Evaluation of a comprehensive school health programme in Zambia

与5岁以下儿童相比，5至14岁儿童的需求历来被忽视。然而，这些儿童还面临着与健康有关的高度挑战，这些挑战是由于无法充分获得预防和治疗而造成或加剧的，而这一时期对他们的发展至关重要。学龄儿童患病时寻求治疗的可能性低于其他年龄组，即使寻求治疗，也不太可能向正规提供者寻求治疗。反过来，学龄儿童得不到预防和治疗对一系列短期到长期的健康、教育和经济成果产生不利影响。世界卫生组织建议实施综合学校卫生规划，但这些建议在低收入和中等收入国家仍然很少得到执行。自2015年以来，一个名为健康学习者（HL）的非政府组织与赞比亚政府合作，以“学校卫生工作者”的概念为中心，开发了这样一个全面的卫生保健计划：每所学校的几名教师经过培训，配备了提供健康教育的设备，与诊所协调提供预防服务，并借助基于平板电脑的临床决策工具进行初步诊断，使他们能够将严重病例转介到诊所，在那里学习者得到优先治疗。该项目旨在严格评估卫生和教育计划对一系列健康和教育成果的影响，并更好地了解该计划对教师和诊所的间接影响。我们将在铜带和卢阿普拉省的6个地区进行随机对照试验。225所学校将随机选择并随机接受三种干预措施中的一种：(1)与HL开发和实施的完整模型相对应的综合SHP （n=90所学校）；(2)根据目前情况，由政府提供和实施的范围有限的学校卫生活动（75项）；(3)扩大保健活动范围（60项），人道主义事务部将支持政府确保定期可靠地提供计划活动（主要是驱虫和维生素A）。这项研究将利用一系列方法和数据来源。将通过项目本身的行政数据和对学校社区成员的定性访谈来评估项目的实施、吸收和成本。为了评估该计划对健康和教育结果的因果影响，我们将在每所学校选择60名学习者，并在SHP开始前、12个月和24个月后进行调查，并在结束时测量客观健康结果。我们将使用图片健康日记收集有关疾病发作和求医行为的详细和可靠数据。我们将通过三次学校调查，以及通过卫生设施评估，探讨对教师可能产生的间接影响。最后，我们将测试该方案是否能够通过教育愿望、福祉以及性健康和生殖健康结果方面的积极变化，在较长期内改善人力资本积累。这项研究的结果将有助于为低收入和中等收入国家的学校卫生项目提供有限的证据基础，并将为赞比亚和类似国家扩大卫生保健计划提供信息。研究小组与参与该项目的规划的卫生部和教育部之间的密切联系将促进在赞比亚产生的影响。最后，该项目还将有一个强大的能力建设组成部分，通过由该团队的高级成员支持和指导的几名年轻研究人员（其中大多数将来自赞比亚）的参与，以及在赞比亚组织旨在加强所有伙伴组织成员评估技能的培训讲习班。

Compared to children under 5, the needs of aged 5 to 14 years have been historically overlooked. Yet these children also face high levels of health-related challenges, caused or compounded by inadequate access to prevention and treatment, during a period critical for their development. 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 turn, lack of access of school-aged children to prevention and treatment has detrimental effects on a range of short- to long-term health, education, and economic outcomes. The World Health Organization recommends the implementation of comprehensive school health programmes (SHP), but these recommendations remain hardly implemented in low- and middle-income countries.Since 2015, an NGO called Healthy Learners (HL) has partnered with the government of Zambia to develop such a comprehensive SHP centred on the concept of "School Health Workers": a few teachers in each school trained and equipped to provide health education, coordinate the delivery of preventative services with clinics, and make preliminary diagnoses thanks to a tablet-based clinical decision tool, allowing them to refer severe cases to clinics, where learners receive priority treatment.This project aims to rigorously assess the impact of the SHP on a range of health and education outcomes and better understand the indirect effects of the program on teachers and clinics. We will rely on a cluster-randomised controlled trial, in six districts of the Copperbelt and Luapula provinces. 225 schools will be randomly selected and randomized to receive one of three interventions: (1) a comprehensive SHP (n=90 schools) corresponding to the full model developed by and implemented HL; (2) a limited range of school health activities (n=75) provided and implemented by the government, as per the current situation; (3) an enhanced range of health activities (n=60) where HL will support the government to ensure the reliable and regular provision of planned activities (mainly deworming and vitamin A).The study will draw on a range of methods and data sources. Implementation, uptake and cost of the program will be assessed through administrative data from the program itself, and qualitative interviews with members of the school communities. To assess the causal impact of the program on health and education outcomes, we will select 60 learners in each school, and conduct surveys before and 12 and 24 months after the start of the SHP, with objective health outcomes measured at endline. We will use pictorial health diaries to collect detailed and reliable data on illness spells and health-seeking behaviours. We will explore potential indirect effects on teachers through three school surveys and on clinics capacity, through health facility assessments. Finally, we will test if the program can lead to improved human capital accumulation in the longer-term, through positive changes in educational aspirations, well-being and sexual and reproductive health outcomes.The results of the study will contribute to the limited evidence base on school health programs in LMICs and will inform the scale-up of the SHP in Zambia and similar settings. The impact in Zambia will be facilitated by the strong links between the research team and the Ministry of Health and Ministry of Education, who have been involved in the planning of the project. Finally, the project will also have a strong capacity-building component, through the participation of several young researchers (most of whom will be from Zambia) supported and mentored by the senior members of the team, and the organisation of training workshops in Zambia aiming to strengthen evaluation skills of members of all partner organisations.