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，在对儿童发展至关重要的时期，这些儿童也面临着与健康有关的高度挑战，预防和治疗机会不足造成或加剧了这些挑战。在患病时，学龄儿童比其他年龄段的儿童更不可能寻求治疗，而且当他们这样做时，也不太可能向正规提供者寻求护理。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、教育和经济结果产生不利影响。世界卫生组织建议实施全面的学校健康计划(SHP)，但这些建议在低收入和中等收入国家几乎没有得到实施。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，开发了这样一个全面的SHP，以“学校卫生工作者”的概念为核心：每所学校的几名教师接受过培训并配备了提供健康教育的设备，与诊所协调提供预防服务，并通过基于平板的临床决策工具做出初步诊断，使他们能够将严重病例转诊到诊所。这个项目旨在严格评估小水电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。我们将依靠在铜带省和卢阿普拉省的六个地区进行的整群随机对照试验。225所学校将被随机选择和随机接受三种干预措施之一：(1)与HL开发和实施的完整模式相对应的综合SHP(n=90所学校)；(2)根据当前情况，由政府提供和实施的有限范围的学校健康活动(n=75)；(3)扩大健康活动的范围(n=60)，HL将支持政府确保可靠和定期提供计划的活动(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。该计划的实施、采纳和成本将通过该计划本身的管理数据和对学校社区成员的定性访谈进行评估。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开始前以及开始后12个月和24个月进行调查，在结束时衡量客观的健康结果。我们将使用图画健康日记来收集关于疾病时期和寻求健康行为的详细和可靠的数据。我们将通过三次学校调查和通过卫生设施评估对诊所能力的潜在间接影响来探索对教师的潜在间接影响。最后，我们将测试该计划能否通过教育抱负、幸福感以及性健康和生殖健康结果的积极变化，在较长期内改善人力资本积累。这项研究的结果将有助于LMIC学校健康计划的有限证据基础，并将为赞比亚和类似环境下小水电的扩大提供参考。研究小组与参与该项目规划的卫生部和教育部之间的密切联系将有助于在赞比亚产生影响。最后，该项目还将有一个强大的能力建设部分，由小组高级成员支持和指导的几名青年研究人员(其中大多数将来自赞比亚)参与，并在赞比亚组织旨在加强所有伙伴组织成员评价技能的培训讲习班。

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.