Research Article: Comprehensive school-based health programs to improve child and adolescent health: Evidence from Zambia

Date Published: May 31, 2019

Publisher: Public Library of Science

Author(s): Dorothy Wei, Rachel Brigell, Aayush Khadka, Nicole Perales, Günther Fink, Elizabeth W Triche.


While school-aged children in low- and middle-income countries remain highly exposed to acute infections, programs targeting this age group remain limited in scale and scope. In this paper, we evaluate the impact of a new and comprehensive primary school-based health intervention program on student-reported morbidity and anthropometric outcomes in Lusaka, Zambia.

A prospective matched control study identified 12 classes in 7 schools for the intervention and 12 classes in 7 matched schools as controls. Teachers in intervention schools were trained to deliver health lessons and to refer sick students to care. In addition, vitamin A and deworming medication were biannually administered to intervention students. The primary study outcome was student-reported morbidity. Secondary outcomes were weight, height, health knowledge, and absenteeism. Multivariable linear and logistic regression models were used to estimate program impact.

380 students ages 4–16 were enrolled in the study in 2015, and 97% were followed up at endline in 2016. The intervention decreased the adjusted odds of self-reported acute illnesses by 38% (95% CI: 0.48, 0.77) and the adjusted odds of stunting by 52% (95% CI: 0.26, 0.87). It also increased health knowledge by 0.53 standard deviations (95% CI: 0.24, 0.81). No impact was found on weight (adjusted mean difference β = 0.17, 95% CI: – 1.11, 1.44) and student absenteeism (adjusted odds ratio (aOR) = 0.89, 95% CI: 0.60, 1.33).

The results presented in this paper suggest that comprehensive school-based health programs may offer a highly effective way to improve students’ health knowledge as well as their health status. Given their low cost, a more general adoption and implementation of such programs seems recommendable. Identifier: NCT03607084.

Partial Text

While child health has been a key global health priority in the past two decades, global child health efforts have largely focused on the first five years of life, when children face the highest mortality risk [1–4]. However, as efforts to reduce child mortality continue with the Sustainable Development Goals, the need to address child and adolescent health more broadly has been increasingly recognized [4–6]. One area of particular importance is late childhood and early adolescence, which is a time of significant emotional, social, intellectual, and physical development, and a period where health adversity has been shown to result in increased school absenteeism, diminished academic performance, impeded intellectual and physical growth, and slowed skills-development [1,3,7,8].

The study protocol for this trial and supporting TREND checklist are available as supporting information; see S1 Checklist and S1 Protocol. The trial is registered at (NCT03607084).

The study was approved by the Institutional Review Board of the Harvard T.H. Chan School of Public Health in Boston, Massachusetts and the Excellence in Research Ethics and Science (ERES) Converge Research Ethics Committee, Ministry of Education, and District Education Board Secretary in Lusaka, Zambia.

380 students were enrolled into the study between July and August 2015. 97% of study participants (N = 367) were followed-up at one year after program launch during July and August 2016. Fig 1 provides an overview of the sample sizes by intervention and control groups across survey rounds.

The results from this study have yielded four main results: First, as documented in other studies, the prevalence of infections is substantial among primary school students [1,2,7–10,28]. At baseline, 23% of students reported experiencing diarrhea, 24% reported the presence of worms in their stool, 35% reported having a fever, and 42% of students reported having a cough with chest pain in the two weeks preceding the baseline survey. Second, despite national efforts to provide vitamin A supplementation and deworming for all children, access to these health services appears to be limited among school-aged children in the studied setting, with only 37% of students reporting receipt of deworming and 38% reporting vitamin A supplementation in the past six months at baseline.




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