Nutritional, Water, Sanitation and Hygiene Related Education Intervention to Address Malnutrition of Early Adolescents in Pakistan: A School Based Study: Protocol
Phase: NA
Conditions: Malnutrition
Sponsor: Aga Khan University

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School-Based Nutritional and Water, Sanitation, and Hygiene Education Intervention to address  
Malnutrition of Early Adolescents in Gojra Pakistan  
Date: 01-08-2023 
  
  
  
  
  
  
  
  
  
  
  
  

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Summary   
Globally, one of the major risk factors for adolescent morbidity is considered Malnutrition. 
Worldwide adolescent age group 10-19 is increasing and they are at increased risk of 
malnutrition-related diseases resulting in high morbidity and mortality. Asian countries are 
suffering from the double burden of malnutrition including Pakistan. The risk factors that 
contribute to malnutrition in the population include unsafe drinking water, poor sanitary 
conditions, lack of proper waste disposal facilities, poor health awareness, and poor nutrition and 
hygiene. However, studies have shown that nutrition education, and water, sanitation, and 
hygiene (WASH) programs in schools are effective strategies to promote the health status of 
adolescents (girls and boys). The primary objective of this study is to determine a school-based 
nutrition and WASH education intervention to improve nutritional status among early 
adolescents. The randomized control trial (RCT) study design will be chosen for this study. This 
study will be carried out in Gojra public schools, in Punjab. The study participants will be 6-8 
grade school-going adolescents (girls and boys), their mothers/immediate caretakers, and school 
teachers. The data collection methods that will be used for the study are surveys, focus group 
discussions (FGDs), and through observation. Anthropometric measurements and specified 
micronutrient levels of adolescents will be measured at baseline and end line. The intervention 
will consist of skill-based nutrition and WASH education for the adolescents along with 
deworming and micronutrient supplementation. Workshops based on nutrition and WASH will 
be arranged for school teachers. This study will be carried out over one year with two-time data 
collection (baseline, and end line). Data will be analyzed by using SPSS and transcription. The 
expected outcome of the study would be that the implementation of identified nutrition and 
WASH strategy is effective to generalize in the poor nutritional status population in schools. It 
will show the promising benefit of education and WASH intervention, in reducing the cases of 

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early adolescent malnutrition. Through the findings of the study, we can bring the revolution at 
the micro-level targeting the community to modify the curriculum of this age group.   
  
  
  
 

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Introduction  
Malnourishment is one of the grave public health issues and a significant cause of high 
morbidity and mortality among young Pakistani children. Several factors determine the high 
prevalence of malnutrition, which includes unsafe drinking water, poor sanitary conditions, lack 
of proper waste disposal facilities, poor health awareness, and poor nutrition and hygiene (Hirani, 
2012). According to a report by the World Health Organization (WHO) published in 2017, 
malnutrition was categorized into three broad groups; “undernutrition (wasting, stunting, and 
underweight), micronutrient related malnutrition (deficiency or excess of micronutrients), 
overweight, obesity and diet-related non-communicable diseases” (Dat, 2018). According to 
another report by WHO, which was based on anthropometry, nutrition was classified as under 
and over-nutrition. According to this classification, undernutrition is divided into thinness, 
stunting, and underweight, while overnutrition is grouped into overweight and obesity. This 
classification of malnutrition was for children over five and adolescents. (De Onis, 2015).  
At present, adolescents constitute the major proportion of all the age groups worldwide 
and 1.8 billion of the total world population consists of adolescents (between 10-19 years of age). 
Out of these, approximately 90 percent belong to Low and Middle-Income countries (LMICs) 
(Patton & Kabir, 201, Christian, 2018). The adolescent population was further divided into early 
and late adolescent by United Nations, the early adolescents age range between 10–14 years, and 
the late adolescents age group range between 15– 19 years (Christian, 2018).   
   
In 2015, about 1.2 million adolescent deaths occurred globally (WHO,2017), 26 % of 
them in the South East Asian Region (WHO,2016). The leading causes of death in early 
adolescents include diarrheal diseases, intestinal infections and respiratory tract infections, and 
road traffic accidents (Dick, 2015). Malnutrition is the major contributing factor coupled with 
other causes of adolescent death (Reiner,2019). Globally, the main nutritional issues affecting 

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adolescents are undernutrition, anemia, and micronutrient deficiencies (Iron, Vitamin A, Zinc, 
and iodine,) (Shahid, 2009). Around 1.2 million adolescents in developing countries face serious 
nutritional challenges (Hossain, 2017 & Akhter, 2013).  
According to the 2018 National Nutritional Survey (NNS) in Pakistan, adolescent (10-19 
years) boys are more affected than girls in terms of being underweight, and more adolescent girls 
are overweight compared to their male peers. The prevalence of malnutrition across Pakistan 
varies from one region to the other. All provinces have different rates of malnutrition, the 
underweight population in Sindh province is higher as compared to other provinces, while the 
prevalence of obesity on the other hand is high in Baluchistan and KP provinces of Pakistan 
along with NMD (newly merged districts). In Punjab province, more adolescent boys are 
underweight than girls.  
Survey also showed that 56.6 % of adolescent girls in Pakistan are anemic (NIPS & ICF 2019).   
All over Pakistan, the high prevalence of both underweight and overweight/ obese 
adolescent populations is a major concern and requires serious attention to addressing all forms 
of malnutrition-associated disorders. According to a report, micronutrient deficiencies and 
malnutrition were observed in young women between the ages of 15-19 years and children under 
five years of age. However, the early adolescent female group and males aged between 10- 19 
years were not studied in this group for micronutrient assessment, although this age group is 23 
% of Pakistan’s total population. The early adolescent group (age 10-14 years) consists of almost 
12 % of the total population of Pakistan (NIPS & ICF 2019).   
The physical and mental growth and learning abilities of adolescents are influenced by 
many factors. These factors include the health condition of the adolescents and their perception 
of their health practices, school environment, socio-economic status of their parents, and nearby 
facilities of health services. The most important factor influencing the health, mental growth, and 

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educational performance among adolescents is their nutrition status (Mwaniki, 2014 & Madjdian, 
2018). Healthy Nutrition results in better growth and development during infancy and 
adolescents. However, nutritional requirements keep changing through the period of adolescence 
(Zulfiqar, 2017). Almost 80 % of adolescent’s growth is completed in the early adolescence 
phase and is associated with emotional, cognitive, and hormonal changes (WHO,  
2006). Adolescents attain 50 % of their physical growth during the early adolescent period 
(Hossen, 2016). Their caloric requirements also reach up to 2000-3000 Kcal per day for males, 
while for females the requirement is 2000-2500 Kcal along with an increase in protein intake 
requirement of 1.1-1.2 g/kg/day (Paracha,2019). The dietary requirements of both early as well 
as late adolescent groups are almost the same as well as macro and micronutrients are concerned 
(WHO, 2006).   
The study conducted in Sialkot in 2013 on three hundred twenty-eight school going 
adolescences of both genders revealed that the diet and nutritional status were not up to the 
standards of adequacy for micro nutrients (minerals), and females are more affected than males 
(Rifat-uz-Zaman, 2013). An increase in physical activity along with deprived eating practices 
and other issues like menstruation highlight the possible risk factor for adolescent’s poor 
nutrition. The results of the research studies conclude that malnutrition leads to deprived physical 
and mental development, poor resistance to diseases and poor performance at school (Bhutta, 
2011 & Haddad, 2015& Bundy, 2018). In addition, adolescent girls’ requirement for iron intake 
increases due to menstrual blood loss. On the other hand, boys have increased iron intake 
requirement due to muscle mass accumulation along with an increase intake of calcium as the 
majority of the skeletal growth taking place in this period (Bundy, 2017).   
Iron deficiency and anemia lead to decrease or slow cognitive functioning, lower 
educational achievement, and lower physical capability. Iodine deficiency causes harmful effects 

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like neural impairment and culminates in poor educational achievements. For healthy immune 
system functioning and optimal vision, Vitamin A is important. A low level of Vitamin A can 
negatively affect physical growth and sexual maturation. Zinc is also vital for attaining maximum 
growth potential (World Bank, 2003).  
   
Other contributory factors of malnutrition include contaminated water, worm infestation, 
poor personal hygiene practices, and unsatisfactory sanitary conditions (United States Agency 
International Development USAID, 2015; WHO, 2004). In adolescents, infectious diseases are 
one of the causes of malnutrition and according to a report by WHO, 88 % of infectious diseases 
are a result of poor sanitary conditions and poor hygiene habits coupled with unsafe drinking 
water (WHO, 2004 & 2008a). Poor sanitary, and hygiene conditions and unsafe drinking water 
resulted in water borne diseases like diarrhea, which in turn contribute to malnutrition. Along 
with this, diarrhea contributes to absenteeism among school-going adolescents particularly in 
Pakistan 34 % of girls compared to 40% of boys 10-14 years are out of school (Centers for 
diseases control and Prevention, 2014 & GAIN,2018).  However, it is evident that wherever 
sanitation facilities improve, accordingly the enrollment rate of girls in those institutions 
automatically increased. According to WHO data, due to the availability of sanitation facilities, 
only 11 % more girls attend school (Njau, 2016).  
   In addition to UNICEF Report 2008, children with worm infestation showed poor 
performance in cognitive capabilities, and academic achievements that increase absenteeism 
from school as compared to their healthy peers (Njau, 2016). The highest burden of worm 
infestation in young school children aged 5-15 years due to poor sanitation and hygiene (Luong, 
2003). Study conducted by WHO in Asia and Africa revealed that deworming has improved 
stunted growth, cognitive performance, and anemia level (Olds,2013). By reducing the pathogen 
load and disease burden of infectious diseases like worm infestation, diarrhea,  

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WASH (water, sanitation, and hygiene) intervention results in better   nutritional status (Dodos, 
2017). Interventions on water sanitation, hygiene, and actions on nutrition has shown positive 
nutritional outcomes (USAID, 2015, Tamiru, 2017).   
United Nations Agency (UNICEF) in 2013 emphasized that community-based nutrition 
program for adolescents should be conducted, that include school based biannual deworming, 
behavioral change communication, promoting girl’s education and also encourage nutrition, 
hygiene, and sanitation practices. In addition, the promotion of nutrition action through teachers, 
parent-teacher associations, and the incorporation of nutrition into the school’s curriculum. 
Furthermore, the promotion of the use of iodized salt and micronutrient supplementation was 
recommended (Gilbert, 2013).   
The results of the 13 randomized controlled trials based on multi-strategy intervention 
(including nutrition education and health of adolescents) from 2000 -2014 revealed that multi-
strategy school-based nutrition programs resulted in good physical and mental growth of the 
adolescents when facilitated by teachers and parents, with adjustment in the school environment 
(Meiklejohn, 2016). Results of similar studies conducted in China revealed that a large number 
of students after nutrition education intervention in schools had better knowledge about the 
nutritional value of different food products than the control group (Wang, 2015). Another study 
finding showed that the prevalence of child malnutrition through planned nutrition education 
program in schools was reduced. The researcher found it a scientific, logical, and cost-effective 
strategy (Pateel, 2015).   
Early adolescents (ages 10-14 years) are generally overlooked, as they are comparatively 
hard to reach, which in turn results to ignore the needs of adolescent girls and boys in this group. 
Early adolescents are a distinctive phase of life because it is a time of maximum physical and 
mental growth (Shahid, 2009). It was found that adolescent of this age group was not given due 

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importance and the focus remain on under five and lactating, pregnant women (LPW) age group. 
(Best 2010). The studies in Pakistan generally focused on physical status of children like weight 
and height in the age groups of 5-15 years. There is the poor outcome of nutritional status and 
WASH practices of early adolescent (10-14 years age) girls and boys, which formulates 12 % of 
the total population in Pakistan (Hirani, 2012 & NNS 2018).   
Many researches and systematic reviews have been conducted in perspective of the 
nutritional status of under-five and lactating and pregnant adolescents by Aga Khan University 
Karachi (Bhutta, 2013,2016 & Salam,2016). However, very few researches have been conducted in 
Pakistan to assess the nutritional status of early adolescents (Fatime,2016 & Ahmed,2016, Ishaque, 
2012). According to researcher knowledge, there is no study available on nutrition education with h 
integration of WASH components in early adolescents. The Government has ignored this fact 
usually, as there is a dire need to focus on the nutrition and WASH education of adolescent girls and 
boys through educational institutions in order to prevent future adverse outcomes (Fatima.2014). 
Therefore, the schools are the best setting to catchup this population and the implementation of the 
intervention strategies. In school-based health education, a conducive classroom environment plays an 
important role for adolescents to learn content and life skills. It also provides an opportunity for interactive 
discussions, to plan and practice community activities, and to reflect on those activities (Bhutta, 2015). 
Furthermore, school-going adolescents can also become a change agent for siblings, parents, and at 
community level.  Studies have shown that the most common school health strategies for health 
education intervention focused on curriculum, school values, and beliefs, general environment, and 
focused on parent and community networks (Wang, 2013). The present study will focus on 
nutritional status with the integration of WASH practices of early adolescents. This study will be 
divided into three phases such as formative, RCT, and dissemination phase.   

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1. In the formative phase of the study focus group discussion with the early adolescents, their 
mothers/immediate caretakers, and school teachers to explore the perception regarding 
healthy diet and WASH practices. Key informant interviews will also be conducted with 
school management to explore the insight regarding enablers and barriers for the 
implementation of the school-based strategies.   
2. In the RCT phase, baseline assessment of the school-going adolescents will be conducted 
(knowledge, attitude, and practices (KAP) regarding healthy diet and WASH practices, 
along with biochemical markers (Blood complete picture, Zinc, Calcium, and Vitamin D 
level) in subset of 180 participants from total adolescent’s target study population. 
Furthermore, intervention focusing multi components strategies like nutrition education, 
deworming, Water, Sanitation, and Hygiene will be implemented for 6, 7, and 8 grade 
school going early adolescents. For the Adolescents mothers/Immediate care taker 
cooking recipe books will be provided in the local context based on Pakistan dietary 
guidelines. Workshop will be arranged for school teachers to train them as master trainer. 
In the end line of the study, KAP evaluation and biochemical, markers will be done to 
assess the effectiveness of the intervention.  
3. Dissemination phase or research uptake   
 Pakistan has significantly high incidence of malnutrition, which needs to be explored and 
addressed in early adolescents. Poor nutritional status in children leads to lot of physical and 
mental problems during this phase of life and afterword. Healthy Nutrition result in better growth 
and development during this period and is a second window of opportunity for catch up growth 
who have already experienced stunting (Bundy,2018 & WHO,2014). According to Hossen, 
“well-nourished adolescents at present can make optimal use of their skills, talents, and energies 
and be healthy, responsible citizens and parents of healthy babies” (Bhutta,2014 & Hossen, 

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2016). Hence, for their physical and mental development a good nutrition has a major role to 
play (Bundy et al., 2018).   
Therefore, this study is designed to assess the effect of Nutrition education and water, 
sanitation, and hygiene intervention on school going early adolescent girls and boys in Gojra,  
Pakistan and to suggest ways how to overcome this health issue.  
Significance of the study  
The agenda of the United Nations' sustainable development goals (SDG) 2030 is to promote the 
person with disabilities. Specifically, SDG 3,4,5,6 aimed to achieve good health and wellbeing 
(end of communicable diseases), quality education (secondary education and conducive learning 
environment), gender equality (empowerment), and clean water and sanitation (safe and 
affordable drinking water, sanitation and hygiene especially to girls) of the target population 
(United Nations ,2016). This project significantly contributes to decreasing the prevalence of 
malnutrition among school adolescents that will contribute towards partially achievement of 
SGD,3,4,5 and,6.  
This study will help address malnutrition in school-going adolescents. The prevalence of 
malnutrition is maximum at the adolescent age as it is the most rapidly growing age in both 
genders. Adolescence is the most important, rapid, and formative phase of human development 
with unique physical, cognitive, social, and emotional changes taking place. National policies 
and programs should incorporate the nutritional consequences of this phase of life. The effect of 
the water, sanitation, and hygiene interventions on nutritional status can better be studied in the 
adolescent (boys and girls) stage. Another important aspect is that adolescence is a transition 
from childhood to adulthood, which carries both types of habits along. During preparation for the 
new demands of adult life, the brain often undergoes complex rewiring processes. With this 
viewpoint, it can be readily understood that adolescence is a very unique age with additional 

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dietary requirements to meet the needs of the growth spurt and with the potential to have a 
significant impact on reproductive health and work, which will in effect affect future generations 
(Bhutta.2014).   
Adolescence is the making or breaking stage of life. Major physical, mental, and psychological 
growth takes place at this age. Adequate and balanced nutrition is a vital requirement to support this 
phase. A good nutritional knowledge regarding balance diet for adolescence goes a long way in 
improving the overall health and producing healthy responsible adults (Bundy,2017).   
Adolescents can contribute health of not only themselves but of their families and communities 
as a whole. The adaptive capabilities of adolescents make them more experimental, exploratory, and 
risk-taking, which in turn makes this age very appropriate to carry the studies which ultimately 
improve all aspects of their lives (Dick,2015).  
The findings of this study will evaluate the knowledge, attitude, and practices of school 
adolescents regarding nutrition and WASH. Previous studies have focused on the nutrition 
intervention of under 5 years of age children or lactating and pregnant women; However, the 
present study will focus on multicomponent (nutrition, WASH, and deworming) intervention for 
school-going adolescents. This will be the first kind of its study conducted in a Pakistan setting. 
The results of this study will serve as a valuable guide for school management and health 
educators to plan suitable nutrition and health programs. This study will also offer 
recommendations for school management to adopt similar interventions for nutrition and WASH 
technique. This will also help them to repeat the same program for other target groups at school 
or community level. It will also encourage government and other stakeholders for the 
development of programs and policies related to nutrition and health at schools, districts and 
province levels. The present study will also add new knowledge to existing practices regarding 
nutrition and health of adolescents group.   

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Philosophical underpinning  
 The study will be guided by the post-positivist paradigm. This paradigm has tended to 
provide the worldview for most research conducted on human behavior typical of the education 
context (KIvunja, 2017). Research in this mode requires an ability to see the whole picture, to 
take a distanced view or an overview. This paradigm allows for observation without 
experimentation and formulation of hypotheses to be tested.   
For clarity purposes, this study will be divided into three phases. Phase I is the formative 
phase for the development of the intervention module. Phase II is the RCT phase in which the 
baseline assessment and intervention module will be implemented through the teachers and 
researcher along with the end-line assessment. Phase III will be research uptake.  According to 
Guba (1990) in post-positivism, reality can never be fully understood but at best only 
approximated. Data, evidence, and rational considerations shape knowledge. The researcher will 
collect information on instruments based on measures completed by the participants or by 
observations recorded by the researcher. Being objective is an essential aspect of competent 
inquiry; the researcher will examine methods and conclusions for bias like the standard of 
reliability and validity.  
Framework    
For this study, a socio-ecological approach will be adopted because to change the 
behaviors of individuals permanently, changes in the environment has to take place (Wang, 
2016). Based on the work of Urie Brofenbrenner, Lori Heise & McLeory in 1998 offered a 
theory-based framework for understanding the multi-layered and interactive effects of personal 
and environmental factors that determine behaviors such as smoking, physical activity, nutrition, 
sexual activity, and intermediate health promotion. This framework consists of five levels that 
are used in different setting at different levels. These levels include intrapersonal, 

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Interpersonal, Institution, Community, and Policy. (Fig 1). Regardless of topic, setting, and 
time period, most of the studies describe intrapersonal or interpersonal level activities with easily 
measurable objectives, while community and policy level activities are much less due to training 
of the health educators or resources to plan and implement institution, community, or policy level 
programs.  However, few studies showed school-based intervention used three or more levels. 
(Level, 2002 & Golden, 2012). Furthermore, this model not only influence the health behavior of 
the target population, but also for the execution of health/ nutrition education, and WASH 
practices (Golden, 2012).) Therefore, this study will use the school health environment, school 
nutrition and WASH program, and family and community involvement based on the socio-
ecological model to design the intervention at all levels.  
Intrapersonal: At intrapersonal level knowledge, attitude, and practice regarding nutrition and 
WASH will be assessed. Skill-based education will be provided to the adolescents regarding 
healthy diet and WASH. Furthermore, monitoring of micronutrient levels and, deworming will 
be carried out.   
Interpersonal: At the interpersonal level, involvement of mothers/immediate caretaker, teachers 
and school management and nutritionist will be ensured. Perception of the adolescent’s 
mother/immediate caretaker and teachers will be assessed regarding nutrition and WASH 
practices. Peer lead, “adolescent to adolescent” approach will be used to develop a friendly 
environment to train the adolescents.   
Institution level: Modification of the school environment, module development for focus areas 
and change in the school curriculum will be worked out.  
Community level: Vendors outside the school will be assessed for food quality and type. Parents 
and community stakeholders will be involved  

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Policy level:  Findings of the study will be shared with the national nutrition program managers 
and with district education and health officer and advocate the issue at all levels to influence the 
policy makers. At policy, level there can be nexus of the health ministry and the educational 
system. However, there will be limitations to influence the policy makers, for example, political 
instability (high turnover of leadership), lack of political will, dissension among the leadership 
between the health and the other division of government, resistance from the professional or 
regulatory bodies, system requirement (human resource), contradictory policies, fair allocation of 
budget, and lack of social accountability by policymakers.  
  
  
  
  
  
   

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Purpose of the study  
To determine a school-based nutrition education and water, sanitation, and hygiene intervention 
to improve nutritional status among early adolescents.  
  
Hypothesis  
 Ho = There will be no effect of nutrition education and WASH intervention on the prevalence of 
malnutrition among 6-8 grade school going adolescents.  
H1= There will be a reduction in the prevalence of malnutrition among 6-8 grade school going 
adolescents through nutrition education and WASH practices.  
Exposure of the study   
1. Nutritional and WASH education module for four months  
2. Micronutrient supplementation for three months  
Outcome of the study   
The main outcome is the reduction of malnutrition among school going early adolescents (6 to 8 
grade) in a school setting that will be assessed through;  
1. Body Mass Index  
2. Micronutrients  
3. Physical examination  
4. Knowledge, attitude, and practices regarding nutrition and WASH  
Measurement of Exposure and Outcome   
a. Independent variables /exposure of study  
 The module on nutrition education and WASH will be implemented such as;  
1. Nutrition education: 12 Sessions will be planned for nutrition education   

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2. WASH education and practices: 4 sessions will be planned for education and hands-on 
practices for WASH especially handwashing and personal hygiene  
3. Deworming will be administered before and after the intervention  
b. Dependent variables/Outcome of study   
1. Body Mass Index: All school going 6- 8 grade adolescents will undergo anthropometric 
measurements such as height, and weight (BMI). The measurement will be taken at 
baseline and end line by using WHO standard growth chart.  
2. Micronutrients: Blood sample will be collected twice (baseline and end line) from a 
subset of 108 adolescents (54 intervention group,54 control group). The blood samples 
will help to assess the impact of intervention on micronutrient deficiencies (Iron, Zinc,  
Calcium, CBC, Vitamin D)   
3. Physical examination: Physical examination like hair, skin, nail, eye (bitot spot), mouth 
(dental caries), and goiter will be assessed for micronutrient deficiencies at baseline 
and end line.  
4. Knowledge, attitude, and practices regarding nutrition and WASH: a structured 
questionnaire will be used to collect data on nutrition and WASH-related indicators. 
The survey will be administered at baseline and end line. The indicator assessed will be 
adolescent health status and knowledge, attitude, and practices regarding nutrition and  
WASH practices.  
Research Question  
1. What is the effect of school-based nutrition education and water, sanitation, and hygiene 
intervention in improving nutritional status among early adolescents?  
2. What is the impact of school-based nutrition education and water, sanitation, and hygiene 
intervention in reducing the prevalence of malnutrition among early adolescents?  

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Objectives of the study  
Primary objective  
To determine the efficacy of school-based nutrition education and water, sanitation, and 
hygiene intervention to improve nutritional status among early adolescents.  
 Secondary objective     
To measure the impact of school-based nutrition education and water, sanitation, and 
hygiene intervention on micronutrient levels among early adolescents.  
  
  
Methodology   
Study design  
A randomized control trial (RCT) will be chosen to see the results of school-based nutrition 
education and WASH intervention in early adolescent girls and boys in Gojra, Pakistan. RCT is a 
type of experimental design in which participants are randomly assigned to either the treatment 
or the control group, whereas they are not assigned randomly in the other type of experimental 
design such a quasi-experiment (Handley, 2018). Random assignment in RCT neutralizes factors 
(other than the independent and dependent variables) that directly infer cause and effect, and also 
avoids any possibility of selection bias in the trial (Kendall, J. (2003). Moreover, randomization 
also reduces the risk of unmeasured confounding that bias the study’s conclusions (Axelrod,  
2006).  
This study meets the criteria of RCT which are;  
i. 
Randomization  
ii. 
Control group compared to the intervention group  
iii. 
Manipulation of the variables   
 In this study, a prospective, comparative experiment will be performed under controlled 
conditions with random allocation of the participants to both the intervention and control groups. 

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In the control group, the early adolescents will receive the routine education with free health 
screening (at the start and end of the study), participation in a health camp at the end of the study, 
and If the financial resources permit then a safe drinking water facility will be provided at school 
level as an incentive whereas in the intervention group, intervention (Nutrition education, WASH 
practices, and deworming) will be applied to the group participants.  
  
Study Setting   
  
For this study, public schools (boys and girls) in Gojra will be selected. There are 40 public 
schools (20 boys and 20 girls) in Gojra. We will invite the schools for study projects that fulfill 
the eligibility criteria (inclusion and exclusion criteria). From these willing schools, four public 
schools that are at least 1-2 Km away from each other (two boys and two girls) will be randomly 
selected via balloting. The inclusion criterion related to distance is intended to reduce 
contamination between schools of different arms. These four schools (boys and girls) will then 
be randomly assigned to either the school (one boy and one girl) with the intervention or to the 
school (one boy and one girl) without the intervention (Control school).   
  
Eligibility criteria for public schools  
Inclusion criteria   
 Schools that have functional facilities of WASH will be selected.  
 Single-gender schools will be selected  
 Schools that will give informed consent to participate in the study  
Exclusion criteria     
 Schools having a public-private partnership  
 School runs by NGO  
 School already participating in any other research program   

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This study will be conducted in three phases.  
I. Form active phase   
II. RCT phase    

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Detail of project activities  
Outline of the study  
 
Formative  Phase   
 
III.  Dissemination  phase   
  
  
  
  
  
  
  
   
  
  
  
  
  
  
  
  
  
RCT Phase   
Base line Assessment  
Adolescents   
•   KAP on Diet  
•   KAP on WASH  
•   Physical assessment   
•   Biomarkers   
Observation check  list   
School Teachers   
  
) 
Master trainer 
( 
  
Adolescents  
•   Nutrition education  
•     WASH education and  
practices  
•   Deworming   
Dissemination phase   
  
Edline Assessment   
Formative Phase   
•   FGD with mother/  
Immediate care taker   
•   FGD with school  
teachers  
•   FGD with adolescents   
•   KII with School  
management   
Document analysis   
Module  
Development   
Intervention   
Research uptake   

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Activities   Strategies   
Target  
Population  
Channels   
Material   
Formative 
assessment 
qualitative  
Focus group discussions  
(FGDs)  
• 
Adolescents  
(6,7,8 grade)  
• 
Teachers  
• 
Mothers/immediate 
caretakers  
Researcher   
FGD interview guide  
Key informant interview  
(KII)  
School management  
Researcher   
Interview guide  
School document analysis  • 
Curriculum  
of 6,7,8 grade  
• 
School policy  
Researcher 
with teachers  
Reviewing school 
curriculum, textbooks, and 
policy   
RCT Phase  
 
Baseline 
assessment 
 
Knowledge, attitude, and 
practices 
(KAP)assessment   
Early school 
adolescents (6,7,8 
grade)  
Researcher  
KAP survey questionnaire  
  
Anthropometric 
measurement (BMI)  
Early school 
adolescents (6,7,8 
grade)  
Researcher   
-Height scale  
-weight machine   
-WHO growth chart   
Micronutrient assessment   
(complete blood picture, 
Zinc and serum calcium, 
Vitamin D)  
Adolescents 
sample 
(subset 
of 
108 
participants,54 
from 
each group)  
LAB (AKU)  
A blood test from Lab   
Physical 
assessment 
(skin, hair, eyes, nail, 
tongue, teeth, gums,)  
Early school 
adolescents (6,7,8 
grade)  
Researcher   
Check list   
Observation (Eating and  
WASH practices) at 
school  
Early school 
adolescents (6,7,8 
grade)  
Researcher   
Observation checklist   
Intervention phase (Duration 4 months)  
 

23  
  
Module 
development 
Development of module on 
Nutrition and WASH 
component   
For early 
adolescents 
(6,7,8 grade)  
• 
Research 
team  
• 
Nutritionist 
 
• 
Pakistan Dietary guideline  
• 
WHO guidelines   
• 
UNICEF guidelines  
• 
Literature search  
Workshop  
2 workshops will be 
conducted for the school 
teachers  
For School 
teachers  
(Teaching 6,7,8 
grade)  
Researcher  Based on the Module & 
teaching strategies   
Deworming Administering Deworming 
medicine to study 
participants   
Early adolescents   
(6,7,8 grade)  
School 
teachers    
Tab Zentel   
  
Micronutrient 
supplementation to study 
participants  
Early adolescents  
(6,7,8 grade)  
School 
teachers    
Micronutrient 
supplementation 1 tab 
daily for three months  
Healthy diet 
education  
• 
Health education session 
• 
Role play  
• 
Quiz and games  
• 
Flip charts  
• 
Log books for food  
intake   
• 
Peer education through a 
group presentation  
• 
Incentive for healthy 
lunch  
Early school 
adolescents (6,7,8 
grade)  
School 
teachers   
• 
Module on Healthy diet   
• 
30-45 min session on 
nutrition on a weekly basis 
for 12 weeks  
• 
Poster and Charts  
• 
Flip charts with key 
messages  
  
  
• Take-home cooking  
recipes based on local 
context and food 
available  
Mother/immediate 
care taker  
• Through  
adolescent 
(6,7,8, 
grade)  
• Diary/log books   
Water,  
Sanitation, 
and  
Hygiene  
(WASH)  
• 
Showing video on steps 
of hand washing  
• 
Demonstration of hand 
washing technique  
• 
Take home handout  
Early school 
adolescents (6,7,8 
grade)  
  
• School  
teachers  
  
• 
Module on WASH  
• 
30-45 min session on 
WASH on weekly basis for 
4 weeks  
• 
Charts and posters   
  
The proposed intervention will be finalized after formative assessment (FGDs with teachers and mothers and KI 
with school management).  
Post-intervention phase (Duration 2 months)  

24  
  
End line 
Assessment  
KAP survey  
Early school 
adolescents (6,7,8 
grade)   
Researcher   
KAP survey questionnaire  
Anthropometric 
measurement (BMI)  
Early school 
adolescents (6,7,8 
grade)  
Researcher   
• 
Height scale  
• 
Weight machine   
• 
WHO growth chart   
Micronutrient assessment  
(Blood complete picture,  
Zinc and Calcium)  
30 % of the total 
Adolescents 
sample (108 
participants, 54 
from each group)  
LAB (Aga  
Khan Lab)  
Blood test from Lab   
Physical assessment (skin, 
hair, eyes, nail, tongue, 
teeth, gums,)  
Early school 
adolescents (6,7,8 
grade)  
Researcher   
Checklist   
Observation (Eating and  
WASH practices) at School  
Early school 
adolescents (6,7,8 
grade)  
Researcher   
Observation Checklist   
 
Dissemination Phase  
 
  
Research uptake   
Stakeholders 
(adolescents, 
mother/immediate 
caretakers, school 
teachers, school 
management. 
community 
stakeholder  
Research team  Health mela, health screening, 
publication  
  
Phase I: Formative phase   
This phase aims to develop a module on Nutrition and WASH components. This phase 
consists of FGD with adolescents, their mothers/ immediate caretakers, and school teachers. Key 
informant interviews will also be conducted with school management. Furthermore, the school 
curriculum and textbooks for 6-8 grade will also be analyzed.  
  
Research Questions   

25  
  
For school adolescents   
1. What is the perception of 6-8 grade school going early adolescents regarding nutrition?   
2. What is the perception of 6-8 grade school going early adolescents regarding Water,  
Sanitation, and Hygiene?   
3. What areas/topics do 6-8 grade adolescents like to learn regarding nutrition and WASH?  
For School Teachers  
1. What is the perception of school teachers regarding adolescents’ nutrition?   
2. What is the perception of school teachers regarding water, sanitation, and hand-washing 
practices at school?  
3. What is the perception of school teachers regarding the nutritional status of school-going 
adolescents?  
4. What are the teacher’s recommendations that how nutrition education and WASH can be 
built into school programs?  
For Mothers/immediate Caretakers   
1. What is the perception of mothers/immediate caretakers of 6-8 grade school-going 
adolescents regarding nutrition?   
2. What is the perception of mothers/immediate caretakers of 6-8 grade adolescents 
regarding water, sanitation, and handwashing awareness at five critical times?  
3. What are the challenges mothers/immediate caretaker face in fulfilling the nutritional 
requirement of their adolescents?  
 Participants  
Participants will be;   
• 
Early Adolescents (6,7,8 grade students)  
• 
School teachers teaching nutrition-related subjects in 6-8 grade adolescents  

26  
  
• 
Mother/ immediate caretaker of adolescents   
• 
School management (head teacher/principal)  
Eligibility criteria for adolescents    
Inclusion Criteria  
• 
Students studying in 6, 7, and 8 grades   
• 
Informed consent given by adolescent’s mothers/immediate caretakers  
• 
Assent was given by the adolescent   
Eligibility criteria for teachers   
Inclusion criteria   
• 
School teachers currently teaching nutrition-related subjects to 6,7, and 8-grade students   
• 
School teachers who will give consent to be part of this study   
Eligibility criteria for mothers/immediate caretakers  
Inclusion criteria   
  
• 
Mothers/ immediate caretakers of adolescents studying in 6, 7, and 8 grades  
• 
Mothers/ immediate caretakers who will give informed consent  
Sample Size & Sampling Strategy  
A purposive sampling technique will be used for the inclusion of the participants. The 
study participant (adolescents, their mothers/immediate caretakers, and school teachers) will be 
included in the study from four public schools (2 boys and 2 girls) from Gojra for the FGD. The 
adolescents, their mothers/immediate caretakers, and teachers will be selected with the help of 
the school management or Headteacher/school principal. The number of FGDs is 1-2 for each 
group in this study and will include 8-12 participants. For the key informant interview, the school 
management from four selected schools will be invited.   

27  
  
Activities of the Formative Phase  
Activities  
Target population  
Purpose  
Focus group 
discussions  
• 
Adolescents   
• 
Mothers/immediate care  
taker   
• 
School teachers  
Explore the perception of adolescents regarding 
nutrition and WASH.  
Explore their perception of what role school can 
play to promote healthy diets and WASH 
practices among adolescents. Their opinion will 
also be sought to devise strategies for 
improving dietary and WASH practices.   
Key Informant 
interviews   
School management   
To explore enablers and barriers to school-
based interventions to improve knowledge, 
attitude and practices related to nutrition and 
WASH practices among school adolescents.  
  
School document analysis: Components of a healthy diet, and personal and environmental 
hygiene will be assessed in the 6-8 grade school curriculum (6-8 grade textbook). School policy 
will also be reviewed for the integration of nutrition and hygiene components.  
Validity and reliability   
Qualitative tool   
For FGD, an interview guide will be used. For validation 1-2 interview will be held 
before identifying the issue that might the respondents face in the interpretation of questions. In 
the present study, the rigor of the qualitative method will be maintained by using Lincoln and 
Cuba’s (1985) criteria. Trustworthiness of research will be maintained by making the data 
credible, dependable, transferable, and confirmable (Pandey, (2014). To make the study credible 
and dependable, following measures will be taken; an interview will be conducted until the 

28  
  
achievement of the saturation. Secondly, detailed information will be provided to the readers 
about all aspects of the study from design to data analysis, so that readers can understand the 
study in detail. This will help the reader to monitor whether research practices have been 
followed in true letter and spirit or not. Prior to the start of the data collection element, the 
researcher will write and review the reflection, so that the influence of his/ her values will be 
minimized. Moreover, a thorough discussion will be a continuous part till the finalization of the 
themes, categories and codes, which will be used for this study.   
Data collection process  
The principal investigator will collect data. Initially, a meeting with the school principal 
and teachers will be done to share the overall scope and objectives of the study and to seek for 
their cooperation throughout the study. Informed consent will be taken from school teachers and 
mothers/ immediate care takers of 6-8 grade school going adolescents. Secondly, to approach 6, 
7, and 8 grade adolescents, informed consent will be first taken from their mothers or immediate 
caretaker and school management. Also, a written informed assent will be taken from the 
adolescents available in Urdu and English or local language. Study participants will be briefed 
about the purpose of the study and assured of anonymity and confidentiality of the information 
shared. In case, participants have any queries related to the discussion, an explanation will be 
provided to them.   
Focus group discussion (FDGs) with school adolescents, school teachers, and mothers/ 
immediate caretakers will be conducted with the help of an interview guide. Adolescents (12-16 
adolescents  
(two-three from each class) will be invited for FGDs with the help of the school management.  
12 -16 mothers / immediate caretakers of 6- 8 grade school-going adolescents will be invited for 
1-2 FGDs in a school setting. The mothers/ immediate caretakers will be selected with the help 

29  
  
of the school management from intervention and control schools. Also, two to three school 
teachers from each intervention and control school will be invited for FDGs. All FGDs will be 
conducted in a separate, quiet, well-lit room in school setting for about 45 minutes to 60 minutes. 
FGDs will be carried out till the point of saturation. In addition, all four schools (control and 
intervention) head teachers/principals will be interviewed. Interview will last about 30 minutes 
and will be conducted with the help of an interview guide.     
Data analysis plan  
Qualitative data  
Content analysis will be checked through the Creswell framework (Creswell, 2013). This 
framework consists of five stages. First of all, in the organization of data the text will be 
transcribed into local language and after that will be translated into English. After that, the code 
number will be allocated to each transcript. The second step is reading and memorizing in which 
text will be read several times to develop an in-depth understanding of the data. Data description, 
classification, and interpretation into themes and codes comprise third step of this framework. 
For the present study, codes, categories, and themes will be developed as described by Creswell. 
The fourth step is interpreting the data, where the finding of the study will be compared with the 
existing literature to verify and identify new findings. Data will be represented and visualized 
into tabular and figure forms for comprehension.   
Phase II.  RCT phase   
This phase includes baseline assessment, intervention, and end-line assessment.  
Baseline assessment   
 Knowledge, attitude, and practices regarding nutrition and WASH will be assessed 
among school adolescents through a KAP survey along with anthropometric 

30  
  
measurement, physical assessment, and micronutrient assessment (CBC, Zinc, Calcium,). 
The observation on the eating and WASH practices of grade 6-8 adolescents will be done 
by the researcher during break time (lunch time) and school off timings.   
Research Question   
  
1. What is the knowledge, attitude, and practices of 6-8 grade school-going adolescents 
regarding the importance of consuming a diverse nutrition diet?  
2. What is the knowledge, attitude, and practices of 6-8 grade school-going adolescents 
regarding water, sanitation, and handwashing at five critical times with soap and water?  
3. What is the nutritional status of 6- 8 grade school-going adolescents’?  
4. What is the level of micronutrient status in 6-8 grade school-going adolescents?  
  
Participants   
  
  
The study will include both 6-8 grade school-going adolescent girls and boys. The following 
eligibility criteria will be followed.  
Inclusion Criteria  
• 
All students studying in 6, 7, and 8 grades   
• 
Informed consent given by adolescent’s mothers/immediate caretakers  
• 
Assent given by the adolescent at baseline    
Exclusion Criteria   
• 
Students leave the school during study  
• 
Consent not given by the mother/immediate caretaker will be excluded from the analysis  
Sample Size & Sampling Strategy  
The sample size was calculated by using PASS software. Sample sizes were estimated to 
change in nutritional status of early adolescent boys and girls. A sample size of 360 adolescents 

31  
  
(180 in each intervention and control group) will achieve 80% power assuming 42% malnutrition 
among students in the control arm and at least 6% reduction in the intervention arm having 90 
students from each school at a two-sided 5% level of significance.   
To assess the micronutrient levels (Iron, Zinc, Calcium, CBC, and Vitamin D) through a blood 
sample, a subset of 108 adolescents 6-8 grade school going adolescents (54 intervention group,54 
control group) from this total sample size (360) will be selected through random selection.  
Data collection tool/instrument  
Data will be collected through adopted and adapted self-administered, structured 
questionnaires from 6,7, and 8-grade school-going adolescents at baseline and the end line. The 
questionnaire will be categorized into four main groups to assess the respondent’s demographic 
data and their knowledge, attitude, and practices (KAP) about nutrition and WASH. Group A  
(demographic characteristic), group B contains physical assessment, group C included 24  
Questions on KAP on nutrition that are adopted from the KAP manual developed by the Food 
and Agriculture Organization of the United Nations (2014) and group D are based on the 16 
WASH items adopted from GSHS version 2013. The questionnaire will be translated into the 
Urdu language. Observation of the eating practices, school canteen, WASH, and school 
environment will be assessed through a checklist at baseline and end line.   
Activities of baseline assessment  
Activities  
Purpose  
Frequency  
KAP survey  
To know the KAP regarding nutrition 
and WASH   
Baseline and end line  
Anthropometric 
measurements  
To identify the number of thin, 
underweight, Overweight, and Obese 
adolescents in 6-8 grade   
Baseline and end line  
Physical assessment   
To identify the health status of 
adolescents  
Baseline and end line  

32  
  
Monitoring CBC, Zinc, 
Calcium, and Vitamin D 
level  
To identify the deficiency of 
micronutrients at baseline and 
improvement at the end line   
Baseline & end line   
Observations  
To assess the practices related to major 
determinants of malnutrition i.e. 
nutrition, water, sanitation, and hygiene.  
Baseline & end line  
  
Validity and reliability   
Quantitative tool  
Standardization of the questionnaire will be ensured by carrying out a pilot testing on 10  
% of 6-8 grade school-going adolescents in a public school from the same urban area (Gojra). 
Amendments to the tool will be made based on the pilot testing. Adolescents' KAP part will be 
assessed by questions based on the dietary part of the validated English version of the Food 
Agriculture Organization (FAO). KAP survey on WASH will be assessed by questions based on 
the Water, Sanitation, and Hygiene component of the Global School Health Survey (Survey 
Questionnaire will be translated into the Urdu language).   
Data collection process  
The principal investigator will collect data. Initially, a meeting with the school principal 
and teachers will be done to share the overall scope and objectives of the study and to seek their 
cooperation throughout the study. Secondly, to approach 6, 7, and 8-grade adolescents, informed 
consent will be first taken from their mothers/immediate caretakers and school management. 
Before collecting the data, a written informed assent will also be taken from the participants 
available in Urdu and English or the local language. Study participants will be briefed about the 
purpose of the study and assured about anonymity and confidentiality of the information shared. 
Finally, the survey questionnaire will be completed which will take around 25-30 minutes. In 
case, participants have any queries related to the questionnaire, an explanation will be provided 

33  
  
to them. Physical assessment will be done by the principal investigator which will take almost 10 
minutes/ individual. For the biochemical markers assistance from the local Aga Khan Laboratory 
will be sought phlebotomists /lab assistants from the Aga Khan laboratory will go to the 
concerned educational institute and draw blood samples from the participants who have given 
their consent for the test.  
Data analysis plan  
Quantitative variables will be described by means and standard deviations whereas 
median with interquartile range will be mentioned for qualitative variables. Frequencies and 
percentages will be calculated for the knowledge, attitude, and practices of adolescents regarding 
nutrition and WASH. The comparison between intervention and control at baseline and end line 
will be performed by using paired t-test and Chi-square. For the variables that are not normally 
distributed, a nonparametric test McNamara will be used. Binary logistic regression and multiple 
linear regression will be used to assess the effect of intervention. All the statistical analyses will 
be conducted using SPSS version 23. A p-value less than 0.05 will be considered statistically 
significant.  
Descriptive   
Inferential   
• 
Mean, SD  
                Normally distributed   
• 
Median, interquartile range  
               Skewed distribution  
• 
Percentages and frequencies 
of knowledge, attitude, and practices  
• 
Chi-Square-McNamara  
              knowledge, attitude, and practices  
• 
T- test paired  
             Continuous variables   
• 
Binary logistic regression and multiple linear 
regression  
• 
Proportion changes - chi-square  
                  Observational checklist  
  
Intervention Phase   

34  
  
Study participants   
Early adolescents studying in 6,7, and 8 grades in selected public schools of Gojra and school 
teachers who are teaching 6-8 grade students.    
Intervention  
The intervention will be planned based on a socio-ecological model and health-promoting 
school framework. School health environment, health education, health services, and nutrition 
programs will be focused in the intervention stage of the study.  
Based on the formative assessment, the module will be developed in consultation with 
Nutritionist, the research team, and recent literature. For the validity of the module, expert 
opinions will be taken from the nutritionist, school education, and WASH experts. Two to three 
workshops will be arranged for school teachers to train them as master trainers who are teaching 
6 to 8-grade school-going adolescents. Sixteen sessions (one session per week) will be arranged 
on nutrition education and water, sanitation, and hygiene for adolescents. Micronutrient tablets 
will be administered to adolescents for three months daily through school teachers. Moreover, 6-
8 grade adolescents will be dewormed before and after the intervention. In addition, Cooking 
recipes in the local language will be shared with the adolescent’s mother/immediate caretakers 
through adolescents. Different strategies will be used in the study sessions like demonstrating 
and showing videos on hand washing, role play, quiz etc.   
During the intervention phase, there are no such risks involved to the study participants 
except their valuable time. Due to deworming and micronutrient supplementation, there may be 
temporary dizziness, nausea, headache, constipation, and dark color stool along with discomfort 
from prick for blood drawing from adolescents. To reduce the temporary side effects of 
deworming administration, the researcher will advise them to keep adequately hydrated 
themselves and take the micronutrient supplementation tablet. Reassurance regarding drawing 

35  
  
the blood samples will be done. The existing referral system will be identified and utilized if 
needed  
  
Post-intervention phase:   
A KAP questionnaire administered before intervention will be used to assess the changes 
in knowledge, attitude, and practices of school adolescents in the post-intervention phase 
Anthropometric measurement, micronutrient assessment, and physical assessment will also be 
done to assess the effectiveness of the intervention. Moreover, the checklist will also use to 
evaluate the changes in the School environment and WASH practices.  
Phase III: Dissemination phase  
1. After the above-mentioned interventions, a one-day health camp will be arranged for all 
stakeholders (School children, school teachers, school health staff, and school 
management). The purpose of this camp is to summarize and reinforce all the concepts of 
the intervention phase of nutrition and WASH education and, deworming).  
a. Puppet show  
b. Games  
c. Free health assessment for all (height, weight, physical assessment, blood 
pressure monitoring)  
2. Outcome and recommendations of the study will be shared with policymakers and 
stakeholders for the improvement of the school system. The results of the study will be 
shared with all the stakeholders (adolescents, teachers, mothers/immediate caretakers).  
The study will be published in peer review journals, including other media channels.  
Findings will also share within advocacy groups of nutrition and WASH.  

36  
  
Ethical consideration  
   
Study Approval will be obtained   from the Aga Khan University Ethical Review  
Committee (ERC). Approval will also be sort from the participating school management in 
Gojra. Anonymity, confidentiality, and respect for human dignity are the main concerns in any of 
research addressing behaviors (Polit & Beck, 2008). Any identification information like name 
and personnel information will be replaced by codes to address anonymity issues. Confidentiality 
of the data will be ensured by keeping the data under safe custody, electronic files will also be 
password protected. Only the primary investigator will access the raw data and the research team 
members involved in data analysis. Respect for human dignity will be safeguarded by completely 
informing the participants about all aspects of the study including purpose, their rights including 
the right to withdraw from the study at any point, and all possible risks and benefits. This 
information will be communicated verbally as well as in writing in the form of consent /assent. 
For the adolescent’s participation, assent will be obtained after taking permission from their 
parents / immediate caretaker. The trial will be conducted in compliance with the protocol, GCP, 
and the applicable regulatory requirement(s).  
Informed consent   
Consent will be taken in the language understood by the participants (Urdu, English, and 
local language). Informed assent will be taken before the start of the study by providing all the 
available information about the study. Upon agreement, consent participants will sign the form. 
For the adolescent’s participation, assent will be obtained after taking permission from their 
parents / immediate caretaker.  
  
  

37  
  
Sustainability of the project  
1. School teachers will be trained as master trainers to teach the nutrition and WASH 
module to 6-8 grade school-going adolescents.  
2. Teachers should be trained in weight and height monitoring.   
3. Encourage to change the behavior of adolescents and their parents to improve personal 
hygiene practices.  
4. Findings of the study will be shared with the national nutrition program 
managers/administrators/policymakers.    
5. Findings of the study will be shared with policymakers and suggested to inculcate the 
module as part of the curriculum.   
Expected outcome  
1. Adolescents' nutritional status will be improved i.e. BMI increase up to the normal range.    
2. Knowledge, attitude, and practices regarding nutrition and WASH will be enhanced.   
3. Adolescents will adopt WASH practices.  
4. Overall, the health of adolescents and personal hygiene practices will be improved.  
Timeline for study:  
After approval of the synopsis and ERC, the selection of schools will be carried out by 
June 2020, the first phase of data collection will be completed by July 2020, and intervention will 
be completed by March 2021. Summer and examination breaks will be excluded from the 
intervention plan. The timeline for the study will also be aligned with the school schedule.  
  
  
 

38  
  
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