Problem

Over the years, the Rural Education Action Project (REAP) has shown that young children at elementary schools across poor parts of rural China suffer from even the most basic of health problems. 34% have iron deficiency anemia (and even more have overall poor nutrition), 10% are nearsighted (but do not have glasses) and, in many places, more than 40% are infected with intestinal worms.

These nutrition and health problems have been shown in China and internationally to adversely affect children's schooling. Anemic children often have trouble concentrating in class, nearsighted children cannot see the lessons written on the chalkboard, and worm infection has been associated with lower cognitive functioning. Unable to gain a solid education, these rural children will become trapped in low-skill jobs, continuing the cycle of poverty.

Feasible, low-cost solutions to these basic health problems exist, but are not being implemented in rural China. REAP's mission is to change this.

Anemia, poor vision, and intestinal worms are invisible epidemics affecting children

Goals

Our work has already shown the effectiveness of several low-cost health interventions in schools. Through the Best Buy Toolkit project, we aim to determine whether and how multiple interventions can work together to improve the health and academic performance of schoolchildren in rural China. Through a meticulously planned experimental design, we will be able to determine the cost-effectiveness of the Best Buy Toolkit, while also identifying potential obstacles policymakers may encounter during the scaling-up process.

In 2011, REAP hopes to touch the lives of more than 5,000 poor students in rural China by improving their health and educational performance. Beyond 2011, we hope to impact the lives of tens of thousands more students by providing evidence on successful approaches to scaling-up health interventions in hundreds and thousands of additional schools.

Approach

 In 2011, REAP will launch a comprehensive project to deliver the best buys in basic health to students in 20 rural primary schools in Shaanxi Province, in Northwest China.

• We will test students' vision and fit students in need with eyeglasses.
• We will provide daily multivitamins with iron to improve overall nutrition and prevent anemia.
• We will train principals, teachers and cafeteria staff at elementary boarding schools about the importance of balanced meals for students and good sanitary practices.
• We will provide WHO-approved deworming medication to rid afflicted children of intestinal worms.

In order to make the project easy to evaluate, so that the results of the intervention can be shared with relevant policymakers across China, the project design follows four key steps:

 I. Creation of the Sampling Frame and Assignment of Schools

Our project will include 40 rural elementary schools with high student prevalence rates of iron deficiency and anemia, poor vision, significant worm infection, lack of nutrition knowledge, and poor boarding school conditions. (This is not a stretch: most schools in poor areas of rural China suffer from all of these problems.)

• Students in 20 schools receive assessments of health and nutrition and, as needed, receive the five treatments from the Best-Buy Tool Kit.
• Students in 20 schools, the control schools, receive no intervention in the first year of the study. (At the end of the first year, at the conclusion of the study, students in these schools will receive the toolkit program treatments, which have been shown to improve health and nutrition and education.)

The 40 study schools will be chosen from a list of all schools in the sample area (to be determined jointly with local collaborators). The schools will be assigned randomly to either the treatment or control groups. We will prebalance across measured characteristics to ensure that at the starting point of study, before the intervention, the groups of treatment and control schools are identical.

 II. Baseline survey

REAP will be working with local officials to conduct a baseline survey in all schools. Specifically, this will include:

1. Finger-prick (Hemocue) blood samples taken by professional nursing teams using state-of-the-art, in-the-field instruments to measure hemoglobin levels
2. Anthropometric measures of height and weight
3. Stool samples collected by official local CDC trained collaborators
4. Eye exams administered by trained professional teams
5. Surveys of students, teachers, parents and boarding school management/staff on health, nutrition and hygiene
6. Visual inspection of boarding school facilities (dormitories, bathroom and cafeteria)

III. The intervention: Taking the Best Buy Tool Kit to local schools

REAP Health and Education Partner Teams will administer the Best Buy interventions from the Toolkit:

a.) Provide multivitamins to all classes with more than 6 students classified as anemic

b.) Provide eyeglasses to all students with near sightedness

c.) Provide deworming tablets to all students, if intestinal worm infection rates are above 20% (in accordance with WHO protocol); and provide deworming tablets to only students with positive evidence of worm infections if infection rates are below 20%

d.) Provide boarding school management training to managers of all treatment schools

e.) Provide nutritional training to principals, teachers and parents of all treatment schools

IV. The Evaluation Survey

The evaluation survey will be a repeat of the baseline survey. In addition, we will keep close track of costs to be able to assess cost effectiveness of the different interventions.

Evaluation

To gather clear and concrete evidence on how well these approaches work when delivered comprehensively and at how low a cost, we will rigorously evaluate the impacts of this "best buy toolkit" on health and education. We will present the project’s feasibility and results to policymakers capable of expanding the project to thousands of schools.

In this way, REAP hopes to ultimately affect the lives of tens of thousands of students who deserve better health and a greater opportunity to learn.