Evaluating the Impact of a Comprehensive School Health Program in Zambia

Last registered on July 17, 2024

Pre-Trial

Trial Information

General Information

Title
Evaluating the Impact of a Comprehensive School Health Program in Zambia
RCT ID
AEARCTR-0013890
Initial registration date
July 16, 2024

Initial registration date is when the trial was registered.

It corresponds to when the registration was submitted to the Registry to be reviewed for publication.

First published
July 17, 2024, 2:16 PM EDT

First published corresponds to when the trial was first made public on the Registry after being reviewed.

Locations

There is information in this trial unavailable to the public. Use the button below to request access.

Request Information

Primary Investigator

Affiliation
LSE

Other Primary Investigator(s)

PI Affiliation
University of Virginia
PI Affiliation
University of Virginia
PI Affiliation
Boston University and National Health Research Authority, Zambia
PI Affiliation
London School of Economics and Political Science

Additional Trial Information

Status
On going
Start date
2024-02-27
End date
2027-06-30
Secondary IDs
Prior work
This trial does not extend or rely on any prior RCTs.
Abstract
While much attention has been dedicated to the health and well-being of children under 5, the needs of older children have been historically overlooked. However, children between 5- and 14-years face health-related challenges higher than previously realized, during a period of life critical for physical, psychological, cognitive and social development. In Zambia, the context for this study, the prevalence of malaria is highest in children aged 5-17, with 40% of children testing positive in endemic areas; a study based in Lusaka, the capital also reported high levels of morbidity in primary school children, with 35% reporting febrile symptoms in the past two weeks, 66% reporting cough, 25% reporting diarrhea, and 32% having worms in their stool. Many of these problems are caused or compounded by inadequate access to prevention and treatment for school-age children. For example, they are less likely to sleep under a bednet than younger children. When ill, school-age children are less likely than other age groups to seek treatment, and when they do, less likely to seek care from formal providers. In Zambia, delayed treatment is often due to the high opportunity costs associated with long waiting times in over-crowded facilities, where children over 5 are no longer prioritized over adults. Long waiting times to access care are particularly acute when government health services are free, as in Zambia. In turn, health-related issues have a negative impact on education outcomes. They are a major cause of the 20-25% absenteeism rate observed amongst school children in Zambia, have been shown to lead to lower cognitive abilities, which, together with absenteeism, increases the likelihood of dropout and early marriage for girls.

In this study, we evaluate a programme which leverages the susbtantial expansion of primary school enrollment in Zambia and uses schools as a platform to improve access to preventive and curative healthcare services for children above five. Since 2015, our partner NGO Healthy Learners has partnered with the Zambian Government to develop a comprehensive and scalable school health program (SHP), making schools an entry point into the healthcare system. The SHP model consists of 4 key features: 1) building capacity by training teachers to become community health workers and building and equipping a school health room; 2) diagnosing and treating sick learners in school health rooms with the help of the ThinkMD clinical decision support system, or referring learners to the local health centre with a fast-track form; 3) proactive monitoring of absent and sick learners (e.g., following up after health centre referrals, a "buddy" system to check up on absent learners); 4) prevention through school health education (delivered by trained teachers) and supply of preventive care in partnership with local health facilities (e.g., vitamin A, deworming, etc.)

While many SHPs in low-income settings only focus on the delivery of some preventive services (eg. deworming, school meals, health talks), the comprehensive model creates a platform that improves access to and delivery of both preventive and curative services. Unlike a school nurse program, which is financially unsustainable, impractical in settings with health staff shortages, and places the onus of providing health services on one individual health worker, this model is integrated into the structures of the Ministry of Education and leverages resources from the entire school community to become involved in supporting the health of students.

We evaluate the impact of the SHP in a cluster-randomised controlled trial conducted in 225 schools, which we will randomly assign to one of three treatment groups: 1) a standard of care control group; 2) the School Health Programme; 3) only the mass drug administration (e.g. deworming) component of the SHP, which will enable us to benchmark the cost-effectiveness of the SHP against mass administration of deworming drugs. The proposed research will answer five main questions:
(1) What factors affect the implementation of the comprehensive SHP and how costly is it?
(2) What is the impact of the programme on health, health-seeking and education outcomes?
(3) What is the added value of such a comprehensive SHP, compared to (i) reliable (ii) or imperfect delivery of a limited range of default school health activities (e.g. deworming)?
(4) What are the indirect effects of the SHP on teachers, schools, health-workers and clinics?
(5) What are the potential implications of the programme for long-term human capital accumulation?
External Link(s)

Registration Citation

Citation
Avitabile, Andrew et al. 2024. "Evaluating the Impact of a Comprehensive School Health Program in Zambia." AEA RCT Registry. July 17. https://doi.org/10.1257/rct.13890-1.0
Sponsors & Partners

There is information in this trial unavailable to the public. Use the button below to request access.

Request Information
Experimental Details

Interventions

Intervention(s)
Since 2015, our partner NGO Healthy Learners has partnered with the Zambian Government to develop a comprehensive and scalable school health program (SHP), making schools an entry point into the healthcare system. The SHP model consists of 4 key features: 1) building capacity by training teachers to become community health workers and building and equipping a school health room; 2) diagnosing and treating sick learners in school health rooms with the help of the ThinkMD clinical decision support system, or referring learners to the local health centre with a fast-track form; 3) proactive monitoring of absent and sick learners (e.g., following up after health centre referrals, a "buddy" system to check up on absent learners); 4) prevention through school health education (delivered by trained teachers) and supply of preventive care in partnership with local health facilities (e.g., vitamin A, deworming, etc.)
Intervention Start Date
2024-09-02
Intervention End Date
2026-11-27

Primary Outcomes

Primary Outcomes (end points)
1. Composite disease burden index at endline (18 months)
2. Proportion of sick children who receive formal medical care at endline (18 months)
3. Attendance rate
Primary Outcomes (explanation)
1. Index combining the school-level prevalence of: malaria (RDT result), moderate to high worm load (stool test), anaemia (hemocue test), schistosomiasis (urine test), UTIs (urine test), diarrhoea (self-reported, past week), coughing (self-reported, past week), skin rash (self-reported, past week)
2. Proportion of children who had any symptoms (such as fever, cough, convulsions) who then receive formal medical care (e.g., receiving drugs in the school health room, being seen in the clinic) reported in household surveys
3. Rate of enrolled students absent during unannounced spot checks in schools, conducted every term over the course of the study

Secondary Outcomes

Secondary Outcomes (end points)
Secondary Outcomes (explanation)

Experimental Design

Experimental Design
We will assess the impact of the SHP in a parallel-arm, cluster-randomised controlled trial (cRCT) in 225 schools (clusters), with a 1:1.25:1.5 allocation ratio of clusters to delivery of (i) the usual school health activities (the control group – 75 schools), (ii) the SHP intervention (90 schools), and (iii) mass drug administration. The trial will be conducted in primary schools (including children from Grade 1 to Grade 7, aged 7-14 years old) in six districts in the Copperbelt (Luanshya, Chingola, Masaiti) and Luapula (Samfya, Mwense, Kawambwa) provinces, covering a range of urban, peri-urban, and rural areas, as well as varying levels of endemicity of infectious diseases (malaria and worms). Of the 286 government schools currently in these districts, Healthy Learners identified 250 that meet their eligibility criteria for programme implementation (sufficient staffing and reachable during the rainy season). Of those, we randomly selected 225 for the trial. To ensure a balanced sample with respect to geography and school environment, the randomization was stratified by district and school size.

In each school, we will collect data from (i) a random sample of 60 learners in Grade 1 (G1), G3 and G5 in 2024 who are present at the time of the baseline survey, whose parent/guardian will provide consent and who will assent to the study; (ii) a random sub-sample of 30 from sample (i) invited to take part in the symptom diary sub-study; (iii) a yearly sample of four classes (G1, G3, G5 and G7) comprising about 120-160 students in total, for the attendance study; (iv) a sample of one headteacher and up to 10 teachers present at baseline and who consent to the study; (v) a sample of 145 healthcare facilities serving the study schools and up to three health workers who staff these facilities.
Experimental Design Details
Not available
Randomization Method
Randomisation algorithm in STATA
Randomization Unit
School
Was the treatment clustered?
Yes

Experiment Characteristics

Sample size: planned number of clusters
225 schools
Sample size: planned number of observations
13,300 households; 13,300 learners; 225 school administrators; 1,700 teachers; 145 health facility administrators; 300 health workers
Sample size (or number of clusters) by treatment arms
90 schools in SHP arm; 75 schools in standard of care control group; 60 schools in mass drug administration arm
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
Assuming an alpha of 0.05, 80% power, an ICC of 0.10, 40 schools per arm and 200 children surveyed per school will allow us to detect, before controlling for any covariates, a reduction in absenteeism of 8 percentage points (based on average of 20% in the control group), an increase in standardized test scores by 0.20SD, a reduction in illness spells by one day (assuming duration of illness spells of 5 days (SD=5) in the control group).
IRB

Institutional Review Boards (IRBs)

IRB Name
ERES Converge
IRB Approval Date
2023-12-07
IRB Approval Number
2023-Oct-010
IRB Name
LSE Research Ethics Committee
IRB Approval Date
2023-10-12
IRB Approval Number
264865