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Additional file 4. Sheet for Anthropometrics and Biomedical Specimen.

Additional file 2. Household Questionnaire.

Additional file 3. Identification Codes.

Additional file 1. School Children Questionnaire.

Additional file 5: Table S1. Changes in key indicators from questionnaire among households in two districts of Nepal, March-May 2015 and June 2016.

Table S1. Results from univariate and multivariate logistic regression analyses for Trichuris trichiura. The multivariate global model includes a random intercept at the level of school adjusting sex, age, district where all the variables were assessed one by one and retained for the global model if their P-value is < 0.2. The final model was obtained by using backward selection with the same level of 0.2. (DOCX 35 kb)

Table S2. Results from univariate and multivariate logistic regression analyses for Giardia intestinalis. The multivariate global model includes a random intercept at the level of school adjusting sex, age, district where all the variables were assessed one by one and retained for the global model if their P-value is < 0.2. The final model was obtained by using backward selection with the same level of 0.2. (DOCX 36 kb)

Results from univariate and multivariate logistic regression analysis for parasitic infection. (DOCX 76 kb)

Results from univariate and multivariate logistic regression analysis for Giardia intestinalis and Entamoeba histolytica/Entamoeba dispar. (DOCX 47 kb)

Summary Background: Undernutrition is a global public health problem, with over 159 million children under the age of 5 years affected in low- and middle-income countries (LMICs). The determinants of children’s nutritional status are multifactorial. The direct causes of undernutrition in children are insufficient energy and nutrient intake, and recurrent infectious diseases, such as intestinal parasitic infection. Underlying determinants of children’s nutritional status include food insecurity, inadequate child care, weak health systems, and a lack of access to clean water, improved sanitation and adequate hygiene (WASH). To address these challenges, international development organisations are increasingly paying attention to enhancing synergies between agriculture, nutrition and health through multi-sectoral collaboration. Yet, there is a lack of evidence to support the effect of agricultural and health interventions on improving children’s nutritional status, particularly for school-aged children. To fill this gap, a project entitled “Vegetables go to School: Improving Nutrition through Agricultural Diversification” (VgtS) was developed to address schoolchildren’s nutrition in a multi-pronged approach, through introducing school vegetable gardens and other school-based health, nutritional and environmental interventions. The VgtS project is funded by the Swiss Agency for Development and Cooperation (SDC) and was implemented in five countries, including Burkina Faso, with the overall goal of improving schoolchildren’s nutritional status. This PhD thesis was embedded in the VgtS project in Burkina Faso as operational research study to improve the evidence-base of the interlinked approach as well as to influence the design and implementation of the interventions. In Burkina Faso, undernutrition, anaemia and diarrhoeal diseases are the leading causes of morbidity in under-5-year-old children. Whilst Demographic and Health Surveys (DHS) and national nutrition surveillance systems have been measuring the height and weight of children under the age of 5 years, there is a paucity of anthropometric data for school-aged children (8-14 years). Likewise, the global burden of disease from polyparasitism of intestinal parasitic infections caused by helminths and intestinal protozoa has not yet been estimated for school-aged children or for the population of any other age group. Goal and objectives: The overarching goal of this PhD thesis was to assess undernutrition and intestinal parasitic infections among children in rural schools in two regions of Burkina Faso, and to generate evidence on the effects of complementary school garden, nutrition and WASH interventions on schoolchildren’s nutrition and health status. Three specific objectives were pursued: (i) to deepen our understanding on undernutrition and associated risk factors among schoolchildren (8-14 years) at a baseline cross-sectional survey before implementing complementary school garden, nutrition and WASH interventions in the two VgtS project regions; (ii) to investigate intestinal parasites and its associations with household- and school-level WASH conditions at baseline of the implementation of complementary school garden, nutrition and WASH interventions in the two VgtS project regions; and (iii) to assess whether complementary school garden, nutrition and WASH interventions reduce the prevalence of intestinal parasitic infections and improve schoolchildren’s nutritional status. Methods: This study was designed as a cluster-randomised controlled trial, with an equal number of schools randomly allocated to an intervention and to a control group. The intervention group benefited from complementary nutrition and WASH interventions linked to the school garden programme. A baseline cross-sectional survey was conducted between February and March 2015 among 385 children aged 8-14 years in eight randomly selected schools situated in the Plateau Central and Centre-Ouest regions of Burkina Faso. An end-line survey was conducted in the same cohort of children one year after the baseline survey, between February and March 2016. In both surveys, the same field and laboratory procedures were employed. Schoolchildren’s nutritional status was determined by anthropometric measurements. Children were asked to provide single stool and urine samples over two consecutive days, which were examined for infection with helminths and intestinal protozoa. The Kato-Katz method was used to diagnose soil-transmitted helminths (Ascaris lumbricoides, hookworm and Trichuris trichiura), Hymenolepis nana and Schistosoma mansoni. The formalin-ether concentration method was employed to detect both, helminths and intestinal protozoa. Urine samples were examined with a urine filtration technique to identify Schistosoma haematobium eggs. Prevalence of anaemia was determined by measuring haemoglobin levels in finger-prick blood samples. All children found anaemic or infected with intestinal parasites received treatments according to national guidelines. Questionnaires were administered to children to determine their knowledge of nutrition and health and their related attitudes and practices (KAP). Children’s caregivers/parents were administered a questionnaire to assess basic household sociodemographic and economic characteristics, health KAP and WASH conditions. Water samples from community sources, children’s households and children’s drinking water cups were analysed for contamination with coliform bacteria and faecal streptococci using a membrane filtration technique. Results: More than a third (35%) of the children surveyed in the two study regions were undernourished at baseline. The prevalence of undernutrition was higher among children aged 12-14 years compared to their younger peers (8-11 years). Intestinal protozoa were highly prevalent (85%), while faecal-oral transmitted helminths and schistosomiasis showed low prevalence (7% and 4%, respectively) and were mainly of light intensity. Intestinal protozoa were significantly associated with household sociodemographic characteristics. Children from households with freely roaming domestic animals, particularly dogs, showed higher odds of Giardia intestinalis infection. Water quality, household drinking water source and storage did not emerge as significant risk factors for intestinal parasitic infections in children. We further observed that undernutrition, anaemia and parasitic infections were strongly associated. Between the baseline and end-line surveys, the prevalence of intestinal parasitic infections decreased in children from both the intervention and control groups (from 90% to 62%, and from 82% to 72%, respectively) with a significantly stronger decrease in children from the intervention group. Furthermore, adequate handwashing practices before eating and after using latrines at schools increased significantly more among children from the intervention group. Indices of undernutrition and anaemia did not decrease at end-line in the intervention group and water quality remained poor without significant changes. Conclusions: Undernutrition and intestinal parasitic infections, particularly intestinal protozoa infections, are an important public health concern among schoolchildren in the Plateau Central and Centre-Ouest regions of Burkina Faso. In view of our findings and of the multifactorial aetiology of undernutrition, concerted efforts are needed to concurrently address undernutrition, intestinal parasitic infections and access to WASH among schoolchildren. By conducting repeated cross-sectional surveys in a cohort of children, this study showed that a combination of nutritional and WASH-based interventions linked to a school garden programme and delivered through a school platform, holds promise for improving schoolchildren’s health and nutritional status. Our findings call for sustaining the achievements made and for increased public health measures tailored to school-aged children, through multi-sectoral school-, household- and community-based programmes.

The critically important role of health for development was underlined in the 16th World Development Report entitled “Investing in health”, published in 1993 [1]. Put forth by the World Bank and enhanced with input from the World Health Organization (WHO), the report examined the interplay between human health, health policy, and economic development. In the period 2000-2015, health for development was strongly emphasized in the Millennium Development Goals (MDGs). Indeed, three of the eight MDGs explicitly featured health [2]. Meanwhile, major achievements have been made in population health. For instance, average global life expectancy has increased by more than 20 years between 1950 and 2010 [3]. Yet, there are areas of unfinished business, such as reducing child mortality and improving maternal health [4]. Key vulnerable groups, such as the poorest and most isolated populations, have been left excluded and marginalized [4,5]. In addition, there are new challenges, as for instance non-communicable diseases have surpassed infectious diseases in terms of global burden [6], novel infectious threats from zoonoses [7] and anti-microbial resistance [8] have emerged, there are toxic mixtures of chemicals compromising human, animal, and ecosystem health, while climate change, urbanization, and migration have amplified health problems and vulnerabilities [9]. Taken together, there are multifactorial stresses that ask for innovative, multi-partner, integrated approaches., Journal of Global Health, 9 (2), ISSN:2047-2986