Comprehensive Analysis of the Program:Salud Escolar
Phase: NA
Conditions: Obesity
Sponsor: Instituto Nacional de Salud Publica, Mexico

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Comprehensive analysis of the program: 
Salud Escolar  
 
 
 
 
Unique Protocol ID: P86-19 
 
 
 
4th August 2020 
 
 
 

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Comprehensive analysis of the program: 
Salud Escolar  
 
 
Nutrition and Health Research Center 
 
 
 
Principal Investigator 
Alejandra Jáuregui de la Mota, PhD 
 
Co-Investigators 
Anabelle Bonvecchio Arenas, PhD 
Selene Pacheco Miranda, MPH 
Armando García Olvera, MPH 
Carolina Batis Ruvalcaba, PhD 
Tania Aburto Soto, PhD 
Lilia Pedraza Zamora, PhD 
 
 
Document translated by Daniel Velazquez MSc & Gabriela Argumedo PhD 
Cuernavaca, Morelos 
October 2019 
 

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Contents 
1. Introduction 
4 
2. Background 
4 
2.1. Epidemiological Overview of Overweight and Obesity in children and adolescents 
4 
2.2. Obesogenic Environment 
5 
2.3. Policies and Programs for The Promotion of Healthy Lifestyles in The School Environment 
6 
3. Conceptual and theoretical framework 
11 
3.1. Risk factors associated with overweight and obesity 
11 
3.2. Socio-ecological model for the promotion of healthy school environments 
12 
3.3. Public policy analysis 
13 
3.4. Design analysis 
14 
3.6 Analysis of results and impact 
15 
3.7 Gender perspective 
15 
4. Problem Statement 
17 
5. Study Rationale 
18 
6. Objectives 
19 
7. Materials and methods 
20 
7.1. Design analysis 
22 
7.2 Analysis of results (baseline measurement) 
27 
7.3 Impact analysis (baseline measurement) 
29 
7.4 Implementation analysis (Second stage) 
35 
8. Ethical considerations 
38 
8.1. Design analysis 
39 
8.2. Impact analysis 
39 
9. Expected results 
39 
References 
41 
 

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1. Introduction  
Excess of weight in children and adolescents has been recognized as a major 
challenge in public health in Mexico and worldwide due to its magnitude, speed of 
growth, and the negative effect on the health of the affected population (Bray, Kim 
and Wilding, 2017). Overweight and obesity in childhood predispose to the 
development of chronic-degenerative diseases considered a risk factors of death 
and premature disability in Mexico (Rtveladze et al., 2014; Soto-Estrada et al., 
2016). Overweight and obesity are conditions that can be prevented. The 
environment is critical promoting individual’s food choices, and to promote regular 
physical activity(World Health Organization., 2016). The school is an ideal venue 
for health promotion and obesity prevention since girls and boys spend a 
considerable amount of time in school (Budd and Volpe, 2006; Brown and 
Summerbell, 2009) 
 
Several strategies have been implemented in Mexico to promote the adoption of 
healthy habits in the school environment (Safdie, Jennings-Aburto and Lévesque, 
2013; Barriguete Melendez et al., 2014). However, gaps remain in policies and 
programs focused on the prevention and reduction of the high prevalence of 
overweight and obesity in Mexican children. As a result, in August 2019 was 
launched the School Health program in Mexico with the aim to promote correct 
nutrition, adequate hydration, and regular practice of physical activity in children 
attending to primary schools. In its first phase, this will be implemented in 58 
schools in Mexico City from October 2019. 
 
The comprehensive analysis of public policies facilitates programs success 
(Guti斴rrez, 2017). This study aim is to comprehensively analyse the design, 
implementation, results, and impact of the School Health program during the first 
phase of implementation using mixed methods. Based on the results derived from 
this analysis, a set of recommendations will be provided to improve the feasibility of 
scaling up the program at the national level. 
 
2. Background 
2.1. Epidemiological Overview of Overweight and Obesity in children and 
adolescents  
Obesity is a global public health problem and it is not exclusive to high income 
countries and involves all age groups, ethnic groups, and socio-economic status 
(Alvear-Galindo et al., 2013). Childhood obesity can track to adulthood, facilitating 
the development of diabetes and other chronic non-communicable diseases 
(CNCDs) and other comorbidities (Hesketh and Campbell, 2010). 
 
The prevalence of obesity and overweight in children has reached levels without 
precedents in recent years. In 2016, it was estimated that 340 million of children 
and adolescents aged between 5 and 19 years were overweight and obese 
worldwide(World Health Organization., 2016). In America, the combined 
prevalence of overweight and obesity (OW/O) among children has been estimated 

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around 30%, percentage that exceeds the world prevalence (10%), and in other 
regions of the world such as Europe (20%) (Lobstein, Baur and Uauy, 2004). In 
Mexico, according to the 2016 National Health and Nutrition Survey (ENSANUT, by 
its Spanish initials), OB/O in girls was 32.8% and boys 33.7% (aged between 5 and 
11 years); and in female adolescents of 39.2% and male adolescents of 33.5% 
(between 12 and 19 years old) (Instituto Nacional de Salud Pública, 2016). While, 
in Mexico City this prevalence rises as high as 25.7% among girls and 39.7% 
among boys whereas among female is 40.1% and male adolescents 43% 
(Shamah-Levy et al., 2018). 
2.2. Obesogenic Environment 
Individual´s behaviours are influenced from obesogenic environments considered 
those that promote high-energy food consumption and limit the opportunities for 
spending that energy (Powell, Spears and Rebori, 2010). The high prevalence of 
overweight and obesity in early ages is can be partially explained by changes in 
eating and physical activity behaviours associated with an obesogenic environment 
(Swinburn, Egger and Raza, 1999; Safron et al., 2011). Multiple conditions in the 
children´s environment could positively or negatively influence the risk of being 
overweight or obese (Hesketh and Campbell, 2010). There is a consensus that 
also genes, biology, and individual behaviour cannot fully explain the rapid 
increase in childhood obesity (Sallis and Glanz, 2009). 
 
Obesogenic environments promote a high-caloric intake in different forms including 
the widespread advertising of foods high in fat, sugar, and salt targeting children 
and adolescents; inadequate nutritional guidance for the population as well as the 
limited availability and accessibility of healthy food and beverages in school 
settings (Sallis and Glanz, 2009; Powell, Spears and Rebori, 2010). In addition, 
these environments limit the access to adequate physical activity facilities including 
road insecurity and high-rate of crime, which contribute to a significant decrease in 
the percentage of children who are physically active and with healthy body 
composition (Sallis and Glanz, 2009). 
 
School is an ideal place for health promotion and obesity prevention since is where 
schoolchildren spend a large proportion of their time. The school provides 
curricular (e.g. physical education course, PE), and extracurricular (e.g. recess, 
tournaments, active transport) opportunities to learn and practice healthy habits 
(De Bourdeaudhuij et al., 2011). Although interventions focused on the adoption of 
healthy lifestyles in schools have shown inconsistent results, they seem to be 
promising options to contribute to the prevention of obesity among schoolchildren 
(Brown and Summerbell, 2009). 
 
In Mexico there is evidence that schoolchildren do not receive sufficient support in 
their school environment to sustain a healthy lifestyle and to prevent overweight 
and obesity (Bonvecchio-Arenas et al., 2010). At school and outside obesogenic 
environments might contribute to the small proportion of children and adolescents 
meeting guidelines recommendations for health (Barquera et al., 2018). The World 
Health Organization (WHO) recommends that diet do not exceed 10% of the total 

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energy from added sugar and maintain a high intake of fruits, vegetables, and fiber 
(World Health Organization, 2015a). However, it has been documented that the 
exposure to high-energy food in Mexican schools and outside contributes to small 
proportion of children consuming fruits (39.2%), and vegetables (26.9%) frequently 
(Instituto Nacional de Salud Pública, 2016).  
 
Recommendations on adequate hydration indicate the sporadic consumption of 
sugar-sweetened beverages (SSBs) and an intake of pure water between 6 to 8 
glasses per day (Salud, 2015). Environmental factors such as the scarce or no 
availability of drinking water in schools and the presence of incentives from SSBs 
manufacturers to sell their products in schools are factors related to the high 
consumption of these drinks (Carriedo et al., 2013). According to ENSANUT 2016, 
83.9% of adolescents and 81.5% of girls and boys consume SSBs frequently 
(Instituto Nacional de Salud Pública, 2016). 
 
Regarding physical activity, opportunities in the school environment in Mexico have 
been exposed as insufficient in various studies. Evidence-based guidelines 
recommend that children and adolescents ages 5 to 17 accumulate a minimum of 
60 minutes a day of moderate to vigorous physical activity (MVPA) (World Health 
Organization, 2010). In addition, it is recommended to not exceed two hours a day 
of screen time (e.g. playing video games, watching TV) (Tremblay et al., 2017). In 
Mexico, only 17.2% of children aged between 10-14 years, and 61% of 
adolescents aged between 15 and 19 years meet the physical activity 
recommendations whereas approximately 80% exceed screen time (>2h/day) 
(Medina et al., 2018). 
 
In terms of academic curricular, there is limited coverage of PE teachers in 
Mexican schools, which leads to frequent cancellations or to the class being taught 
by the generalist teacher (Medina, Barquera, Peter T Katzmarzyk, et al., 2015), 
who in most cases does not have physical activity literacy or training to teach that 
subject. The equipment and facilities necessary for adequate PE have been 
reported as insufficient .21 The frequency and duration of the class have been 
documented to be only once a week, and generally last 33.6 minutes, which is 
below the established in the curriculum (Gharib et al., 2015). Furthermore, the time 
dedicated to the practice of AFMV corresponds to only 16-24% of the total minutes 
allocated for the EF class (Gharib et al., 2015). Regarding extracurricular 
opportunities, it has been identified that only 10% of the break time is dedicated to 
MVPA (Medina, Barquera, Peter T. Katzmarzyk, et al., 2015).  
2.3. Policies and Programs for The Promotion of Healthy Lifestyles in The School 
Environment 
Schools have been considered as an ideal space to develop strategies that help 
improve lifestyle and prevent obesity problems among schoolchildren worldwide 
(Brown and Summerbell, 2009; Gharib et al., 2015). The WHO recognizes the 
importance of schools in promoting health and physical activity and has developed 
global (World Health Organization (WHO), 2007) and regional strategies to 
strengthen this role (Ippolito-Shepherd, Cerqueira and Ortega, 2005). 

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The Political Declaration of the High-Level Meeting of the General Assembly of the 
United Nations (UN) on the Prevention and Control of Noncommunicable Diseases 
recognized the crucial importance of reducing unhealthy diet and physical 
inactivity.25 In September 2015, the Assembly adopted the 2030 Agenda for 
Sustainable Development, an action plan for people, the planet and prosperity. 
Among its objectives, "Health and Wellbeing" stands out (Organización de las 
Naciones Unidas, 2015). In addition, the WHO created the Global Action Plan for 
the Prevention and Control of Noncommunicable Diseases 2013-2020 (World 
Health Organization, 2013). This plan includes a reduction of the prevalence of the 
main risk factors for CNCDs and the strengthening of protective factors, 
emphasizing children, and vulnerable groups among its main lines of action 
(OPS/OMS, 2014). Specifically for the Americas´ region, the WHO and the Pan 
American Health Organization (PAHO) formulated in 2014 the Action Plan for the 
Prevention of Obesity in Childhood and Adolescence (OPS/OMS, 2015). The 
general objective of this plan is to stop the accelerated increase in the obesity 
epidemic in childhood and adolescence by considering a multisectoral approach 
based on the socio-ecological model (OPS/OMS, 2015). 
 
In recent decades, it has been evident a rise of school interventions to promote 
healthy lifestyles mainly focused on diet and physical activity and obesity 
prevention. In the most recent systematic review of such strategies, Brown and 
Summerbell identified 1,553 interventions to prevent obesity through changes in 
diet and physical activity (Brown and Summerbell, 2009).National policies such as 
Healthy Schools in the United States of America have demonstrated the potential 
to promote health in parallel with the academic development of schoolchildren 
(Brown and Summerbell, 2009). 
 
In Mexico, education and health are fundamental rights recognized by the nation 
and are administered primarily by the Political Constitution of the United Mexican 
States, the General Law of Education, the General Law of Health and the General 
Law of Rights. of Girls, Boys, and Adolescents (OPS/OMS, 2015). In recent years, 
a set of norms and guidelines related to the health of children and adolescents 
have been developed, including: 
 
Mexican Official Standard NOM-009-SSA2-2013. This, aims to establish the 
criteria, strategies, and activities of the personnel in health promotion and disease 
prevention aimed at the school population of the National Education System. It is 
the normative instrument of the actions carried out by the Ministry of Health 
(Secretaría de Salud, SS for its abbreviation in Spanish) in collaboration with the 
Ministry of Public Education (Secretaría de Educación Pública, SEP for its 
abbreviation in Spanish) for the promotion of school health in the basic, middle-
higher and higher education schools within the National Educational System. In 
addition, this standard establishes the recognition of Health Promoting School for 
those schools that develop and practice specific actions for the benefit 
schoolchildren´s health.(Diario Oficial de la Federación, 2013; Secretaria de Salud 
and Secretaría de Educacion Pública, 2019). 

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National Agreement for Food Safety. The agreement was launched in January 
2010 by the SS with the aim to prevent overweight and obesity in different 
contexts, including schools. In this agreement, the 5 Steps Strategy for School 
Health was promoted, which provided food and healthy lifestyle guidance to 
students of all educational levels through five simple and practical actions (get 
active, drink water, eat vegetables and fruits, measure yourself, share) (Secretaria 
de Salud and Secretaría de Educacion Pública, 2019). 
 
General guidelines for the sale and distribution of prepared and processed 
food and beverages in the schools of the National Educational System. The 
guidelines were published in the National Gazette in 2010 and updated in May 
2014 (Diario Oficial de la Federación, 2015a). These guidelines include the 
nutritional criteria for the food and beverages preparation or sale of in all public and 
private schools of the National Educational System. They also establish the 
obligations of suppliers and the sanctions of those who fail to comply these 
guidelines (Diario Oficial de la Federación, 2015a; Secretaria de Salud and 
Secretaría de Educacion Pública, 2019).  
 
General guidelines for the installation and maintenance of drinking fountains 
in the schools of the National Educational System. They were published in 
December 2015 in the National Gazette (Diario Oficial de la Federación, 2015b). 
They resulted from an agreement between the SEP and the SS in order to define 
the needs for water supply and quality. The guidelines were developed considering 
the school population, educational level, time and geographic location, as well as 
the design, installation, and maintenance of drinking fountains in schools of the 
National Educational System (Diario Oficial de la Federación, 2015b; Secretaria de 
Salud and Secretaría de Educacion Pública, 2019) More recently, various inter-
institutional efforts have been focused on programs to improve indicators of 
education and health in children and adolescents (Figure 1). 
 

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Figure 1. Programs to improve education and health indicators in Mexico. 
From Programa Salud Escolar (Secretaria de Salud and Secretaría de Educacion Pública, 
2019)  
 
The Health in your School Program (Programa Salud en tu escuela, in Spanish) 
was launched in 2017 and continued during two academic periods. This program 
sought to strengthen the prevention, promotion, and health care in children and 
adolescents through the acquisition of health behaviors. The main lines of action of 
the program are direct diagnostic, monitoring, training, communication 
interventions in schools, and referral to medical services (Secretaria de Salud and 
Secretaría de Educacion Pública, 2019) (Figure 2). 
 
 
Figure 2. Lines of action Health in your School program. From: Programa Salud en tu 
Escuela (Secretaría de Educación Pública, 2017). 
 
In response to the alarming prevalence of obesity and inadequate compliance with 
international health recommendations, in 2019 the SEP in coordination with the 
SS, the Mexican Institute of Social Security (IMSS, for its abbreviation in Spanish), 
the Institute of Security and Social Services of State Workers (ISSSTE, for its 
abbreviation in Spanish), the National System for the Integral Development of the 
Family (DIF, for its abbreviation in Spanish) and the National Institute of Public 
Health (INSP, for its abbreviation in Spanish) developed the School Health: 
Comprehensive Food 
Social Assistance 
Strategy 2011 
Specific action 
program School and 
Health 2007-2012 
Regionalized recipes 
to generate healthy 
menus in full-time 
schools  2015 
Health in your school                  
2017- Sept 2019 
Educating for 
health
• Strengthening 
PE class
Curricular 
autonomy
• Adaptation to the 
needs of the 
students
Health 
professionals at 
your school
• Monitoring and 
health promotion
Collaboration 
with teachers and 
orientation to 
parents
Healthy schools
• Promotion of the 
use of drinking 
fountains

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Healthy and Active Schools program (Salud Escolar: Escuelas Saludables y 
Activas, in Spanish) through a series of intersectoral workgroups (Secretaria de 
Salud and Secretaría de Educacion Pública, 2019).  
 
This program aims to modify the school environment to promote healthy habits. It 
consists of a series of activities grouped into three components: Correct diet, which 
consists of updating and monitoring compliance with the general guidelines for the 
sale and distribution of prepared and processed foods and beverages, the delivery 
of hot breakfasts, and the strengthening of curricular contents on food and health. 
Adequate hydration refers to ensure the availability and accessibility of fresh water 
and promote its consumption during the school day. Physical activity consists of 
increasing the quantity and quality of physical activity among the school community 
before, during, and after the school day (Secretaria de Salud and Secretaría de 
Educacion Pública, 2019). 
 
The first phase of implementation will be in 58 schools in Mexico City during the 
2019-2020 school year among approximately 20,000 schoolchildren. The following 
strategies will be carried out in these schools using an intersectoral form: 
• Measurement of weight and height in schoolchildren by DIF staff. 
• Supervision of food and beverages availability by SS supervisors, and 
supervision of drinking fountains availability by the Federal Commission for 
the Prevention of Health Risks (COFEPRIS for its abbreviation in Spanish). 
• Behavior change campaign by SEP. 
• Application of a food and health questionnaire by SS supervisors. 
• Training for the community delivered by SEP. 
• Promotion of physical activity by conducting quality physical education 
sessions, implementing active recreation strategies and active breaks. The 
SEP will be responsible of these strategies by general teachers (active 
breaks) and physical education teachers (physical education classes). 
• Promote healthy hydration by SEP. 
• Validation of a health-promoting school by SS supervisors. 
• Delivery of hot breakfasts by DIF. 
During the second phase (August 2020-July 2021) the program will be scaled to 14 
states in the country where there are regions among the highest levels of 
marginalization including: Chiapas, Veracruz, Guerrero, Oaxaca, Yucatán, Hidalgo, 
San Luis Potosí, Puebla, Quintana Roo, Nayarit, Durango, Chihuahua, Campeche 
and Michoacán (Secretaria de Salud and Secretaría de Educacion Pública, 2019). 
29 Finally, in a third phase (August 2021 - July 2022) the program will be scaled 
nationwide. The implementation of the program will be carried out through SEP 
teaching staff (Secretaria de Salud and Secretaría de Educacion Pública, 2019). 

 11 
 
3. Conceptual and theoretical framework 
3.1. Risk factors associated with overweight and obesity 
Overweight and obesity are defined as abnormal or excessive accumulation of fat 
that can be harmful to health (World Health Organization, 2000). In the case of 
children and adolescents from 5 to 17-year-old, overweight and obesity is 
determined based on certain considerations (Organización Mundial de la Salud, 
2020): Overweight is the Body Mass Index (BMI) for age with more than one and 
less than two standard deviations above the median established in the WHO child 
growth patterns. Obesity is greater than two standard deviations above the median 
established in the WHO Child Growth Standards. In adolescents aged 18 and 19 
years, overweight and obesity are defined according to the WHO cut-off points, 
which indicate that overweight is a BMI equal to or greater than 25 and obesity is a 
BMI equal to or greater than 30 (Organización Mundial de la Salud, 2020). 
 
Obesity is a multifactorial health problem (Department of Health & Human 
Services, 2018), therefore, attention to this condition requires the analysis of the 
different risk factors. These factors can be from the individual (e.g. lifestyle 
behaviors) to the environmental sphere (e.g. exposure to foods with high energy 
value), social (e.g. social norms), among others (Pate et al., 2013). Certain 
modifiable lifestyle behaviors have been consistently associated with the 
development of obesity in children and adolescents (Katzmarzyk et al., 
2015).These behaviors are mainly physical inactivity (Martinez-Gomez et al., 
2010), insufficient sleep time (Garaulet et al., 2011), sedentary behaviors (e.g. 
watching TV) (Prentice-Dunn and Prentice-Dunn, 2012) and some aspects of the 
diet such as SSBs consumption (Malik, Schulze and Hu, 2006). 
 
Diet is made up of foods, which in turn are made up of nutrients and other 
elements (Tapsell et al., 2016). In this sense, a correct diet is based on 
recommendations for maintaining a healthy diet. These key factors include 
consuming at least 400g of fruits and vegetables per day (World Health 
Organization, 2003), reducing total lipids to less than 30% of the total energy of the 
diet,(FAO, 2010) consuming less than 5 grams of salt per day (Mozaffarian et al., 
2014), limit the consumption of added sugars to a maximum of 10% of the total 
energy of the diet (Tapsell et al., 2016). 
 
Physical activity (PA) can be defined as the body movement produced by the 
contraction of the skeletal muscle that increases the energy expenditure above the 
basal level, that is, the level at rest (World Health Organization., 2019). Regularly 
practiced physical activity has been shown to be a determining factor in energy 
consumption, making it essential for achieving energy balance and weight control, 
with the aim of reversing risk factors for the development of CNCD (Press, 2005). 
The term physical inactivity is associated with the lack of compliance in time and 
intensity that should be allocated to the practice of PA according to the 
recommendations by age group (Tremblay et al., 2010). 
 

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Sedentary lifestyle includes any activity that does not increase energy expenditure 
substantially, such as sleeping, sitting, lying down, watching television and other 
types of entertainment in front of the screen (Tremblay et al., 2010).  
 
SSBs are all those that contain added sugars (sucrose, high-fructose corn syrup) 
(World Health Organization, 2015b). A frequent consumption of SSBs has been 
observed to be associated with an increased risk of weight gain and, therefore, to 
other comorbidities including cardiovascular diseases, diabetes, metabolic 
syndrome, and hypertension (Juan Ángel Rivera Dommarco, Anabel Velasco 
Bernal and Angela Carriedo Lutzenkirchen, 2015).  
3.2. Socio-ecological model for the promotion of healthy school environments 
Socio-ecological models propose that in the development of overweight and 
obesity there is an influence of various environmental factors on behavior and on 
the choices of individuals that lead to an unhealthy lifestyle (Sallis and Glanz, 
2009). The socio-ecological model proposed by the Center for Disease Control and 
Prevention (CDC) contemplates five levels to understand and address the different 
factors interrelated with the development of overweight and obesity (Centers for 
Disease Control and Prevention, 2020). Effective programs for the prevention and 
reduction of these problems should consider each of these levels (Figure 3). 
Therefore, this proposal for political analysis considers the different levels 
proposed in this model as a reference (Centers for Disease Control and 
Prevention, 2020).  
 
 
Figure 3 Socio-ecological Model. From Center for Disease Control and Prevention (CDC). 
From: The five-level social-ecological model. Atlanta, GA: Centers for Disease Control and 
Prevention, Division of Nutrition, Physical Activity and Obesity, 2020.  
 
Social
Community
Organizational
Interpersonal 
Individual

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The individual level of the model focuses on changing knowledge, attitudes, and 
practices, whereas, the interpersonal level focuses mainly on interpersonal 
processes and groups that provide identity and support, such as the family. The 
organizational level is linked to environments outside the home such as schools, 
workplaces, and community centers. These settings determine the food and 
beverages offered and the opportunities for physical activity provided (Centers for 
Disease Control and Prevention, 2020). The community is defined as a large 
organization capable of making changes in politics and the environment to provide 
the best possible options related to food and physical activity. Interventions at the 
social level are those that operate on a larger scale, and are linked to the 
mandatory national and state legislation and school welfare policies (U. S. Centers 
for Disease Control and Prevention, 2020). 
3.3. Public policy analysis 
Policies may include laws, programs, and projects. A public policy is understood as 
a government action that mobilizes human, financial, and institutional resources to 
solve public problems within a society (Tapia et al., 2010). Public policies refer both 
to actions and inactions that affect the set of institutions, organizations, and 
services (Tapia et al., 2010). Policy analysis refers to the retrospective evaluation 
of policies to learn what works and what does not for the development of future 
policies (Buse, Mays and Walt, 2005). Public policies can be designed to achieve 
results such as increasing income, learning, preventing, or reducing disease. For 
this reason, the analysis of public policies constitutes an essential tool for their 
success (Gertler et al., 2017). Despite policy analysis is considered a fundamental 
piece of public health practice, it is not consistent or is not adequately integrated 
into the daily administration of many programs (Prevention, 1999). 
 
According to the Organization for Economic Cooperation and Development 
(OECD), policy analysis allows to determine the value or meaning of an activity, 
intervention, program, or policy (Centers for Disease Control and Prevention, 
2019). In Mexico, the National Council for the Evaluation of Social Development 
Policy (CONEVAL, by its Spanish initials) establishes that the analysis of public 
policies is a tool to constantly improve performance and knowledge about the 
effectiveness of the actions or strategies contemplated in these (Consejo Nacional 
de Evaluación de la Política de Desarrollo Social CONEVAL, 2019). The analysis 
of social programs and policies should systematically and objectively assess the 
design, implementation, results, and impacts of an intervention. In order to have a 
clear idea of the program performance, it is necessary to analyze the results of all 
the elements subject to the analysis. Each type of analysis has a specific objective, 
a general diagnosis of a program or public policy can be reached by the 
complementarity of all objectives (Gutiérrez, 2017).  

 14 
 
 
Figure 4 Types of analysis for social programs and policies 
 
3.4. Design analysis  
The analysis of program or policy design should be conducted during the first year 
of implementation to determine whether the design is adequate to respond to the 
target problem (Consejo Nacional de Evaluación de la Política de Desarrollo Social 
CONEVAL, 2017). This type of analysis provides elements to determine whether 
the actions or strategies proposed are likely to solve the problem, are adequate 
and fit with the platform for delivery and existing capabilities. It also enables the 
program's strengths, opportunities, weaknesses, and threats to be identified that 
minimize future risks (Suarez Bustamante, 2012).  
 
In terms of planning, the design analysis provides information on the national and 
sectoral objectives to which each of the programs aligns and the relationship of 
complementarity that they have with other national programs that seek to solve 
related problems (Consejo Nacional de Evaluación de la Política de Desarrollo 
Social CONEVAL, 2017). In the design analysis, It is verified that there is a theory 
of the program and the matrix of indicators for results, in which the proposed 
activities and components are aligned with the purpose and purpose of the 
program or public policy (Consejo Nacional de Evaluación de la Política de 
Desarrollo Social CONEVAL, 2017). Having a matrix of indicators for results 
feedback the design and facilitates the implementation, monitoring, and evaluation 
of the program.  
 
3.5. Implementation analysis  
Implementation poses important challenges in the policy cycle and its analysis. 
Implementation research has been defined as a scientific method to identify how 
the process of implementing policies, programs, or interventions has been, and if it 
fits with what is planned (Suarez Bustamante, 2012; Peters DH, Tran NT, 2014). 
Implementation research purpose is to understand the execution of programs in 
real conditions and contexts, rather than controlling these conditions or removing 
their influence and possible effects (Peters DH, Tran NT, 2014). Since the central 
node is the users or beneficiaries of a program or intervention, and not only the 

 15 
 
generation of evidence or knowledge working in the places where a program or 
strategy is implemented is imperative, rather than selecting users who do not 
necessarily represent the target population (Proctor et al., 2011).Implementation 
research includes a wide range of methods and approaches to identify and 
address barriers in the program execution. Implementation methods includes 
identifying, evaluating and expanding implementation innovations, strategies to 
enhance the utilization of existing evolutionary science of implementation 
knowledge, tools and frameworks (Tumilowicz et al., 2019). 
3.6 Analysis of results and impact 
The analysis of the results of a program or public policy consists of verifying the 
achievement of the established objectives (Nebot, Ma José López, et al., 2011).In 
the public health arena, the direct results of a program may not be translated 
immediately into an improvement in health outcomes, such as reducing mortality or 
morbidity, thus there are usually expected results at immediate,  intermediate and 
long-term (Nebot, M. José López, et al., 2011). Short-term results include changes 
in knowledge, attitudes, and self-efficacy, changes in services demand and usage, 
and access to products. Intermediate refers to changes in practices or behaviours, 
and long-term results correspond to changes in health outcomes such as 
decreased diarrheal infections, improved nutritional status, and decreased 
anaemia (Nebot, M. José López, et al., 2011). 
The impact analysis of a program focuses on understanding what is the impact (or 
causal effect) of a program on an outcome of interest. The impact analysis 
analyzes the changes in the result directly attributable to the program. The 
causality and attribution approach are the hallmark of program impact analysis 
(Gertler et al., 2017). 
3.7 Gender perspective 
Mainstreaming gender is a comprehensive approach that is aligned with 
Sustainable Development Goals (United Nations, 2019).The United Nations 
Children's Fund (UNICEF) recognizes that integrating perspective into the process 
of preparing, designing, implementing, monitoring, and evaluating programs is a 
strategy to achieve gender equality (UNICEF South Asia, 2018). Mainstreaming 
the gender perspective in the programmatic process seeks to apply the application 
of gender knowledge to implement programs more effectively and take advantage 
of opportunities to promote equality between women and men, and girls and boys 
(UNICEF South Asia, 2018). 
 
Gender perspective permeates at the political, institutional and programmatic 
levels through seven principles. These are: 1) applying  a gender lens to existing 
structures, processes and culture; 2) recognizing the needs and interests of 
women and men, girls and boys as different and equal; 3) promoting the joint work 
of women and men to rebalance access and control over resources and power; 4) 
political will to lead the process; 5) commitment of all the actors to incorporate the 
gender perspective, 6) gender advisor to support and promote skills; and 7) staff 
responsible for implementation aware of the gender perspective (UNICEF South 

 16 
 
Asia, 2018). Figure 5 illustrates the key points for achieving the incorporation of the 
gender perspective in the programmatic phrases.  
 
 
Figure 5 Key points to achieve gender mainstreaming during programming policies. From:  
Gender Toolkit. Integrating Gender in Programming for Every Child in South Asia, 2018. 
 
Likewise, the incorporation of a gender perspective in the program cycle ranges 
from identifying how gender relations and differences in the roles of women, men, 
girls and boys impact the program's objective, as well as barriers and opportunities 
(U. S. Centers for Disease Control and Prevention, 2020). Table 1 details the steps 
at each stage of the program cycle to integrate the gender perspective. 
 
 
Table 1 Integration of the gender perspective at each stage of the program cycle 
Program stage 
Incorporation of the gender perspective 
Planning 
Collection of information disaggregated by sex and age 
Overview of the situation and gender analysis 
Identification of gender problems 
Definition of interventions that address gender inequalities 
Design 
Program design considering gender issues, ensuring the 
participation of women and girls 
Implementation 
Implementation of actions to transform gender inequality 
Monitoring 
Gender-sensitive monitoring, using information 
disaggregated by sex and age 
Evaluation 
Evaluation results based on gender and human rights 
indicators 
Results report 
Sharing results  
Information for future programs 
Note. Adapted from Gender toolkit. Integrating Gender in Programming for Every Child 
in South Asia, 2018. 
1. Information
- Gender analysis.
-Participatory consultation of 
key actors
2. Promotion 
-Incorporation of gender 
perspective.
-Multisector strategies 
3. Support 
-Financial reources
-Institutional capability
-Political Willigness
4. Stregtening
Gender sensitive and 
monitoring evaluation
5. Source
-Experts in gender topics
-Knowledge dissemination

 17 
 
 
4. Problem Statement 
According to ENSANUT 2016, the prevalence of overweight and obesity is 32.8% 
for girls and 33.7% for boys (5-11 years old). A slight increase was observed in 
girls and a decrease of approximately 3 percentage points in boys compared to 
ENSANUT 2012 (Medina et al., 2018). For adolescents between 12 and 19 years 
of age, the prevalence of overweight and obesity in women from rural areas from 
27.7% in 2012 to 37.2% in 2016, and in urban areas from 38.6% in 2012 to 39.8% 
in 2016. ENSANUT 2016 shows heterogeneous results in Mexico related to 
overweight and obesity among schoolchildren (Medina et al., 2018) contrastingly to 
other developed countries which have shown a tendency to stabilize with small 
reductions in the prevalence of overweight and obesity. This could be associated 
with the fact that in the last 30 years Mexico has faced several demographic, 
economic, environmental, and cultural changes that have negatively impacted the 
lifestyle of children (Aceves-Martins et al., 2016; Shamah-Levy et al., 2018). 
 
In Mexico, national policies and programs have been established to reduce and 
contain overweight and obesity in children (Secretaría de Educación Pública, 
2017). Even though various efforts have been made to reverse this trend, high 
rates of obesity are still observed. Policies with a common and concerted vision of 
strategies focused on changing eating patterns and increasing physical activity are 
required. In addition, a rigorous analysis of these is needed to guide the pertinent 
adjustments to maximize their effectiveness (Shamah-Levy et al., 2018).  
 
The monitoring and analysis are fundamental elements of health policies and 
programs provide a set of essential tools that allow them to verify and improve their 
quality, efficiency, and effectiveness (Shamah-Levy et al., 2018). The analysis of 
programs should start from the clear identification of the problems that need to be 
addressed and the understanding of the factors that associated to its origin that are 
susceptible to intervention. In this continuum, each phase in the life of a program is 
subject to an evaluation. The analysis of the different stages of a program 
facilitates the understanding whether the process is actually working to reach 
success. Each phase of the analysis of a program is in turn conceived as a product 
and an input, that is, the evidence is generated on a relevant and pertinent aspect 
of a program and feeds the development of an additional stage of evaluation 
(Shamah-Levy et al., 2018). 
  
The comprehensive analysis of public policies seeks to contribute to decision-
making and social equity, generating knowledge and evidence on the effectiveness 
of programs for the best allocation of resources (Guti斴rrez, 2017). It must be done 
at the beginning, during and after the program runs, starting from the idea of the 
program cycle through a staggered, interactive and interdependent sequence 
(Shamah-Levy et al., 2018).56 The implication of not having a comprehensive 
program analysis approach could lead to overestimating or underestimating the 
findings derived from the practice of a specific evaluation. An evaluation that does 

 18 
 
not identify challenges, areas of opportunity or recommend improvements is a 
weak evaluation and its improving program performance is limited. 
 
Research questions 
1.- Does the current design of the School Health program contribute to improving 
the school environment through strategies aimed at promoting correct nutrition, 
adequate hydration, and increased MVPA? 
2.- What are the barriers and facilitators for the implementation of the School 
Health program? 
3.- What are the changes in the knowledge, attitudes, and practices that boys and 
girls from 3rd to 6th grade of primary have associated with the implementation of 
the School Health Program? 
4.- What is the impact of the School Health program on physical activity levels, 
water, and fruit and vegetable consumption in girls and boys from 3rd to 6th grade 
of primary school? 
5. Study Rationale  
Low- and middle-income countries (LMIC) are currently undergoing a rapid 
epidemiological, demographic, and nutritional transition, which has led to a rapid 
increase in the prevalence of overweight and obesity in the child and adult 
population (Popkin, Lu and Zhai, 2002; Lobstein, Baur and Uauy, 2004; Popkin, 
2004; Popkin, Adair and Ng, 2017). The rapid increase of overweight and obesity 
their prevalence and incidence, multifactorial origin and relationship with the 
development of CNCD make them a public health problems (Rivera et al., 2002). In 
the last four decades, obesity in children between the ages of 5 and 19 has 
increased in most regions and countries. It is estimated that by 2016 there are 
around 340 million of children and adolescents living with overweight or obesity  
(WHO, 2020).In Mexico, 1 out 3 girls and boys from 5 to 11 years old have been 
classified with overweight or obesity, the prevalence even higher among girls and 
boys living in Mexico City (41.6%). These figures are even more worrying when the 
short and long-term consequences of childhood obesity are considered (Rivera et 
al., 2002). 
 
Overweight and obesity in children and adolescents have been associated with 
multiple health outcomes in adulthood such as sleep apnoea, hypertension, 
cardiovascular disease, type 2 diabetes, osteoarthritis, and certain types of cancer 
(Park et al., 2012; Bentham et al., 2017). Likewise, it leads to social and 
psychological problems including nonattendance to school (An et al., 2017), 
bullying (Griffiths et al., 2006; Bacchini et al., 2015), stigmatization, depression and 
low self-esteem (Puhl and Heuer, 2009, 2010). In addition to the association with 
multiple chronic diseases, an increased risk of premature mortality in adulthood 
has been observed (Must et al., 1992; Reilly and Kelly, 2011). 
 
Childhood obesity has been translated into increased costs for the health system 
and society due to its multiple and serious consequences. Childhood obesity is 
associated with high direct and indirect costs,(Hamilton, Dee and Perry, 2018)  
non-attendance at school affecting educational and productive indicators and the 

 19 
 
decrease in productivity and income in the future (Shamah-Levy et al., 2018). By 
2017, it was estimated that costs related to medical care for overweight and 
obesity in Mexico would reach 77,909 million pesos, while the costs associated 
with lost productivity would reach 72,951 million pesos (Hernández Ávila and 
Martínez Montañez, 2011). 
 
In the context of the serious outcomes and high costs for the health system, 
preventing and reversing overweight and obesity in children and adolescents is a 
crucial investment in a country's public health. Interventions aiming to prevent and 
reduce the prevalence of obesity from an early age have great potential to lead 
substantial economic and health benefits (Hamilton, Dee and Perry, 2018). 
According to an OECD report, comprehensive prevention programs could annually 
prevent 55,000 deaths from chronic diseases in Mexico (Sassi, 2010), and among 
the most effective measures to prevent obesity are interventions in the school 
setting. 
 
Multi-component Interventions in the school environment that promote healthy 
eating and physical activity  and focused on prevention instead of treatment 
generally succeed (Gonzalez-Suarez et al., 2009; Lobelo et al., 2013; Safdie, 
Jennings-Aburto and Lévesque, 2013). Systematic reviews of interventions in 
multiple countries indicate that the key elements for the prevention of overweight in 
programs at the school level include: training of school personnel, curriculum 
integration, modification of environments and the design of materials and programs 
specific to the population objective (Kahn et al., 2002; Hoehner et al., 2008). The 
School Health program integrates key elements of effectiveness for the promotion 
of healthy lifestyles and the prevention of overweight and obesity. The activities 
designed by SEP and SS aimed at promoting correct nutrition, adequate hydration, 
and physical activity in Mexican children and adolescents providing a unique 
opportunity to improve the health and well-being of this population beyond short 
terms benefits. However, in order to reach their full potential, these types of 
interventions require a comprehensive analysis of their design, implementation, 
results, and impact to identify the effect and mechanisms by which they could be 
effective (Verstraeten et al., 2012). Comprehensive analyses also contribute to 
building in evidence that facilitates decision-making processes towards scalability. 
Thus, the School Health program comprehensive and rigorous analysis is 
imperative. 
6. Objectives 
General  
To conduct a comprehensive analysis of the Programa Salud Escolar in public 
primary schools in Mexico City. 
 
Specific 
• To analyze whether the design of the School Health program contributes to 
improving the school environment through the promotion of correct nutrition, 
adequate hydration and the increase of MVPA 

 20 
 
• To identify whether the School Health Program is being implemented 
according to its design and the regulations established for this purpose. 
• To identify barriers and facilitators for the implementation of the strategies of 
the School Health Program associated with correct nutrition, adequate 
hydration, and quality physical activity among schoolchildren. 
• To estimate changes in knowledge, attitudes, and practices related to 
correct nutrition, adequate hydration, and physical activity in schoolchildren 
from 3rd to 6th grade of primary school after one year of implementation of 
the School Health program. 
• To analyze the impact of the School Health Program on schoolchildren 
physical activity levels, water consumption, and fruit and vegetable 
consumption. 
7. Materials and methods 
A comprehensive analysis of the design, implementation, results, and impact of the 
School Health Program will be carried out, which will be implemented in 58 schools 
in Mexico City during the first phase of implementation from October 2020. This 
study includes a design analysis of the Health School program, a quasi-
experimental study to evaluate the impact of School Health on the individual 
outcomes of interest in the program (correct hydration, healthy eating, and physical 
activity), as well as an evaluation of the implementation. This analysis will be 
developed through three methodological stages which are presented in Figure 6.  
In this protocol is presented the first stage of implementation of this analysis only.

 21 
 
Figure 6. Stages, measurements and instruments of the Comprehensive analysis 
of Salud Escolar program 
 
 
First Phase 
Analysis and 
Reporting 
Procedure 
Second Phase 
Third Phase 
Analysis and 
reporting 
procedure 
Analysis and 
Reporting 
Procedure 
2 months 
4 months 
2 months  
Baseline 
outcome 
measurement 
Baseline impact 
measurement 
4 months 
4 months 
2 months  
2 months  
Implementation 
2 months  
2 months 
Survey 
Questionnaire applied by the Ministry 
of Health  
(n=58 schools)  
Survey 
Questionnaire applied by the Secretary 
of Health  
(n=58 schools)  
Observation 
Compliance verification 
* Food and beverage sales 
guidelines 
* drinking fountain (n = 58 
schools) 
Quantitative component 
Qualitative component 
n=6 schools (3 x NSE) 
 
* 12 focus groups with parents (2 x school) 
* 12 focus groups with children (2 x school) 
* 12 interviews with teachers (2 x school) 
*  6 interviews with principals (1 x school) 
*  6 interviews with food and beverage sales managers (1 x school) 
* Between 6 to 10 interviews with institutional heads 
Individual  
Accelerometry (n = 150) 
Nutritional quality assessment 
school lunch and hydration 
(n = 1200) 
 
Environmental 
Questionnaires / observation 
Environment indicators 
School audit and SOFIT 
(n = 12 control schools and 12 
intervention) 
Individual  
Accelerometry (n = 150) 
Nutritional quality assessment 
school lunch and hydration 
(n = 1200) 
 
Environmental 
Questionnaires / observation 
Environment indicators 
ISCOLE, SOFIT 
(n = 12 control schools and 12 
intervention) 
Final 
Measurement 
of Results 
Final Impact 
Measurement 
Design 
Analysis 
Documentary analysis 
Semi-structured interviews 
(n=10)  

 22 
 
7.1. Design analysis  
The design analysis of Salud Escolar will be conducted through a desk-review and 
semi-structured interviews (if necessary). The information derived from this 
analysis will (1) facilitate decision-making processes to improve the internal 
logistics of Salud Escolar, and (2) facilitate the understanding of how Salud Escolar 
may contribute to solve the target health problem. 
 
Several meetings will be held between the research team and the technical team of 
Salud Escolar in order to define key aspects of the methodology, such as the 
documents to be reviewed and the key actors to interview (if necessary), as well as 
for the review, discussion, and socialization of the preliminary results. The analysis 
will be carried out from October to November 2019 through the following phases: 
 
Desk-review 
Administrative records, databases, documents and public documentation related to 
Salud Escolar will be gathered. Additional information or documents considered as 
relevant by Salud Escolar technical team will be included. An adaptation of 
CONEVAL’s design evaluation Terms of Reference (TOR) will be used as an 
instrument to conduct the desk-review (Table 2). In addition, references from the 
United Nations Children's Fund (UNICEF) will be considered to include a gender 
perspective during the analysis (Table 3). This approach considers the differences 
in roles and responsibilities attributed to women and men, girls and boys (UNICEF 
South Asia, 2018). 
 
Three main documents have been considered for the desk-review to answer the 
questions of CONEVAL’s instrument (Table 2): 1) Document Salud Escolar: 
Escuelas Saludables y Activas, 2) Program diagnostic and supervision 
instruments, 3) results of other international school-based programs that have 
been successful in promoting healthy habits in children and adolescents,. 
Additionally, the following documents could be considered as well: 
• General guidelines for the sale and distribution of prepared and processed 
foods and beverages in the schools of the National Educational System 
(Diario Oficial de la Federación, 2015a). 
• Official Mexican Standard NOM-251-SSA1-2009, Hygienic practices for the 
process of food, beverages or supplements (Diario Oficial de la Federación, 
2015a). 
• Official Mexican Standard NOM-043-SSA2-2005, Basic health services. 
Promotion and education for health in nutrition. Criteria for providing 
guidance (Diario Oficial de la Federación, 2005). 
• General guidelines for the installation and maintenance of drinking fountains 
in the schools of the National Educational System (Diario Oficial de la 
Federación, 2015b).  
• Official Mexican Standard NOM-201-SSA1-2002, Products, and services. 
Water and ice for human consumption, loose and packaged (Diario Oficial 
de la Federación, 2002a).  

 23 
 
• Official Mexican Standard NOM-230-SSA-2002, Environmental Health. 
Water for human use and consumption, sanitary requirements that must be 
met in public and private supply systems during water management (Diario 
Oficial de la Federación, 2002b).  
• Guidelines for the Comprehensive Strategy for Food Social Assistance - 
School Breakfasts (Secretaría de Salud, 2019).  
CONEVAL’s instrument includes questions with dichotomous response options 
(YES / NO), which should be supported by documentary evidence. When the 
answer is YES, one of the four levels of response defined for each question will be 
selected (https://www.coneval.org.mx/Evaluacion/MDE/ Documents / 
TDR_Diseno.pdf) considering the adaptations made by the evaluation team (Table 
2). Questions that do not have binary answers (do not include response levels) 
should be answered based on the desk-review and providing a rationale for the 
response. Each question will be answered in a maximum of one page. The 
following concepts will be included: a) the question, b) the binary (YES / NO) or 
open answer (as appropriate), and c) the analysis that justifies the answer. When 
the characteristics of Salud Escolar do not allow answering a specific question, the 
option "Does not apply" will be also available requesting an explanation of this. 
 
Table 2 Research questions contained in the CONEVAL’s instrument 
Section 
Questions 
Creation of program 
creation and design 
Is the priority problem or need that the program seeks to 
solve identified in a document? 
Is there any diagnosis of the problem that the program is 
aiming to address? 
Is there theoretical or empirical evidence that support the 
type of intervention in the program? 
Does the program have a theory of change? 
Is there evidence that a formative research has been 
carried out whose results have been contemplated in the 
program design? 
Contribution to 
national goals and 
objectives 
The program purpose is linked to the objectives of the 
sectoral, special, or institutional program? 
Which goals and objectives, transversal strategies of the 
current National Development Plan are linked with the 
sectoral, special, or institutional objectives associated with 
the program? 
How is the purpose of the program linked to the 
Sustainable Development Goals? 
Potential and target 
population 
Are the populations (potential, objective, and attended) 
defined in official documents and/or in the diagnosis of the 
problem? 
Record of 
beneficiaries and 
service mechanisms 
Is there evidence of the goods and services of the 
program recipients? 
Do the procedures for granting the goods or services to 
the beneficiaries have the desired characteristics? 

 24 
 
Results Indicator 
Matrix (MIR) 
Is there one or a group of activities for each of the MIR 
components of the program? 
Do the components in the MIR meet the expected 
characteristics? 
Does the purpose of the MIR have the desired 
characteristics? 
Does the end of the MIR have the desired characteristics? 
Is it possible to identify the narrative summary of the MIR 
in the normative document of the program? 
Are there indicators to measure program performance 
with the desired characteristics at every level of the 
program's MIR? 
Do the program indicator technical sheets have the 
desired information? 
Do the goals of the program's MIR indicators have the 
desired characteristics? 
How many of the MIR indicators have means of 
verification specified with the desired characteristics? 
Is it possible to identify the desired information 
considering the verification set objective-indicators-
means? 
Do you suggest modifications to the MIR of the program 
or adding changes to solve the drawbacks identified. 
Budget and 
accountability 
Does the program identify and quantify the goods and 
services expenses and break them down into the 
recommended categories? 
Does the program have transparency and accountability 
mechanisms with the recommended characteristics? 
Do the procedures for the execution of works and / or 
actions have the recommended characteristics? 
Complementarities 
and coincidences 
with other federal 
programs and / or 
social development 
actions 
The evaluated program could be complementary and / or 
coincide with other federal programs and / or social 
development actions? 
 
 
If missing elements are identified in the Matrix of Results Indicators (MIR, by its 
Spanish initials) during the desk-review, the research team will propose an 
adequate indicator. The MIR will represent the summary of the strategy in a four-
row by four-column matrix describing the purpose, components, activities, and the 
means of verification and assumptions for each objective of the strategy (UNICEF 
South Asia, 2018). The desk-review will conducted by INSP researchers with 
extensive experience in the evaluation of health and nutrition policies and 
programs in Mexico and Latin America with at least a master degree. 
 

 25 
 
Data gathering 
Based on the results of the desk-review, semi-structured interviews with key actors 
will be conducted. The mapping of actors will be carried out in coordination with the 
technical team of Salud Escolar to identify the key actors that may be related to the 
design of the program. An agenda with the identified key actors will be prepared. 
 
Recruitment of participants 
After mapping the key actors, the technical team of Salud Escolar will send an 
invitation e-mail to each key actor. Then, the INSP research team will explain 
potential participants the nature and objectives of the project and provide a short 
summary with the main activities in which they would participate. Interviews will be 
scheduled for all informants who consent to participate in the study. 
 
Table 3 UNICEF references for gender mainstreaming in program design 
Program phase 
Reference 
Planning 
1 B. During the planning, was accurate information 
collected about women, men, girls and boys for the design 
of the program? 
Design 
2b. Were concerns about the role of gender included? 
3b. Is the full participation of women and girls ensured? 
Implementation 
4b. Do the planned actions ensure the participation of all 
gender-aware groups? 
Monitoring 
5.b Is monitoring of the program gender-sensitive using 
data disaggregated by sex and age? 
Evaluation 
6b. Does the program use indicators based on gender and 
human rights? 
Note. Source: Gender Toolkit. Integrating Gender in Programming for Every Child 
in South Asia, 2018. 
 
Techniques and instruments for data collection  
Interviews will be conducted with the purpose of strengthening and complementing 
the results derived from the desk-review. The instruments will be piloted before 
data collection. 
 
Semi-structured interviews 
Qualitative methodologies have been widely used to explore the limitations of 
health interventions or programs (Farquhar et al., 2006). A purposive sample of 
key actors will be selected according to the purpose of this analysis. An average of 
ten semi-structured interviews will be conducted. Table 4 describes the sectors and 
areas to which these key actors participate within the program, as well as the 
mechanism that will be used to record the data from the interviews. The profile of 
the key informants and the final number of interviews will be defined according to 
the needs identified in the desk-review. An interview guide in the semi-structured 
format previously designed and discussed with the technical team of the School 
Health Program will be used (Appendix 1). Before conducting the interviews, an 
informed consent will be sough (Appendix 2), and the character of voluntary 
participation will be highlighted. The interviews are planned to last 50 minutes. 

 26 
 
 
Table 4 Description of the objective, sectors, and areas of interference of the 
participants in the semi-structured interviews 
Technique Objective 
Participants Sectors 
Areas 
Data register 
Semi-
structured 
interviews 
Strengthen 
and 
complement 
the results 
derived 
from the 
cabinet 
analysis 
4 
Health 
Health 
promotion 
The interviews 
will be audio 
recorded, 
transcribed 
verbatim and 
analysed. 
4 
Education Planning 
2 
 
DIF 
 SEDIF and 
SNDIF 
Note. SEDIF= State System for the Integral Development of the Family, 
SNDIF=National System for the Integral Development of the Family. 
 
The content of the interview guides is summarized in Table 5. 
 
 
Table 5 Description of the thematic axes and subtopics to be addressed in the 
interviews 
Topics 
Subtopics 
Creation of the School 
Health Program 
Role in the design of the program 
Formulation process 
Program communication plan 
Training plan 
The problem to be solved 
Content and focus of 
the School Health 
Program 
Objectives 
Components 
Activities 
Potential and target 
population 
Coverage 
Procedures for granting goods and services 
Information recording systems 
Budget and 
accountability 
Transparency and accountability mechanisms 
Budget allocated 
Complementarians 
and coincidences with 
other federal 
programs 
Sectors involved in its implementation 
Complementarity between programs 
Gender perspective 
Mainstreaming gender in the phases of the Program 
 
 
Fieldwork  
The staff responsible for data collection will have a minimum level of expertise with 
experience in qualitative research and in research projects associated with public 
health policies. 

 27 
 
 
Analysis and systematization of information  
Interviews will be transcribed verbatim. Transcriptions will be carried out by 
specialized personnel following guidelines previously established by the research 
team. The analysis will be guided by the principles of the thematic analysis, which 
consists in a method for identifying, analysing and reporting patterns (themes) 
within the data (Braun and Clarke, 2006). Themes and codes will be identified a 
priori from the objectives of this study considering the thematic axes previously 
described, and according to the information collected in the field (emerging themes 
and codes). Subsequently, the categories and codes initially developed will be 
refined to proceed with the analysis of the entire data (Liamputtong, 2016). A 
codebook with be developed to define and name the themes and codes. The 
collected data will be coded using the software NVivo 12. 
 
 
 
The results derived from semi-structured interviews will be triangulated with the 
findings of the desk-review. According to Denzin (Denzin, 1978), triangulation 
refers to the use of qualitative and quantitative methodology, as well as data 
sources, theories and researchers for the study and understanding of a 
phenomenon. In the case of this evaluation, triangulation includes different: 1) 
times for data collection, 2) places for data collection, and 3) participants. Within 
the framework of a qualitative investigation, the triangulation of data includes the 
use of various strategies to study the same phenomenon, for example, the use of 
various methods (individual interviews, focus groups, observation, etc.) (Mathison, 
1988). When performing the triangulation of different techniques or strategies, it is 
believed that the weaknesses of each particular strategy do not overlap with those 
of the others and instead their strengths add up. Data triangulation will be 
conducted to visualize the phenomenon from different angles and to complement 
the information 
 
Preparation of SWOT analysis and formulation of recommendations  
Based on the results of the previous stages, the main strengths, opportunities, 
weaknesses, threats (SWOT), and recommendations associated with each of the 
sections considered in the framework of this evaluation will be integrated into a 
table. 
7.2 Short-term results analysis (baseline measurement) 
The results of Salud Escolar will be estimated by measuring changes in 
knowledge, attitudes, and practices related to correct nutrition, adequate hydration 
and physical activity. The Health and Nutrition Questionnaire, prepared by the 
Ministry of Health, will be used. This questionnaire has two versions [for 3rd grade 
of primary school (Appendix 3); and for 4th to 6th grade (Appendix 4) and consists 
of 3 main sections ( Figure 6).The questionnaires were previously used in the 
Health in your School program. Data collection will be conducted by the Ministry of 
Health and the INSP research team will be solely responsible for data analysis.  
 

 28 
 
Sample 
The questionnaire is addressed to all girls and boys from 3rd to 6th grade (n = 
approximately 20,000 girls/boys) of the 58 primary schools selected for the 
implementation of the first phase of Salud Escolar. As part of Salud Escolar, staff 
from the Ministry of Health will go to the schools on the first day and give teachers 
a diptych announcing the Program, actions, and objectives (Appendix 5) and 
informed consent for parents. Teachers will send these documents in children’s 
backpack and parents will review and return the signed consent (if given) on the 
next day.  
 
Data collection 
The Ministry of Health staff will apply the questionnaires with the support of the 
teaching staff. The questionnaires will be administered indoors (e.g. classroom) 
during school hours. Children whose parents have given their consent to 
participate will be included and children’s oral assent will be obtained.  
 
Data processing and analysis 
Data will be coded by the Ministry of Health staff using an automated system and 
the database will be given to the INSP research team for subsequent analysis. A 
descriptive analysis of the data will be carried out, estimating means standard 
deviations for the continuous variables and proportions (%) for the categorical 
variables. Likewise, all available information will be disaggregated by sex and age. 
 
 
Figure 7 Sections included in the Health and Food Questionnaire 
 
 
Knowledge
•Intellectual capacity to remember terminology related to food, nutrition, 
and physical activity.
•Section of the food and health questionnaire: “What I know"
Attitudes
•Emotional, motivational, perceptual, and cognitive beliefs that can 
positively or negatively influence an individual's behavior or practice 
(e.g. perceived benefits, perceived barriers, self-efficacy, preparation for 
change)
•Sections of the food and health questionnaire: "What I like" and "What I 
think I am capable of doing"
Practices
•Observable actions of an individual that could affect their health, 
nutrition or that of other people
•Section of the food and health questionnaire: "What I do"

 29 
 
7.3 Impact analysis (baseline measurement) 
Considering that Sauld Escolar aims at creating healthy school environments, the 
impact analysis will be focused on the evaluation of some individual and 
environmental indicators. 
 
Study design 
A quasi-experimental design with baseline and endline evaluation will be used in 
schools where the School Health Program will be implemented (intervention 
group), and in schools where the program will not be implemented (control group). 
Measurements will be made prior to the start of the school program (pre-
intervention), and 10 months after its implementation (post-intervention). 
 
Study hypothesis  
Based on similar studies previously carried out in the school population (Carriedo 
et al., 2013; Safdie, Jennings-Aburto and Lévesque, 2013; McKenzie, 2015), we 
hypothesized the following changes in the endline measurement among children 
exposed to Salud Escolar, in comparison with those in the comparison group (not 
exposed to the intervention program): 
• water consumption will increase by 171 ml (Carriedo et al., 2013), 
• time engaged in MVPA will increase in total 10 minutes per day, with an 
increase of 4 minutes per day during school recess and 4 minutes per day 
during physical education classes (Haerens et al., 2007), 
• the percentage of girls/boys who consume fruits and vegetables daily in the 
school environment will increase by 6.7% (Safdie, Jennings-Aburto and 
Lévesque, 2013). 
 
Sample size calculation 
The impact analysis study will be carried out in 30 primary schools in Mexico City 
(Intervention group = 15; Control Group = 15). The number of schools included 
was defined to better identify the effect (with a small number of schools the effect 
of the intervention could be confused with the characteristics of the schools) (Soto-
Estrada et al., 2016). Other criteria considered were the short time available for 
data collection (no more than three months according to reports by the Ministry of 
Health based on their experience during the implementation of the Health in your 
School program), as well as the available funds. 
Table 6 presents the sample size necessary for hypotheses testing, considering a 
significance level of α = 0.05, a statistical power of 80%, and a correlation of 0.2 
between the basal and final measurements. Considering that the largest sample 
size required is the one to estimate the effect of the intervention on fruit and 
vegetable consumption (n = 388), a design effect of 2, and 20% losses to follow-
up, it is estimated that a total of 980 girls and boys (n = 490 per intervention group) 
are needed.  
A baseline measurement of 1000 girls and boys has been proposed. Considering 
the same assumptions of design effect and loss to follow-up, it was estimated that 
a sample size of 595 girls and boys is required for accelerometry measurements 
and the System for Observing Fitness Instruction Time (SOFIT). 

 30 
 
 
Table 6 The sample size required to estimate expected differences 
Indicator 
Standard 
deviation 
Expected 
difference 
Sample 
size 
Water consumption (ml/day) 
631 
171  
384 
MVPA (min/day) 
40 
10  
248 
MVPA (min/PE) 
9  
3.8  
248 
MVPA (min/recess) 
12  
3.9  
244 
Fruit and vegetable consumption (% of 
schoolchildren) 
 
6.2% 
388 
Note. MVPA= moderate to vigorous physical activity; PE= physical education. 
 
Schools selection 
The intervention group schools will be selected randomly from the predefined list of 
58 schools selected by the Ministries of Health and Education to participate in the 
first phase of implementation of Salud Escolar. The control group will be selected 
from a list of schools available in Mexico City provided by the Ministry of Education, 
where the program will not be implemented. Given that the selection of the 58 
schools of the intervention group will not be at random, schools from the control 
group will be as similar as possible to those in the intervention group. Thus, it will 
be sought that the schools of both groups (i.e, intervention and comparison) are 
paired based on the following characteristics: 
 
• Location: schools should be in the same geographical area< 5 km. 
• Basic Geostatistical Area (BGA): within a similar BGA level 
• Type of working day: in the same type of working day (regular, extended or 
full time) 
• Hours: both in the morning or in the afternoon 
• Size: schools from both groups will be expected to have a similar number of 
students and classes. 
Participants  
For the evaluation of the individual indicators, boys and girls from 1st to 6th grade 
of primary school will be selected at random from the attendance lists of the school 
groups. A written consent from parents will be requested (Appendix 6) and and an 
assent from the participants (Appendix 7). In the case of the evaluation of 
environmental indicators in schools, all schools´ principals will be invited to 
participate and a written consent will be requested (Appendix 8).  
 
Inclusion and exclusion criteria for schools and participants 
Students who have provided assent to participate and who have the informed 
written consent of parents or caregivers will be eligible. Children who have a 
physical or mental disability to participate the program will be excluded. 
 
Measurements 
 

 31 
 
Healthy diet. Two instruments will be used, a 24-hour recall to estimate the total 
diet of schoolchildren, and food weighing to estimate food consumption within the 
school environment. 
 
24-hour recall. This instrument will be used to measure and evaluate the total diet 
of schoolchildren. A 24-hour recall will be applied to mothers, fathers, or caregivers 
of participants responsible for feeding and preparing meals at home (Appendix 9). 
The registration system used for the National Health and Nutrition Surveys will be 
used (Shamah-Levy et al., 2018). The 24-hour recall consists of an interview in 
which participants are asked to remember and describe all the food and beverages 
consumed the day before the interview, from the first intake of any food or drink, up 
to the last food or drink consumed before sleeping (Shim, Oh and Kim, 2014). The 
adult responsible for feeding the child will be asked to name, describe and quantify 
the amounts of all the food and drinks consumed by the participant the previous 
day. The information collected will include the characteristics of the food or drink, 
including preparation method, brands and quantity consumed (considering edible 
portion and total proportion consumed). Food and beverages consumed at school 
or outside the home without the adult being interviewed will be reported by 
schoolchildren. The instrument will be applied by trained staff and will be collected 
with the use of a laptop, using a software to collect 24-hour recalls in the Mexican 
population. 
 
Since part of the objectives of Salud Escolar is to improve the quality of the 
schoolchildren's diet and reduce the consumption of highly processed foods, the 
information obtained from the 24-hour recall will be used to evaluate the 
consumption of fruits and vegetables, sugar sweetened beverages (SSBs), and 
highly processed foods. A comparison will be conducted between participants 
consumption against the recommendations established in the Dietary and Physical 
Activity Guidelines in the Context of Overweight and Obesity in the Mexican 
Population (Bonvecchio, 2015). The proportion of schoolchildren who consume 
fruits and vegetables, and ultra-processed foods as outcome variables will be 
estimated. 
 
Food and drink consumption during recess. Trained staff will record the food and 
drinks consumed during recess (snack or lunch) to objectively measure food 
consumption at school. Schoolchildren will be asked to show their lunch and 
beverages (brought from home or purchased at school) and what is contained will 
be recorded and weighted. This process will allow the detailed recording of the 
consumption of food and beverages at school campus, and the evaluation of the 
changes in food and beverages brought from home and purchased at school. 
 
Correct hydration. 
To analyze the impact of Salud Escolar on water consumption, a Beverage Diary 
will be applied to participants from 3rd to 6th grade (Appendix 10). The diary has 
been previously used and validated in different studies carried out by the INSP 
among schoolchildren (unpublished data) (Safdie et al., no date; Pérez, 2016). 
Participants will receive a hard copy of the diary and will be asked to complete it at 

 32 
 
home during  three days. Data will be coded in Excel format and the consumption 
of water and SSBs (ml/day) will be estimated based on previously standardized 
procedures (Salud, 2015). 
 
Physical activity 
Direct observation and accelerometry will be used to measure physical activity. 
 
Direct observation. This will be used to analyze the effect of Salud Escolar on the 
quality of physical education (PE) classes and active recess of the program 
(minutes of MVPA). The System for Observing Fitness Instruction Time (SOFIT) 
will be used to evaluate PE and an adapted version will be used to measure 
physical activity during recess. SOFIT is a comprehensive tool for evaluating 
physical education in terms of student physical activity levels, class context, and 
teacher or instructor behavior (McKenzie, 2015). This is a validated and reliable 
tool, which can be used in multiple contexts (McKenzie, 2015).  Prior to the start of 
the lesson, target students will be selected. One student will be observed for 4 
minutes, then the observer will focus on the other remaining students for 4 minutes 
(each) until class ends. Prerecorded verbal prompts on CDs, MP3s, or audiotapes 
will be used to help the observer to systematically follow up the class on a 10-
second intervals basis throughout the class. During each registration interval, the 
observer records a code corresponding to the behaviors of interest (students, 
context, or teacher). 
 
All data will be recorded in a specific format for subsequent analysis (Appendix 11). 
Data will be summarized by time (3 intervals = 1 minute), percentage of intervals or 
class time, or estimated energy expenditure. Comparisons may be made between 
different categories, between classes over time, or against established standards. 
The main variables to obtain from this observation method are: 
• The physical activity levels of students: Minutes and % of the PE class in 
each of the intensities of physical activity (including minutes of MVPA), 
energy expenditure estimated per session (kcal/kg) and rate of the 
estimated energy expenditure (kcal/kg/min) (Department of Health & Human 
Services, 2018). 
• Physical education schedule: frequency of sessions and adherence to the 
proposed schedule, scheduled duration and actual duration of the sessions. 
• Context of the session: minutes and % of the session time spent in 
administrative matters, instruction, physical fitness, skill exercises, play time 
and others. 
• Teacher behavior: % of the class that the teacher or instructor invests in 
promoting the activity during and outside of class time. 
Accelerometry 
Actigraph GT3X + accelerometers (ActiGraph, LLC, Pensacola, FL, USA) will be 
used to assess the effect of the intervention on total physical activity (minutes per 
day of MVPA). Accelerometry is a method for objectively monitoring physical 
activity and providing rich data about users’ physical activity intensities. 
Accelerometers will be distributed to a subsample of participants in schools by 

 33 
 
trained staff who also will record allocation and collection of the devices (Appendix 
12).  
 
Participants will be asked to wear an accelerometer with a flexible belt, on the right 
side at the axillary midline, for at least 7 full days (plus one day of familiarization 
and the morning of the last day), including two weekend days. Wearing time will be 
at least for 7 days in order to maximize the number of participants with sufficient 
valid data (minimum wearing time of 4 days with 10 hours each day). Participants 
and their parents or caregivers will be explained to remove the accelerometer only 
during bedtime and water-based activities (e.g. swimming), clear information and a 
demonstration of wearing the device will be provided by trained staff (Appendix 
14). To ensure the adequate use of accelerometers, a daily checklist (Appendix 13) 
will be used to record the use of the accelerometer every morning at the school by 
trained staff. This school visits will be an opportunity for the trained staff to clarify 
participants questions about the accelerometer. Phone messages and calls, and 
small incentives (stickers) at the time of verification by the staff will be used as 
compliance enhancing strategies.  
 
The software ActiLife 6.13.4 will be used for accelerometer initialization prior to 
allocation and data download after collection. Daily MVPA will be estimated using 
an algorithm prepared by the research team. Freedson's cut-off points will be used 
to estimate the schoolchildren time per day spent at different intensities of physical 
activity (Department of Health & Human Services, 2018).  
 
Other variables 
 
Anthropometry 
Weight and height will be measured in the whole sample (Hernández and Rivera, 
2006).96 Weight will be used as an indicator of total body mass and will be 
measured using portable scale with an accuracy of ± 200 g. The scale will be 
placed on a flat surface in vertical line to a wall, at a 90-degree angle. The weight 
will be recorded with the participant standing in the central part of the scale, behind 
the wall, in a straight position (barefoot, with heels together, toes slightly apart and 
arms hanging parallel to the axis of the body). Participants should be barefoot and 
in light clothing (no sweater or objects in the bags) during weight measurement. 
 
Height will be used as an indicator of schoolchildren linear growth. A stadiometer 
will be used to measure height. This consists of a flexible metal measuring tape 
with a length of 2 m and a portable square that is placed on a right wall at a 90-
degree angle with the floor. The height will be measured in a straight position with 
the  back and head resting on the wall. Participants´ heads will be oriented by 
looking for the Frankfort plane (horizontal line from the lower orbital end to the 
upper edge of the external ear canal that keeps the head parallel to the floor). 
Participants will be asked to remove their shoes and any objects on their head (e.g. 
pins, buns, high hairstyles). The size will be recorded to the tenth centimeter 
(0.1cm). 
 

 34 
 
Socioeconomic status 
The questionnaire from the Mexican Agency for Market Research Agencies (AMAI, 
by its Spanish initials) will be used to estimate the socioeconomic level of the 
family (Appendix 15) (AMAI, 2018). This questionnaire considers the following 
variables: 1) number of full bathrooms, 2) number of cars, 3) home broadband, 4) 
household income of more than 14 years, 5) average monthly salary (<$ 2,699; $ 
2,700 - $ 6799; $ 6,800- $ 11,599; $ 11,600- $ 34,999;> $ 35,000). This model 
defines a total number of points for each of the items and uses a maximum score 
of 300 points that are distributed among 7 socioeconomic levels from A/B to E. 
• A/B. The socioeconomic level A/B includes 82% of households in which the 
head of the family has professional studies, of these 98% of households 
have home broadband. In this level there is the highest investment in 
education (13%) and one with the lowest proportion spent on food (25%). 
• C+. The 89% of households at this level have one or more transport 
vehicles and 91% have home broadband. Around 31% of their spending 
goes to food and 5% to footwear and clothing, which is, similar to other 
levels. 
• C. The 81% of the households at this level have a head of household with 
studies higher than primary and 73% have home broadband. Of the total 
expenses of this level, 35% are destined to food and 9% to education. 
• C-. In the 73% of households at this level have a head of household with 
studies above. Of these homes 47% have home broadband, 38% of the 
expenses is allocated for food, and 5% is for clothing and footwear 
• D+. In 62% of households at this level, the head of the household has a 
higher education than primary. Only 19% have home broadband, 41% of the 
expenses is in food and 7% to education 
• D. In 56% of households the head of the household has studies until primary 
school, 4% has home broadband, and 46% of the expending is in food. 
• 
E.  Most households at this level (95%) have a head of household with 
studies not higher than primary education and only 0.1 % have home 
broadband. The spending at this level allocated to food is 52%) and this is 
the group with the lowest proportion of spending dedicated to education 
(5%). 
 
Environmental indicators 
The School Audit Tool developed for the International Study of Childhood Obesity, 
Lifestyles and the Environment (ISCOLE) will be used to measure school 
environment (Broyles et al., 2015). This tool has been found feasible and reliable to 
be applied in school contexts in different countries (Broyles et al., 2015). The tool 
will be applied in the school of intervention and comparison groups. The School 
Audit Tool evaluates school policies and practices related to healthy eating and 
physical activity and will be carried out through direct observation and 
questionnaires applied to the school's administrative staff. 
 
This tool was developed based on surveys from The school administrator survey 
(Council of Chief State School Officers, no date), from the “School Health Policies 

 35 
 
and Practices” (SHPPS) study (Council of Chief State School Officers, no date), 
from the Health Behavior in School-Aged Children (HBSC) survey (Council of Chief 
State School Officers, no date), and from the School Health Environment Survey 
(SHES) (Kroeker et al., 2006). The components of the School Audit Tool assessing 
the school's built physical environment were taken from the school audit tool of the 
Sport, Physical activity and Eating behavior: Environmental Determinants in Young 
people (SPEEDY) study showing acceptable validity and reliability (Jones et al., 
2010). The tool also includes items to characterize the school grounds, the 
aesthetics of the school, the supply of food and access to fast-food restaurants 
around the school, and the amount of class time spent on physical education 
(Appendix 16). 
 
Data analysis. 
For the baseline evaluation, a descriptive analysis of the sample is contemplated, 
estimating the means and standard deviations for continuous variables, as well as 
percentages for categorical variables. Descriptive variables will be estimated in the 
total sample and by study group. A consistency in the results from the research 
team and the characteristics of the schools reported in the School Audit Tool will 
be conducted, using paired t-tests for continuous variables and Chi-square tests for 
categorical variables. The statistical package Stata 14 will be used for data 
analysis which will be disaggregated by participants sex and age. 
The impact of Salud Escolar will be estimated using a difference in difference 
analysis considering schools as clustering variables. Behaviors of interest will be 
the outcome variables and group allocation and time will be the independent 
variables. The effect of Salud Escolar will be tested by introducing an interaction 
term between time and group allocation.  
 
Fieldwork  
The fieldwork will be carried out by three teams of six members, three supervisors 
(one for each brigade) and a coordinator. In each team two members will apply 
accelerometry and anthropometry measurements, four will apply the beverage 
diary and the 24-hour recall. Each team is estimated to work within each school for 
approximately one week, which represent a total of 12 schools visited in a month 
and two and a half months for the full data collection at the baseline stage.  
7.4 Implementation analysis (Second stage) 
An analysis of the implementation of the first phase of Salud Escolar will be carried 
out approximately 6 months after the program begins. The study will be cross-
sectional and mixed methods will be used. The application of both approaches (i.e. 
qualitative and quantitative) for the analysis of health programs is favorable to 
understand different aspects of the implementation process (Jones et al., 2010). 
This analysis will be carried out in the months of January and April 2020, through 
the phases described below. 
 
Quantitative component 
Information gathering 

 36 
 
It will take place in the 58 schools selected for the implementation of the first phase 
of the Program. A checklist designed by the SS will be used to verify compliance 
with the General Guidelines for the Sale and Distribution of food and beverages 
prepared and processed in the schools of the National Educational System and the 
General Guidelines for the installation and maintenance of drinking fountains in the 
schools of the National Educational System. This instrument will be applied 
simultaneously by the INSP research team and the SS as follows: 1) verify that the 
processes are being carried out as established in the Guidelines, and 2) analyze 
the validity of the instrument.  
 
Field operative 
For the instrument validity eight firework teams of two members each will apply the 
checklist in the 58 schools on two different times (at least 15 days apart), each 
checklist is estimated to take 60 min. This information will be captured at the time 
of visiting the schools on the REDCap platform. 
 
Analysis of the information 
The statistical package STATA 2015 will be used to conduct a descriptive analysis 
using means ± standard deviation for continuous variables and n (%) for 
categorical variables. 
 
Qualitative component 
Semi-structured interviews and focus groups will be used as techniques for data 
collection. Data collection will be conducted in a subsample of six schools, selected 
according to their degree of deprivation (3 of low level and 3 of medium level). In 
coordination with the Ministries of Health and Education, the location and school 
directives will be identified to facilitate the planning of the visits of the fieldwork staff 
to the school. Participants for the semi-structured interviews and focus groups will 
be eligible if any of the following profiles are met: 1) institutional managers in the 
program implementation, 2) school principals and teachers, 3) school food and 
beverages vendors, 4) mothers and fathers of schoolchildren, 5) schoolchildren. 
Table 7 describes the specific inclusion and exclusion criteria according to 
participant profiles. 
 
Table 7 Inclusion and exclusion criteria for the analysis of the implementation of 
Salud Escolar  
Profile 
Inclusion criteria 
Exclusion criteria 
Institutional responsible 
for the program 
implementation  
In the required position  
A minimum of 6 months 
in the position 
Agree to participate in 
the study 
During vacation, license 
or commission during 
data collection 
School principals and 
teachers  
In the required position  
A minimum of 6 months 
in the position 
Agreed to participate in 
the study. 
During vacation, license 
or commission during 
data collection.  

 37 
 
Being in the position to 
substitute the titular. 
School food and 
beverage vendors  
Agreed to participate in 
the study 
 
Parents of schoolchildren Agreed to participate in 
the study 
Age<18 years old 
Schoolchildren  
Having a signed 
authorization from 
mother, father or 
guardian to participate in 
the study 
Refuse to participate in 
the study 
 
 
Techniques and instruments 
 
Semi-structured interviews  
Participants will be selected using purposive sampling. Profiles considered for the 
application of the interviews are the following: institutional managers (n = 10), 
principals (n = 6), teachers (n = 12), managers of the food and beverages school 
vendors (n = 6). 
 
Semi-structured interviews will be conducted by two members of the research 
team, one will direct the activity and the other will take notes during its 
development. Semi-structured interview guides designed and piloted by the INSP 
research team will be used (Appendix 18). They will be applied once granted the 
informed consent of the participant (Appendix 19). 
 
Focus groups 
In order to accomplish study objectives, the selection of the participants for the 
focus groups will be purposeful. There will be 12 focus groups with parents, and 12 
focus groups with schoolchildren. Each group will be integrated by 8 to 12 
members. Focus group guides will be designed and piloted by the INSP research 
team (Appendix 20) and applied once informed consent from parents and 
schoolchildren assent (Appendix 21) is obtained. The estimated length of focus 
groups is of120 minutes. 
 
Participants’ profile, instruments, and implementation constructs to be explored are 
summarized in Table 8. Likewise, the number of interviews and focus groups 
expected by each profile is included. 
  
Table 8 Techniques and instruments to identify barriers and facilitators for the 
implementation of Salud Escolar 
Participants 
Profile 
Technique Number Instruments 
Constructs to explore 
Institutional 
directors 
Interviews 
6-10 
Interview 
guide  
Acceptability, adoption, 
suitability, costs, 

 38 
 
feasibility, fidelity, 
sustainability, coverage 
School 
principals  
Interviews 
6 
Interview 
guide 
Acceptability, adoption, 
suitability, costs, 
feasibility, fidelity, 
sustainability 
Teachers 
Interviews 
12 
Interview 
guide 
Acceptability, adoption, 
suitability, costs, 
feasibility, fidelity, 
sustainability 
School vendors Interviews 
6 
Interview 
guide 
Acceptability, adoption, 
suitability, costs, 
feasibility, fidelity, 
sustainability 
Parents 
Focus 
group 
12 
Focus group 
guide 
Acceptability, suitability, 
costs, feasibility 
Schoolchildren 
Focus 
group 
12 
Focus group 
guide 
Acceptability 
 
 
Semi-structured and focus group interview guides will be piloted as this process 
provides relevant information on possible failures in the instrument and allows 
revaluating the design if necessary. Before each interview and focus group, 
participants sociodemographic data will be collected (age, sex, degree of study, 
occupation, place of residence, among others) and authorization to audio-record 
the interviews and focus groups will be obtained. 
 
Analysis and systematization of information 
Sociodemographic information will be captured in Excel and next in STATA 2015. 
A descriptive analysis will be conducted including means and standard deviation 
for continuous variables and n (%) for categorical variables. Chi square tests and 
Student's t test will be used to analyze differences between samples. 
 
Interviews will be transcribed Verbatim and coding will be conducted with the 
support of the software NVivo 11. Analytical categories will be established a priori 
based on the constructs of the research on the implementation of health policies 
and programs (Gutiérrez, 2017; Consejo Nacional de Evaluación de la Política de 
Desarrollo Social CONEVAL, 2019), and according to emerging categories 
resulting from the reading of the corpus of transcripts. A thematic analysis will be 
carried out (Braun and Clarke, 2006). A triangulation of data (of the different 
profiles) and of methods (between qualitative and qualitative techniques) will be 
conducted to strengthen the quality of the analysis (Soto-Estrada et al., 2016).  
8. Ethical considerations 
This research proposal will be carried out taking into consideration the guidelines 
contained in the INSP Research Ethics Committee Regulations (Instituto Nacional 

 39 
 
de Salud Pública, 2015). In addition, the study will be evaluated by the institutional 
Research and Biosafety Commissions. 
8.1. Design analysis 
Key actors participating in the semi-structured interviews will be provided with 
written informed consent, and they will be able to keep a hard copy of this consent. 
The consent copy includes contact information of the project manager and the 
director of the INSP Research Ethics Committee to be able to contact them in case 
of questions or concerns about the study arose. Participants will be assigned an 
identification number (ID) that is not related to any personal data or job title. The 
testimonies of the key informants that are presented in the results reports derived 
from this study will be identified with the participant ID. 
 
8.2. Impact analysis 
Parents written consent will be requested for the application of the 
sociodemographic questionnaire, and for the authorization of the collaboration of 
their children in the following activities: 1) diet questionnaire, 2) hydration 
questionnaire, 3) accelerometry. Likewise, the consent of the schoolchildren will be 
requested. For the application of the School Audit in the intervention and control 
schools, the written consent of the schools´ principals will be requested. Each 
participant will be assigned a unique ID. 
 
The information obtained as part of this research will be kept confidential and will 
be known by the evaluation team only. All field records will be kept in the principal 
investigator's office, with restricted access for people who are not involved in the 
project. The audio files will be deleted once completed data transcription and 
analysis. 
 
Since the study will not handle human samples, it does not imply biosecurity risks. 
Regarding the ethical aspects, we consider that the proposal involves minimal risks 
for the participants since, the ethical principles of the field research will be 
respected including informed consent, autonomy and freedom to participate or not 
in the project. 
9. Expected results 
Knowledge gained from this comprehensive analysis will facilitate the development 
of further recommendations and strategies to support evidence-based decision-
making processes towards the nationwide upscaling of Salud Escolar. These 
recommendations will be based on the gender perspective grounds. In addition, it 
will be possible to compare strategies included in Salud Escolar against evidence-
based interventions for the prevention and control of childhood overweight and 
obesity. Results from this study will allow to establish a baseline evidence on the 
knowledge, attitudes, and practices of schoolchildren attending to public primary 
schools in Mexico City regarding correct nutrition, adequate hydration, and physical 
activity. This study will provide an up-to-date data of the schoolchildren physical 
activity and diet to subsequently analyze the results and impact of Salud Escolar. 

 40 
 
 
10. Timeline 
The timeline for the general project is presented in Figure 6. For Stage 1, two 
weeks of training and two and a half months for gathering information are 
considered. 
 
11. Funds and deliverables 
UNICEF will provide funding for this project resulted from a request of the General 
Directorate for Health Promotion of the Ministry of Health (Appendix 17). The 
research team has contacted UNICEF and the collaboration agreement is currently 
in the process of being signed. The funds breakdown and committed deliverables 
are summarized in Table 9. 
 
Table 9 Funds breakdown and committed deliverables of the study 
Concept 
Funding 
Deliverables 
Stage 1 
1,050,634 
Protocol and instruments. 
Report of the results of the design analysis. 
Recommendations for improving the program. 
Stage 2 
1,593,807 
Report of the results of the analysis of the 
program implementation process. 
Recommendations for improving the program 
for the nationwide dissemination. 
Stage 3 
1,297,502 
Report of the results of the impact analysis  
Stage 4 
258,854 
Six dissemination materials for the general 
population and decision-makers. 
Stage 5 
327,314 
Outline of two articles publishable in peer-
reviewed journals. 
Total 
4,528,111 
 
Note. Stage 1 corresponds to the current stage of the study 
 

 41 
 
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