However, little is known about the long-term effectiveness of peer-led SRE. In this randomized cluster trial, the researchers compare the effects of a peer-led SRE program and teacher-led sex education given to13- to 14-y-old pupils on abortion and live birth numbers among young women up to age 20 y. In a cluster randomized trial, participants are randomly assigned to the interventions being compared in “clusters”; in this trial, each “cluster” is a school.
What Did the Researchers Do and Find?
Twenty-seven schools in England (about 9,000 13- to 14-y-old pupils) participated in the RIPPLE (Randomized Intervention of PuPil-Led sex Education) trial. Each school was randomly assigned to peer-led SRE (the intervention arm) or to existing teacher-led SRE (the control arm). For peer-led SRE, trained 16- to 17-y-old peer educators gave three 1-h SRE sessions to the younger pupils in their schools. These sessions included practice with condoms, role play to improve sexual negotiating skills, and exercises to improve knowledge about sexual health. The researchers then used routine data on abortions and live births to find out how many female study participants had had an unintended pregnancy before the age of 20 y. One in 20 girls in both study arms had had one or more abortions. Slightly more girls in the control arm than in the intervention arm had had live births, but the difference was small and might have occurred by chance. However, significantly more girls in the intervention arm (11.2%) self-reported a pregnancy by age 18 than in the intervention arm (7.2%). There were no differences between the two arms for girls or boys in any other aspect of sexual health, including sexually transmitted diseases.
What Do These Findings Mean?
These findings indicate that the peer-led SRE program used in this trial had no effect on the number of teenage abortions but may have led to slightly fewer live births among the young women in the study. This particular peer-led SRE program was very short so a more extended program might have had a more marked effect on teenage pregnancy rates; this possibility needs to be tested, particularly since the pupils preferred peer-led SRE to teacher-led SRE. Even though peer-led SRE requires more resources than teacher-led SRE, this form of SRE should probably still be considered as part of a broad teenage prevention strategy, suggest the researchers. But, they warn, their findings should also “temper high expectations about the long-term impact of peer-led approaches” on young people's sexual health.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050224.
This study is further discussed in a PLoS Medicine Perspective by David Ross
Every Child Matters, a Web site produced by the UK government, includes information on teenage pregnancy, the Teenage Pregnancy Strategy, and teenage pregnancy statistics in England
Directgov, an official government Web site for UK citizens, provides advice for parents on talking to children about sex and teenage pregnancyand advice for young people on sexual health and preventing pregnancy
Teachernet, a UK source of online publications for schools, also provides information for parents about sex and relationships education and the UK government's current guidance on SRE in schools
Avert, an international AIDS charity, also provides a fact sheet on sex education
The Sex Education Forum in the UK is the national authority on Sex and Relationships Education
doi:10.1371/journal.pmed.0050224
PMCID: PMC2586352  PMID: 19067478
20.  Problem and pro-social behavior among Nigerian children with intellectual disability: the implication for developing policy for school based mental health programs 
Background
School based mental health programs are absent in most educational institutions for intellectually disabled children and adolescents in Nigeria and co-morbid behavioral problems often complicate intellectual disability in children and adolescents receiving special education instructions. Little is known about prevalence and pattern of behavioral problems existing co-morbidly among sub-Saharan African children with intellectual disability. This study assessed the prevalence and pattern of behavioral problems among Nigerian children with intellectual disability and also the associated factors.
Method
Teachers' rated Strengths and Difficulties Questionnaire (SDQ) was used to screen for behavioral problems among children with intellectual disability in a special education facility in south eastern Nigeria. Socio-demographic questionnaire was used to obtain socio-demographic information of the children.
Results
A total of forty four (44) children with intellectual disability were involved in the study. Twenty one (47.7%) of the children were classified as having behavioral problems in the borderline and abnormal categories on total difficulties clinical scale of SDQ using the cut-off point recommended by Goodman. Mild mental retardation as compared to moderate, severe and profound retardation was associated with highest total difficulties mean score. Males were more likely to exhibit conduct and hyperactivity behavioral problems compared to the females. The inter-clinical scales correlations of teachers' rated SDQ in the studied population also showed good internal consistency (Cronbach Alpha = 0.63).
Conclusion
Significant behavioral problems occur co-morbidly among Nigerian children with intellectual disability receiving special education instructions and this could impact negatively on educational learning and other areas of functioning. There is an urgent need for establishing school-based mental health program and appropriate screening measure in this environment. These would afford early identification of intellectually disabled children with behavioral problems and appropriate referral for clinical evaluation and interventions. The need to focus policy making attention on hidden burden of intellectual disability in sub-Saharan African children is essential.
doi:10.1186/1824-7288-36-37
PMCID: PMC2880106  PMID: 20465841
21.  The Impact of Disability on the Lives of Children; Cross-Sectional Data Including 8,900 Children with Disabilities and 898,834 Children without Disabilities across 30 Countries 
PLoS ONE  2014;9(9):e107300.
Background
Children with disabilities are widely believed to be less likely to attend school or access health care, and more vulnerable to poverty. There is currently little large-scale or internationally comparable evidence to support these claims. The aim of this study was to investigate the impact of disability on the lives of children sponsored by Plan International across 30 countries.
Methods and Findings
We conducted a cross-sectional survey including 907,734 children aged 0–17 participating in the Plan International Sponsorship Programme across 30 countries in 2012. Parents/guardians were interviewed using standardised questionnaires including information on: age, sex, health, education, poverty, and water and sanitation facilities. Disability was assessed through a single question and information was collected on type of impairment. The dataset included 8,900 children with reported disabilities across 30 countries. The prevalence of disability ranged from 0.4%–3.0% and was higher in boys than girls in 22 of the 30 countries assessed – generally in the range of 1.3–1.4 fold higher. Children with disabilities were much less likely to attend formal education in comparison to children without disabilities in each of the 30 countries, with age-sex adjusted odds ratios exceeding 10 for nearly half of the countries. This relationship varied by impairment type. Among those attending school, children with disabilities were at a lower level of schooling for their age compared to children without disabilities. Children with disabilities were more likely to report experiencing a serious illness in the last 12 months, except in Niger. There was no clear relationship between disability and poverty.
Conclusions
Children with disabilities are at risk of not fulfilling their educational potential and are more vulnerable to serious illness. This exclusion is likely to have a long-term deleterious impact on their lives unless services are adapted to promote their inclusion.
doi:10.1371/journal.pone.0107300
PMCID: PMC4159292  PMID: 25202999
22.  Caring for children with disabilities in Kilifi, Kenya: what is the carer's experience? 
Child  2011;37(2):175-183.
Background
Carers of children with disabilities have repeatedly highlighted their feelings of discrimination, stigma and exclusion in many domains of their lives. There is little research from Africa addressing these issues. This study investigated the challenges encountered by these carers and the mechanisms of coping with these challenges while caring for children with disabilities in a poor rural setting in Kenya.
Methods
Thirty-five in-depth interviews were conducted with 20 carers, 10 community members and 5 primary school teachers. Ten unstructured observations were also conducted in home environments to observe mechanisms used in meeting the needs of the children with disabilities. All interviews were tape-recorded, transcribed and translated from the local dialect. Note-taking was performed during all the observations. Data were stored in NVivo software for easy retrieval and management.
Results
The arrival of a disabled child severely impairs the expectations of carers. Hospital staff underestimate carers' emotional distress and need for information. Fear for the future, stress, rumour-mongering and poverty are encountered by carers. As they grapple with lost expectations, carers develop positive adaptations in the form of learning new skills, looking for external support and in some cases searching for cure for the problem. For their emotional stability, carers apply spiritual interventions and sharing of experiences.
Conclusion
Despite the challenges faced by the carers, values and priorities in adaptation to the challenges caused by the child's disability were applied. It is recommended that these experiences are considered as they may influence programmes that address the needs of children with disabilities.
doi:10.1111/j.1365-2214.2010.01124.x
PMCID: PMC3072473  PMID: 20645990
carers; challenges; coping strategies; disability
23.  Primary headaches, attention deficit disorder and learning disabilities in children and adolescents 
Background
Primary headaches and Learning difficulties are both common in the pediatric population. The goal of our study was to assess the prevalence of learning disabilities and attention deficit disorder in children and adolescents with migraine and tension type headaches.
Methods
Retrospective review of medical records of children and adolescents who presented with headache to the outpatient pediatric neurology clinics of Bnai-Zion Medical Center and Meyer Children’s Hospital, Haifa, during the years 2009–2010. Demographics, Headache type, attention deficit disorder (ADHD), learning disabilities and academic achievements were assessed.
Results
243 patients met the inclusion criteria and were assessed: 135 (55.6%) females and 108 (44.4%) males. 44% were diagnosed with migraine (35.8% of the males, 64.2% of the females, p = 0.04), 47.7% were diagnosed with tension type headache (50.4% of the males, 49.6% of the females). Among patients presenting with headache for the first time, 24% were formerly diagnosed with learning disabilities and 28% were diagnosed with attention deficit disorder (ADHD). ADHD was more prevalent among patients with tension type headache when compared with patients with migraine (36.5% vs. 19.8%, p = 0.006). Poor to average school academic performance was more prevalent among children with tension type headache, whereas good to excellent academic performance was more prevalent among those with migraine.
Conclusions
Learning disabilities and ADHD are more common in children and adolescents who are referred for neurological assessment due to primary headaches than is described in the general pediatric population. There is an association between headache diagnosis and school achievements.
doi:10.1186/1129-2377-14-54
PMCID: PMC3698063  PMID: 23806023
Migraine; Tension type headache; Attention deficit disorder; Learning disabilities
24.  Efficacy of methylphenidate in children with attention-deficit hyperactivity disorder and learning disabilities: a randomized crossover trial 
Objective: To determine whether children with attention-deficit hyperactivity disorder (ADHD) and learning disabilities respond differently to methylphenidate (MPH) compared with children with ADHD only. Methods: We conducted a prospective, double-blind, placebo-controlled, randomized, 2-week crossover trial of MPH, during which response to MPH was assessed. Learning ability was appraised using the Wide Range Achievement Test, Revised (WRAT-R), for English-speaking students and the Test de rendement pour francophones for French-speaking students. The study was conducted at the Douglas Hospital, a McGill University–affiliated teaching hospital in Montréal. Ninety-five children, aged 6–12 years, who met the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), criteria for ADHD participated in the study, which ran from 2001 to 2004. The outcome measure used was the Consensus Clinical Response, an indicator of the degree of clinical improvement shown when taking MPH. Results: The proportion of children with learning disabilities who responded to MPH (55%) was significantly smaller (χ21 = 4.5, p = 0.034) than the proportion of children without learning disabilities who responded adequately to MPH (75%). This difference was mainly because of children with mathematics disability being particularly unresponsive to MPH (χ21 = 4.5, p = 0.034). Children with reading disability did not show this pattern of poor response (χ21 = 1.0, p = 0.33). Conclusion: Children with ADHD and comorbid learning disability tended to respond more poorly to MPH. In particular, children with disability in mathematics responded less to MPH than those without disability in mathematics. Additional therapy may be indicated for this group of patients.
PMCID: PMC1325066  PMID: 16496035
attention deficit disorder with hyperactivity; learning disorders; methylphenidate
25.  Exercise-Induced Bronchospasm and Atopy in Ghana: Two Surveys Ten Years Apart 
PLoS Medicine  2007;4(2):e70.
Background
Asthma and allergic diseases have increased in the developed countries. It is important to determine whether the same trends are occurring in the developing countries in Africa. We aimed to determine the time trend in the prevalence of exercise-induced bronchospasm (EIB) and atopic sensitisation over a ten-year period in Ghanaian schoolchildren.
Methods and Findings
Two surveys conducted using the same methodology ten years apart (1993 and 2003) among schoolchildren aged 9–16 years attending urban rich (UR), urban poor (UP), and rural (R) schools. Exercise provocation consisted of free running for six minutes. Children were skin tested to mite, cat, and dog allergen. 1,095 children were exercised in 1993 and 1,848 in 2003; 916 were skin tested in 1993 and 1,861 in 2003. The prevalence of EIB increased from 3.1% (95% CI 2.2%–4.3%) to 5.2% (4.3%–6.3%); absolute percentage increase 2.1% (95% CI 0.6%–3.5%, p < 0.01); among UR, UP, and R children EIB had approximately doubled from 4.2%, 1.4%, and 2.2% to 8.3%, 3.0% and 3.9% respectively. The prevalence of sensitisation had also doubled from 10.6%, 4.7%, and 4.4% to 20.2%, 10.3%, and 9.9% (UR, UP, and R respectively). Mite sensitisation remained unchanged (5.6% versus 6.4%), but sensitisation to cat and dog increased considerably from 0.7% and 0.3% to 4.6% and 3.1%, respectively. In the multiple logistic regression analysis, sensitisation (odds ratio [OR] 1.77, 95% CI 1.12–2.81), age (OR 0.88, 95% CI 0.79–0.98), school (the risk being was significantly lower in UP and R schools: OR 0.40, 95% CI 0.23–0.68 and OR 0.54, 95% CI 0.34–0.86, respectively) and year of the study (OR 1.73, 95% CI 1.13–2.66) remained significant and independent associates of EIB.
Conclusions
The prevalence of both EIB and sensitisation has approximately doubled over the ten-year period amongst 9- to 16-year-old Ghanaian children irrespective of location, with both EIB and atopy being more common among the UR than the UP and R children.
The prevalence of both exercise-induced bronchospasm and sensitisation has approximately doubled over the ten-year period amongst 9- to 16-year-old Ghanaian children
Editors' Summary
Background.
The proportion of children with asthma is thought to be increasing worldwide, and particularly among children that live in more developed countries. However, it is not clear why this is, since many different aspects of lifestyle and the environment have been linked with the onset of asthma. In Africa, asthma has typically been thought of as being very uncommon, and indeed in many African dialects there is no word for asthma or the symptoms, such as wheezing, that asthmatic children experience. However, some research studies have suggested that asthma might be becoming more common in Africa and that this could be linked to ongoing economic and social changes.
Why Was This Study Done?
The researchers here wanted to understand whether the trend for childhood asthma to be on the increase worldwide was also the case in Africa. Economic growth is bringing about rapid changes in lifestyle in many developing countries, and at the same time the burden of disease is changing. In order to make sure that health systems are appropriately resourced, it's important to anticipate future changes in the burden of different diseases.
What Did the Researchers Do and Find?
This study was based on a comparison between two surveys, carried out ten years apart, of children attending three schools in Ghana's second largest city, Kumasi. The surveys were done in 1993 and 2003, and the schools surveyed were a rich city school, a poor city school, and a school in the nearby countryside. The same methods were used in the two different surveys. Importantly, the researchers used an exercise test as an indicator for asthma, because language differences meant they could not find out whether children were indeed asthmatic. In the exercise test, the schoolchildren ran outdoors for six minutes, and the researchers measured how fast the children could breathe out before and after exercise (their “peak flow”). Children whose drop in peak flow was more than 12.5% were classified as having exercise-induced bronchospasm, which is thought to predict asthma. The children were also tested for their response to extracts that commonly cause allergic reactions, such as from dust mites and cat and dog hair. 1,095 children were studied in 1993 and 1,848 in 2003, paralleling the growth of the city, which also meant that by 2003 the rural school had become incorporated into the city. Over this period of time, the proportion of children with exercise-induced bronchospasm increased in all three schools; overall this proportion went up from 3.1% to 5.2%. Children from the rich city school were most likely to have exercise-induced bronchospasm at either survey date. However, children from the poor city school experienced the biggest change over the time period studied, with more than double the proportion of children having exercise-induced bronchospasm in 2003 as compared to 1993. The researchers also saw similar trends in children who had allergic reactions to common substances.
What Do These Findings Mean?
The researchers observed substantial increases in the rate of exercise-induced bronchospasm, and allergic reactions, between the two survey dates. This finding suggests that asthma is likely to have become much more common in that time. However, exercise-induced bronchospasm is not an exact indicator of asthma so it is not possible to be certain about this. These changes are likely to be linked with the adoption of westernized lifestyles, but which precise factors are responsible for the increase is not clear. Factors linked to the development of asthma include a lower rate of childhood infections, a lower rate of breast-feeding, environmental pollution, and many others. Links between the increase in exercise-induced bronchospasm and any of these factors were not examined in this study. However, these results suggest that if the findings here are common to other African cities as well, a greater proportion of African health budgets will need to be devoted to asthma care in the future.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040070.
Wikipedia has an entry on asthma (Wikipedia is an internet encyclopedia anyone can edit)
The World Health Organization's Ghana minisite has information on this country
Patient information from NHS Direct on asthma
An accompanying PLoS Medicine Essay by Matthias Wjst and Daniel Boakye discusses research on asthma in Africa
doi:10.1371/journal.pmed.0040070
PMCID: PMC1808098  PMID: 17326711

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