Problem

Intestinal worms are a significant public health problem in many developing countries. About one quarter of the world’s population is infected. Invisible to the naked eye, intestinal worms quietly sap valuable nutrients from their host, often leading to stunted growth and malnutrition. In addition to the negative health effects, infection with intestinal roundworms has also been linked with poor performance on tests of memory and intelligence, and with lower school attendance rates.

Poor sanitary conditions and low education breed trouble in rural Guizhou province

With so much at stake, we were surprised that no comprehensive rigorous study had been undertaken to look at the problem in China. Thus, in 2010, REAP began investigating intestinal worms, its causes and its impact on health and educational outcomes in rural Guizhou and Shaanxi province.

In collaboration with the National Institute of Parasitic Diseases (NIPD) at the Chinese Center for Disease Control and Prevention (CDC), REAP surveyed 1701 children from 46 schools and found that 35 percent were infected with intestinal worms. Some villages in Guizhou province showed infection rates of 80 percent! Chinese officials called the findings in REAP’s official policy brief “shocking” and proceeded to earmark $10 million for a worm eradication project.

However, intestinal worm infection continues to be a subject of speculation and debate among national-level policymakers. Some think that intestinal roundworm infection is harmless and does not merit government intervention. Others are hesitant to proceed without sufficient evidence on the best overall strategy to combat intestinal worms.

Given the serious implications for not only child health and school performance, but China’s economic growth, REAP has partnered with NIPD to identify the most effective strategy to reduce infection rates. We believe providing hard evidence could help tip the scales towards decisive action to eliminate intestinal worms in rural China.

Objectives

The overall goal of our proposed project is to identify the most effective way to reduce the incidence of intestinal roundworms among children in high-prevalence areas of rural China. We would like to evaluate two distinct strategies of parasite control that are currently under debate within the top levels of the Chinese government. Both strategies have been used in the past, and both could easily be scaled up to be used as a nationwide roundworm control program in the future. They are:

1. An in-depth health education campaign targeting village clinicians, parents of pre-school aged and school aged children, and school teachers;
2. A systematic deworming program

      3.  An in-depth health education campaign plus a deworming program.

Approach

Our project will be adopting a cluster-randomized controlled trial design, and is structured in such a way as to identify which strategies work and which do not, so that those strategies that work can be implemented on a wider scale in high-risk communities.

Project Sample

Our sample would be comprised of 220 randomly selected rural villages in 12 nationally designated poverty counties in Guizhou province. One of China’s poorest provinces, Guizhou was selected due to the province’s low levels of health and education, and the high prevalence of intestinal worms.

Project Intervention

The study will have three intervention groups and a control group with no intervention:

• Group 1: Health education campaign targeted clinicians, parents, and teachers.
• Group 2: All individuals in the village will receive 400 mg of albendazole (deworming medicine).
• Group 3: Both the deworming campaign and the health education campaign.
• Group 4: Control (no intervention).

Data Collection

After obtaining a list in each village of all households with children aged 3-16, we will randomly select 20 households for testing. Stool samples will be collected and a smear test will be performed on each sample.

Six months following the collection and testing of stool samples, we will administer baseline surveys to a second set of 20 randomly selected households. The survey will include a grade level-appropriate standardized academic test, the Zhou Mental Health Test for school-aged children, and anthropometric measurements of all sampled children.

Parents (or other caregivers) will also be asked to complete a socioeconomic survey and a survey to assess their knowledge of intestinal roundworm infection and household sanitary behaviors. Data on school participation will be collected from the homeroom teacher.

Evaluation

Can a health education campaign and/or a deworming program give her a better future?

At the end of the study, we will administer an endline survey to the same 20 households per village that were included in the baseline survey. The endline survey will be identical to that administered at the baseline. Stool samples will be collected at the same time as the rest of the survey, and all children who test positive for infection will be given the appropriate treatment.

Policy Implications 

At REAP, we emphasize the policy relevance of our research findings. Our collaborator on the project, the National Institute for Parasitic Disease, will be able to use the results of the evaluation to show national-level policymakers hard evidence of which anti-worm strategy is most effective. By providing concrete findings of improvements in child health or school performance (if any), the NIPD will be able to better argue its case for more sustained funding for parasite control, and will also have information and data that can be used to inform its own national parasite policy, and ultimately provide better local policy guidance. We hope that through our efforts, children in rural China will be healthier and have a better chance of not only succeeding in school, but succeeding in China's future workforce.