India Spiti Health Project

Spiti1

2017/2018 Team Leader: Tina Gao (tinagao@alumni.ubc.ca)
Location: Munsel-ling School, Spiti Valley, India
Date & Duration of Project: 1 month in summer 2018
Positions: 5 medical students, 1 dentistry student
Faculty Supervisor: Dr. Videsh Kapoor

The Spiti Project began in 2006 with establishing a partnership with the Munsel-ling Boarding School for children (Kindergarten to Grade 11) run by a local NGO. Since 2007, GHI teams have collaborated with the local community NGO, a Vancouver-based NGO (TRAS) and several other foreign NGOs (Dutch, Australian, Indian) to improve the health of children attending the school. The Indian NGO identified health problems and asked for assistance in developing an approach to promoting health and preventing disease. Munsel-ling School is located in a remote high-altitude valley in the Indian Himalayas, with no access in or out for ~ 7 months of the year due to snow on the high mountain passes. Access to health care, basic services, medications, and medical supplies is limited for most of the year.

GHI has been working with the Munsel-ling School and Spiti community since 2007, with team field visits during the summer months. Students participate in project research, planning, pre-departure training and post-field analysis and presentations. Project teams complete a pre-departure activity proposal including: project leaders, partners, background information, rationale, literature search, objectives, methods, and measurable outcomes.

Each team builds upon the work of the previous team and with constant reporting and input from our Indian and other NGO partners.  Teams have consisted of students from the faculties of Medicine, Dentistry, Engineering, Land and Food systems, Journalism, Integrated Science and Medical Residents, under the mentorship of a Family Physician, Dr. Videsh Kapoor.

Health Screens

Health Screens

Health screens on ~ 600 school children are conducted annually since 2007 measuring growth parameters, hemoglobin, and a basic physical exam and dental screen. Unwell children or those with unusual findings are referred to the government health doctor in the neighbouring village 8 km away or are flagged for a recheck by one of the visiting foreign doctors. All data is recorded in health booklets, which were developed and initiated for every child in 2007. Data analysis is done by the Department of Statistics at UBC. Based on results of the health screens, children have been treated annually since 2007 for scabies, lice, and intestinal helminths.

 

Anemia Screen

Hemoglobin testing with a HemoCue B Analyzer was performed in 2007, demonstrating greater than 70% anemia in this population. Iron supplementation for 3 months was initiated in 2007, 2008, and 2010 based on WHO guidelines for mass treatment of anemia. Blood smears were done on 197 children in 2008 demonstrating a mixed cause etiology for anemia (iron and vitamin/mineral) most likely due to dietary deficiencies and blood loss from intestinal worms. Factors linked to poor diet and high worm burden were also surveyed. The results of the 2009 screen showed reduction in anemia from 78% (2008) to 71%. In addition to iron supplementation, children were treated for lice, scabies, and worms.

In 2016 and 2017, hemoglobin testing was repeated using the HemoCue Hemoglobin Hb 201+ Analyzer to reassess anemia prevalence. Preliminary data suggests there is still a significant, increasing burden of anemia in this population (>90% prevelance). Further strategies, including sustainable and affordable methods of iron supplementation and enhanced nutritional intake with iron-rich foods need to be developed and implemented.

 

Health Education

Health education programs began at Munsel-ling school in 2007 and revisions were made to the curriculums in 2010 and 2014. In 2015, the team was asked to develop a new health education curriculum for Munsel-ling school. The curriculum focuses on oral health and hygiene; hand washing, nose-blowing, and toileting hygiene; water safety; and gastrointestinal infections and diarrhea. To provide culturally sensitive methods of health education and interventions, the team collaborated with the boarding school staff such as the school nurse, boarding school mothers, teachers, and the school principal. The team worked with the Student Health Council to find strategies and ways that health education can be implemented at the school.

The 2017 team decided to take a new approach towards health education at Munsel-ling.  Based on previous research that has shown that there is better comprehension and retention of topics when they are delivered in a format meaningful for the learner, we decided that we would work with students to create a short film that demonstrates healthy and hygienic behaviors around the school.  After discussing with the Student Health Council, we came up with the project, “Germbusters,” which would focus on washing hands before eating and after using the toilet, brushing teeth every day, and using the bathroom properly—all topics highlighted by the Health Council as needing to be addressed.  The completed film was shown to the entire school at an assembly and was left with the school administration to be shown at a semi-regular basis.  Next year, follow-up focus groups will be held to gauge degree of retention of key topics in the film.

 

Menstrual Hygiene

A pilot project with Diva International Inc. was implemented in 2016. Older female students were asked questions about menstrual hygiene during the annual health screen and it was found some of the girls did not have access to adequate products. School administration was also concerned about the impact of currently used disposable products on the toileting system. Meetings with administration and nursing staff confirmed the school was willing to find a sustainable and reusable menstrual hygiene solution and that The DivaCup was a culturally appropriate choice. Six female staff at the school were given samples of The DivaCup and taught how to use and clean them. The feedback was positive and the DivaCup was found to be an effective product for menstrual hygiene management in Spiti.

In 2017, a qualitative feasible study was implemented titled “Exploring the feasibility and sustainability of menstrual cups and reusable pads for menstrual hygiene management in a remote Himalayan Indian Community with an adolescent women population”. The goal of this pilot study was to introduce alternative and sustainable menstrual hygiene management methods to young women in Spiti Valley, India. 40 girls were recruited for the study, and were provided training on how to use these products. Culturally appropriate workshops were created and facilitated in English and Hindi for adolescent girls. These workshops aimed to create a safe space for discussing intimate health issues such as menstruation, puberty and reproductive health. All eligible participants were each given 1 menstrual cup set (DivaCup, bowl, soap) and 1 reusable pad set (4 Eco Femme pads). They were also given a menstrual hygiene diary, where they will record their experience with these products after each period. The diaries will be collected on an ongoing basis for 12 months, until the study completion in July 2018.

The results of the study will hopefully highlight participants' preference for menstrual cups, reusable pads, or other methods, and aims to find solutions to current challenges with menstrual hygiene management at Munsel’Ling School.

 

Oral Hygiene

Between 2009-2016, the Australian Dental team led by Dr. Bob Lavis has been routinely providing urgent dental care for Munsel-ling students. Past Spiti teams have worked with Dr. Lavis to make the screening process for children with gross caries more efficient by including a dental records page in the health booklets. An oral screening station was included in the health screens to help streamline urgent dental cases to the Australian team. Every year, each team delivers in class oral health instructions to reinforce the importance of good oral hygiene.

With the help of a UBC Dental student, the 2017 Spiti team gathered data on the prevalence of dental caries and oral hygiene behaviors amongst the students. Five hundred toothbrushes and toothpastes were donated by Dr. Bob Lavis. With the help of the wardens and the teaching staff, a daily storage and distribution system was developed for the donated toothbrushes and toothpastes. Mandatory tooth brushing sessions, supervised by the wardens and senior kids, were implemented for the kindergarten to fifth grade students. Letters in English and Hindi were written to the parents of the younger children, discussing the overall findings of the dental screens and stressing the importance of enforcing routine tooth brushing at home. A few members of the Health Council were trained and supervised in delivering oral health education in the hopes to create a sustainable educational model.

 

Water and Sanitation

Due to the remote location and mountainous landscape, continuous and safe water access is a problem in Spiti. Sanitation systems are minimal or absent. In 2007, GHI funded a toilet block proposed by the school; however, there are still many problems with maintenance and usage of the toilets. The 2008 team completed a community survey of water use and access and hygiene practices. They concluded that the sanitation systems are minimal or absent. The team also complied a proposal, requested by the Indian NGO, to construct a water tank, which would act as a reservoir for the school, buffering the fluctuations of water flow to the school. This tank was funded by the Vancouver NGO and completed in 2010, holding 18,000 L. The 2009 team completed coliform testing on the school’s water sources. Their findings demonstrated that the surface water source was highly contaminated due to its exposure to animal and human fecal deposits, whereas the groundwater well source was uncontaminated. Upon their return, they began to develop a chlorine injection system into a single drinking water tank. The 2010 team implemented a modified version of the initial plan and installed hand-washing tanks. In conjunction with the new infrastructure, school staff was trained in chlorine purification and monitoring to develop a sustainable process of providing clean water. Furthermore, the children were involved with decorating the tanks during construction and received hand-washing education.

In 2012, a comprehensive evaluation found that the existing water infrastructure was insufficient in delivering accessible clean water to the student population due to inadequate distribution to meet the needs of the school’s population, as well as due to E.Coli contamination.

2013 was a landmark year for drinking water improvement efforts. Following the completion of a comprehensive safe water study undertaken by UBC GHI in 2012, Munsel-Ling put forth a proposal to improve the quality, quantity and accessibility of drinking water delivered to the student population. The mandate of the 2013 project team was to integrate the recommendations of the 2012 project team with the Munsel-Ling proposal into a feasible, sustainable, locally appropriate, technically sound and constructible detailed design. As a result, the capacity, durability, and accessibility of the summer water distribution system was improved, and a new winter water system with insulated pipes and an electric pump began to take way, which would supply clean water year-round to hand washing and dishwashing stations adjacent to the school’s dining hall.

A mutually beneficial public-private partnership was established in order to develop a technically sound detailed design.  Following preliminary meetings with Hatch Mott MacDonald (HMM), a local consulting engineering firm, in November 2012, the design development process took place from December 2012 to May 2013 by senior engineering students from the University of British Columbia (UBC Engineers). In the face of slow internet connections, community review of the design drawings was achieved through email and conference calls in early 2013. A 10-week site presence by UBC Engineers ensured construction met the design intent and facilitated adaptation of the final design to site conditions.

Winter System:  In order to eliminate water supply interruptions (common in the winter due to freezing) while increasing school-wide drinking water capacity and accessibility, a robust year-round potable water system was designed. A locally available electric pump replaced a hand pump on the existing deep well, which testing had previously confirmed to house clean water. Upstream from the pump, well water was distributed to a new drinking water/hand washing station through a network of insulated pipes. The new drinking/hand washing station was built adjacent to the community dining hall, which is warm in winter, to allow the taps to function year-round. A generator was specified for use during electricity interruptions, especially common in the winter months. The 2014 UBC GHI team oversaw the implementation of the winter system during their site visit at the Munsel-Ling. Currently, the electric pump is functioning and providing water to dishwashing and hand washing stations adjacent to the dining hall.

Summer System:  Completed on July 18, 2013, the summer system was built to augment the winter system and

Safe water drinking and handwashing station

Safe water drinking and handwashing station

meet the higher summer demands for water. The final design builds on the success of a small-scale batch chlorination pilot project, in operation since 2010, which was found to eliminate pathogenic E. Coli from the contaminated surface water source. The batch chlorination system was thus scaled up to serve as the water decontamination method for the summer system. The system was expanded to four permanent chlorinated hand washing stations with a total of 36 metal auto-shut off taps from a single tank with only one functioning tap, thus greatly improving the clean water accessibility at Munsel-Ling.

The 2014 team completed follow-up maintenance checks on the summer system. They completed a thorough walk-through of the system in search for any leaks, broken taps or tanks to ensure the system is performing adequately as well as ensure the system was being monitored and supported by local staff at school. In conjunction with a physical evaluation, they also conducted study to assess the behavioral usage of the system using GPS tracking units and video surveillance. Through their data collection analysis, they discovered that although their overall drinking and hand washing improved, a lot of the children were not demonstrating proper sanitation behaviors, such as washing their hands before eating and after defecating. As a result, the team implemented more health education and signage to teach and remind the children of proper sanitation behaviors.

The 2015 team repeated the behavioral study using GPS tracking units. The aim was to observe how the students’ behavior changed following the addition of a new water station outside the dining hall, an increase in education, and more time to become accustomed to proper sanitation behavior. The data analysis showed that overall, proper sanitation behaviors have improved significantly; however, the younger students showed no improvement in hand washing tendencies following toileting. These results will help in improving the health education that students of different ages receive.

In 2016, E-coli testing was repeated and almost all of the drinking and hand-washing stations were found to be potable. One station was not receiving proper chlorination; therefore, a better implementation strategy was initiated with the staff member responsible for chlorination.

In 2017, the team performed an updated assessment and walkthrough of the various sanitation and water facilities. They ensured the system is functioning appropriately in both the winter and the summer, and assessed the hygiene and efficacy of the toilets and hand-washing stations. Through discussions with teachers and community leaders, several recommendations and needs were identified regarding possible infrastructure projects moving forwards, and various repairs needed.

 

Nutritional Analysis:

Using anthropometric measurements (weight and height – based on World Health Organization [WHO] standards), clinical signs and symptoms and a HemoCue B analyzer, the population was assessed for stunting/wasting, micronutrient deficiency and anemia. A nutrition analysis of the school meals was conducted using a weekly menu, food stock records and Daily Recommended Intake (DRI) values. The nutrition/health screen found that 20% of the population showed signs of micronutrient deficiency, 20% are stunted (based on Indian growth charts), and 71% are anemic. The dietary assessment showed student meals are adequate in calories and carbohydrates but inadequate in dietary fat, high biological value (HBV) protein, iron, folate, zinc and B12. A report of this analysis has been used by the Indian NGO that runs Munsel-ling School to lobby the state government for more school food funding.

Greenhouses:

As a result of the short growing season and limited diversity due to high altitude and climatic factors, the Munsel-ling school community is deficient in vitamin-rich fruits and vegetables and anemia is widely prevalent amongs the students.  In 2008, our partner Indian NGO initiated a greenhouse project and GHI funded the pilot greenhouse this same year followed by two more in 2009.  The pilot greenhouse was constructed using a French model used in a neighbouring state with similar geography, and the community was surveyed on greenhouse knowledge and interest.  In previous years, research was conducted on crop selection and planting location, and it was determined what vegetables would be most successful and beneficial for Munsel-ling. In 2012, UBC collaborated with the founder and director of the school to bring this information together into a comprehensive report summarizing past, present, and future directions for the greenhouse project. Furthermore, incorporating local knowledge has long been identified as an essential part of the project and this summer a local NGO, Ecosphere, was contacted and a workshop was organized to address the special techniques used for greenhouses. The goal for future years is to monitor the progress of this comprehensive plan and continue to develop strategies to make the greenhouses a sustainable, year-round source of food for the school. In 2014, it was shown that a variety of small crops could be grown in the greenhouses. In subsequent years, the most successful crops have been planted in higher proportions and a gardener who manages the greenhouse has been hired.

Diarrheal disease:

In 2014, the medical team investigated the prevalence of diarrhea amongst Munsel-ling students and identified barriers to safe sanitation. We individually interviewed 258 students between Grades 3 and 10 (ages 7-17), completing a standardized survey. A translator, often a teacher at the school, and a Hindi version of the survey was used to overcome language barriers. The survey included an internationally accepted stool chart to classify the consistency of the stool. The utilization of safe drinking water sources and hand-washing habits were also investigated. Students with a concerning diarrheal history proceeded to be seen by a doctor at the local health clinic for appropriate investigations and treatment. The diarrheal prevalence data in 2014 was compared to 2011 to evaluate the introduction of health education and improvements in sanitation infrastructures.

Data collected from our survey suggest that overall diarrheal rates have increased since 2011. In 2014, 51.9% of students experienced diarrhea in the past 14 days compared to 46.6% and 42.7% in the past 7 and 30 days, respectively, in 2011. The risk of diarrhea decreased by 11.8 % as the students’ age increased per year. This was consistent with the finding that students in the grades 9 and 10 cohort had the lowest diarrheal risk rate. Self-reported rates of intestinal helminth infections were found to have decreased in 2014 (8.9%) compared to 2011 (22.5%). Furthermore, students drinking from unsafe water sources had an increased risk of diarrhea by 65% compared to those utilizing safe sources of water, as well as a 138% increase in the risk of bloody diarrhea. Finally, students who washed their hands before meals decreased their risk of diarrhea compared to students who never washed their hands but was not a significant predictive factor for bloody diarrhea.

These findings will help shape our recommendations to Munsel-ling school. With the current prevalence of diarrhea, the children are at increased risk of malnutrition, which is a concerning result of gastrointestinal illness in many developing countries. It is anticipated that Munsel-ling school will continue to deliver health education modules surrounding good hygiene behaviour and will emphasize the adherence to correct hand washing technique. Finally, the annual preventative anti-helminth treatment was shown to be beneficial in reducing the rates of self-reported helminth infections at Munsel-ling. Overall, future objectives will continue to address diarrheal rates and encourage healthy behaviours.

Solar energy:

The Indian NGO is very keen on using solar energy to reduce fuel and wood consumption.  In 2012, GHI and our Vancouver-based partner NGO co-funded the installation of a solar water heating system that reduces fuel costs for bathing and cooking.  Using local expertise for installation, Munsel-ling School can support ongoing maintenance and expansion of this project.  Solar water heaters are working well and the water supply is being integrated into the overall water delivery management design plan that we are working on with Munsel-ling.

Oral History Project:

I bet they have a story to tell!

In 2013, a new Health Narrative Project was initiated with the goal of using multiple qualitative methodologies to: (1) Improve our understanding of the complex, heterogeneous health beliefs and health needs of the Spiti community; (2) Investigate whether past project setbacks can be partially explained by cultural misconceptions; and (3) Develop a common framework that can be used by other UBC global health projects to assess community’s health beliefs and thus facilitate effective, sustainable projects. Focus groups were conducted with teachers, hostel mothers and upper administration at the school, and students took part in creative art classes and participatory photography. Data has been transcribed and analyzed to identify themes in definitions of health, determinants of health, healing practices and health needs among the community members. These findings were compiled into a report that helped guide and align the school’s own strategic plan, future directions of GHI and other global health teams. It is hoped that this will improve project sustainability, empower the community and develop an understanding of the role of qualitative assessment modalities in the planning and evaluation of community-based global health initiatives.

Community Surveys:

  • Tobacco/Alcohol (2009 and 2010)
    • The 2009 study assessed the prevalence of tobacco and
      alcohol consumption among adults living in the Spiti Valley region of northern India. Sixty-four adults within the Spiti Valley completed an interview regarding their tobacco and alcohol use. Interviews were conducted with the collaboration of nursing students fluent in the local language. Tobacco use items were derived from the WHO Global Adult Tobacco survey. Alcohol use items asked about typical consumption patterns and the occurrence of problems as a result of alcohol use. The results of this survey will be used as an initial step towards developing a community based-approach to reducing the negative health effects of tobacco and alcohol consumption in the Spiti Valley. The 2010 survey was administered to intermediate and senior students.
  • Vaccination (2008)
    • A survey of vaccination knowledge and administration.
  • Hygiene (2008)
    • School children were surveyed on handwashing and toileting behaviours.
  • Greenhouse/Water (2008)
    • A community survey of greenhouse knowledge and interest and water access.
  • TB prevalence and DOTS program (2008)
    • A survey of TB prevalence and management using the WHO DOTS program

The 2017 team will take the results from the health screens to adjust existing projects and identify continuing health concerns and areas of need, such as toilets, anemia and environmental health. The GHI Spiti 2018 team will continue to enhance ongoing projects, and build on the relationship with the local health professionals fostered by the 2017 team. Efforts are expected to include:

 

- Health Screen, continuing health education strategies, and follow up focus groups

- Tangible strategies to address the >90% anemia prevalence rate, including trials of sustainable and affordable methods of iron supplementation

- Data collection, follow up and participant feedback for the Menstrual Hygiene Project to examine the effects of the study

- Maintenance of oral hygiene initiatives and continuing education surrounding tooth brushing, and proper oral care

- Monitoring of toilets and water facilities

Partnerships:

RinchenZangpo Society for Spiti Development (Indian NGO)
Trans Himalayan Aid Society (TRAS – Vancouver NGO)
Medical Checks for Children (MCC – Dutch NGO)
Australian Dental Team
Dr. Raina (Delhi Nursing students)
Sleeping Children Across the World (SCAW – Toronto NGO)*

*The RinchenZangpo Society asked for assistance writing proposals because of their limited English writing skills. These proposals were use to apply for funding from local government and NGOs. The 2008 team wrote proposals for the water tank and to replace the hostel bedding. The latter was presented to SCAW who distributed new bedding to the school with the assistance of the 2009 team. The 2009 team will also provide reports of their water quality testing, nutritional analysis, and tobacco/alcohol survey.

Publications:

Assessment and Management of Anemia in a Population of Children Living in the Indian Himalayas: A Student-Led Initiative
Diala El-Zammar, Matthew Yan, Cindy Huang, Dianne Fang, Fiona Petigara, Luke Bornn, Tyler Ngai, SanjaBrkanovic, JaspreetKhangura, Noah Alexander, Saelle Hendry, Jonathan Lubin, Christopher Wallis, Jason Ford, Videsh Kapoor
UBCMJ 2011 2(2):12-18.

Consultants:

Dr. Marion Tipple (Pediatric Cardiology, TRAS Director)
Dr. Jason Ford (Hematology)
Dr. Judy McLean (Land and Food Systems)
UBC Engineering

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