Evaluation of a Comprehensive School Health Programme in Zambia

N/AActive Not RecruitingNCT06560853

London School of Economics and Political Science28,700 enrolled

Overview

In Zambia, the health and well-being of children aged 5 to 14 has often been overlooked, leading to various health challenges affecting their development and education. The Healthy Learners (HL) program, in collaboration with the Zambian Government, aims to address this gap by implementing a comprehensive school health program. Trained teachers, known as school health workers (SHWs), play a key role by delivering health education, coordinating preventative care with local clinics, and overseeing a 'school health room' for sick students. This study is a large cluster-randomized control trial in 225 schools. The goal of this trial is to compare the effects of the comprehensive school health programme (SHP) developed by HL against two alternatives: the current level of school health provision and the current school health activities enhanced with deworming and vitamin A coordination by HL, with their technical and financial support ensuring the reliable delivery of all health activities currently planned by the government. 1. What is the impact of the program on health-seeking, health, and education outcomes? 2. What are the indirect effects of the program on teachers and clinics? 3. What is the added value of such a comprehensive SHP, compared to (i) optimized (ii) or imperfect (status-quo) delivery of a limited range of school health activities (e.g., deworming and vitamin A supplements)? 4. How costly is the comprehensive SHP, and what factors affect its implementation? 5. What are the potential benefits of the program for long-term human capital accumulation (learning, well-being etc)?

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

NONE

Enrollment

28,700

Conditions

Interventions

Comprehensive School Health ProgrammeOTHER

Combination intervention which consists of: * Upgrading sanitation facilities and constructing a 'health room' in the school * Health teacher training: 5-10 teachers per school are recruited and trained for two weeks to become School Health Workers (SHWs) by Healthy Learners * The SHWs: (1) deliver education on health and good sanitation and hygiene (2) coordinate with local clinics to deliver preventive care (e.g. school deworming and vitamin A supplementation); (3) assess sick students in the health room with a tablet-based clinical decision support system (CDSS); (4) treat sick students in the health room for some conditions (malaria, diarrhoea, schistosomiasis, pneumonia, conjunctivitis) or (5) refer to the health facility for treatment; (6) monitor absence of learners * Referral: learners referred by SHWs are given a referral form by the SHW, which contains information about symptoms and suggested diagnosis by the CDSS. The learners are prioritised in the local clinic.

Deworming and vitamin A supplementation deliveryOTHER

Schools implement the government policy of distributing deworming drugs and vitamin A supplementation to learners twice a year. Additional support from Healthy Learners ensures reliable delivery.

Eligibility

Sex: ALLMin age: 5 YearsHealthy volunteers:

Medical Language ↔ Plain English

* Schools: eligible for SHP (not inaccessible in the rainy season, within 10km of health centre) * School administrator: has at least one year experience in school and is the primary or deputy school manager (e.g., headteacher, deputy headteacher, senior teacher acting as financial officer) * Learners: registered and in attendance in school during baseline, in grade 1, grade 3, or grade 5 * Parents, primary caregivers or guardians of selected learners. Guardians are eligible if they stay with the child and make schooling and health decisions for the child in the absence of parents/primary caregivers. * Teachers: any teacher employed by study eligible schools (not volunteers) * Health facilities: designated facilities in the catchment area of study schools * Health facility staff: any staff doing OPD consultation present during facility data collection days

Locations (6)

Chingola District Education Board

Chingola, Copperbelt, Zambia

Luanshya District Education Board

Luanshya, Copperbelt, Zambia

Masaiti District Education Board

Masaiti, Copperbelt, Zambia

Kawambwa District Education Board

Kawambwa, Luapula Province, Zambia

Mwense District Education Board

Mwense, Luapula Province, Zambia

Samfya District Education Board

Samfya, Luapula Province, Zambia

Outcomes

Primary Outcomes

Any healthcare utilisation

The proportion of learners who sought formal care (any government health centre or hospital, or the school health room). Equals one if reported at least once during the health diary observation period.

Time frame: Eight-week daily health-diary window, completed once per child in either term 1 (rainy season, January-March 2026; ~16-18 months after intervention start) or term 2 (cold season, May-July 2026; ~20-22 months). Data reported across both rounds.

Proportion of serious illness episodes where child sought healthcare

The investigators will calculate this as the proportion of "serious" illness episodes for which a child seeks care, at the child level. In other words, the number of serious illness episodes with care divided by the total number of serious illness episodes, for all children with at least one serious illness episode. A serious illness episode is one during which a child's ill-health symptoms are severe enough to require medical care, either immediately or the next day. This classification is based on WHO tools (c-IMCI and IMAI): Care is needed when (i) a child experiences any red-flag symptom (e.g. difficulty breathing, convulsions); (ii) has symptoms suggestive of certain conditions (e.g. measles, malaria); (iii) has experienced mild symptoms for a long time (coughing for 14 days, etc). During an illness episode, a child will be considered to seek medical care if they visit (i) the health room (treatment arm) or (ii) a government clinic or hospital (any arm).

Panel-based attendance rate

The program's effect on school attendance is assessed using data collected through repeated, unannounced spot checks at each school. The primary attendance measure will be based on the sample of children enrolled in the study at baseline and confirmed to still be enrolled in their original school at the time of the visit. In this sample, the attendance rate, measured at each attendance spot check, will be the proportion of those children confirmed present in class on the day of the visit.

Time frame: Repeated measure captured at each of five unannounced attendance spot checks: term 1 2025, term 2 2025, term 3 2025, term 1 2026, and term 2 2026 (alongside endline), approximately 4-22 months after the start of the intervention (September 2024)

Additional measure of attendance, focusing on students in grades 1, 3, 5, and 7 at the time of the spot check. This register-based measure is defined as the proportion of children on the register who are present on the day of the spot check and confirmed by school staff as enrolled in the selected class on the visit day.

Time frame: Repeated measure captured at each of four unannounced attendance spot checks: term 2 2025, term 3 2025, term 1 2026, and term 2 2026 (alongside endline), approximately 8-22 months after the start of the intervention (September 2024)

Secondary Outcomes

Malaria prevalence (proportion of children testing positive for malaria)

Testing for the presence of P. falciparum, non-falciparum species, or a mixed infection. The tests are performed using a rapid diagnostic test (RDT) on the sample of children taking part in the health diaries (testing will occur at the end of the period).

Time frame: Single biomarker measurement at the end of the child's diary round - term 1 (~March 2026; ~18 months after intervention start) or term 2 (~July 2026; ~22 months). Data reported across both rounds.

Proportion of children with moderate or severe anaemia

Haemoglobin concentration measured using a HemoCue photometer in the sample of children taking part in the health diaries (testing will occur at the end of the period). Anemia severity categories will be based on the WHO classification which depends on the age and sex of the child. Haemoglobin is first adjusted for elevation using the WHO (2024) continuous adjustment, defined in g/L as 0.0056384 times elevation in metres plus 0.0000003 times elevation squared, evaluated at each school's recorded GPS elevation and subtracted from the measured value. Moderate-to-severe anaemia is considered when adjusted haemoglobin is below 11.0 g/dL, a threshold common to all age bands represented in the sample.

Proportion of children with diarrhoea

Incidence of diarrhoea - carer report of the child experiencing three or more loose or watery stools.

Haematuria prevalence

An indicator for incidence of haematuria (blood in urine) reported by the caregiver.

Time frame: Endline, May-July 2026 (approximately 20-22 months after the start of the intervention, September 2024). Recall over last 7 days.

Share of diary days with any reported symptom

Data from ClinicalTrials.gov

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The share of days on which the child was reported to have any symptom, over the eight week symptom diary recording period (0 days if no symptoms recorded). Proportion of completed health-diary days on which the child reported one or more symptoms. Computed per child as (diary days with ≥1 reported symptom) ÷ (completed diary days). Defined for all children in the diary sub-sample; no conditioning on illness status.

Duration of illness episodes - all episodes

Mean number of consecutive symptom-days per illness episode, among episodes in children who reported illness during the diary window. Estimated from a discrete-time hazard model for symptom resolution: episodes still ongoing at the end of the observation window contribute their observed (censored) days rather than being dropped; episodes already symptomatic on the first diary day are excluded (start date unobservable / left-truncated). Reported as a restricted mean over the eight-week observation window.

Duration of illness episodes - serious episodes

As for the all-episodes duration outcome, restricted to episodes classified as serious. A serious illness episode is one during which a child's ill-health symptoms are severe enough to require medical care, either immediately or the next day. This classification is based on WHO tools (c-IMCI and IMAI): Care is needed when (i) a child experiences any red-flag symptom (e.g. difficulty breathing, convulsions); (ii) has symptoms suggestive of certain conditions (e.g. measles, malaria); (iii) has experienced mild symptoms for a long time (coughing for 14 days, etc). Mean consecutive symptom-days per serious episode, estimated from the same discrete-time hazard model, with ongoing episodes contributing observed (censored) days and day-1 episodes excluded as left-truncated. Reported as a restricted mean over the eight-week window.

Menstrual health knowledge

Share of correct responses across three menstrual health knowledge items. The item set is the final items retained after in-country piloting for comprehension and relevance, from a pre-specified pool adapted from validated instruments. Computed per respondent as (correct responses) / (items answered), averaged within the relevant sub-sample: girls grade 5 or above who have heard of menstruation. Higher values indicate greater knowledge.