Lay Fieldworker Led School Health Program for Rural Primary Schools
Condition: Health Promotion; Diarrhea
MeSH terms: Diarrhea
Study type: Interventional

Summary: 
      School-aged children in low and middle-income countries (LMIC) face significant challenges to
      their health and development which contribute to poor academic achievement. Multi-component
      comprehensive school health programs guided by the World Health Organization's (WHO) Health
      Promoting Schools (HPS) framework have been shown to positively impact health outcomes. Such
      programs are implemented widely throughout the world. However, in LMIC the scope and reach of
      school health programs are limited by human resource constraints. A key challenge to
      effective implementation has been the identification of effective delivery agents.

      A potential alternative approach is to leverage existing community members as lay
      fieldworkers for the delivery of school health promotion. Our hypothesis is that
      lay-fieldworkers can effectively implement comprehensive school health programs in
      resource-constrained primary schools. This hypothesis will be tested by retrospectively
      analyzing data obtained during a 5-year pilot of a school health program (CHHIP) in rural
      primary schools of the Darjeeling Himalayas of India.
    

Detailed description: 
      The Comprehensive Health and Hygiene Improvement Program (CHHIP) is an intense
      multi-component comprehensive school health program. The content of the program is structured
      around three reinforcing components: 1) health education, 2) basic primary health services,
      and 3) a healthy school environment. This holistic approach is based on the WHO's Health
      Promoting Schools framework and designed in accordance with the Indian National Rural Health
      Mission's operational guidelines for the school health programme. Delivery of the program is
      led by lay fieldworkers termed School Health Activists (SHAs). SHAs are existing community
      members without formal background or certification. The SHAs serve as the primary delivery
      agent for all components of the program.

      From 2012 to 2016, the CHHIP program was implemented by Darjeeling Prerna, an Indian
      non-governmental organization, in the rural Darjeeling Himalayas, a region of the state of
      West Bengal in India. The program was implemented in both low-cost private and government
      primary schools. A convenience sample of 22 primary schools (13 government and 9 low-cost
      private) was chosen by the project team. Program implementation occurred in 16 schools and
      was led by 4 lay fieldworkers. The intervention was implemented as a community development
      program with a rigorous evaluation component and all data was collected prospectively. This
      research study was added post-hoc with data transmitted to the research team prior to any
      analysis.

      The study is designed as a mixed methods stepped-wedge cluster controlled evaluation. A
      primary school will be a cluster and each step in the study will be a single academic year.
      In accordance with guidelines for the design and evaluation of complex evaluations, this
      study will couple process evaluation with that of definitive impact. The intervention will be
      evaluated across three domains: outcomes, implementation, and mechanism of impact.

      The primary impact outcome will be the incidence of diarrheal illness as assessed by 14-day
      parental recall. A secondary outcome, health knowledge as assessed by pre and post-test, will
      be utilized as a key mediator to assess for differential impact on mechanisms of impact.
      Statistical analysis will be carried out as a comparison between the intervention and control
      arms within the context of the stepped-wedge framework. The analysis will be based on
      individual student-level data, with the unit of assignment (schools) included as a cluster
      effect in the regression analysis. Exposures of interest will be explored for association
      with the outcome in univariate analyses. Diarrheal incidence rate ratios will be calculated
      via multivariable Poisson regression analysis and mean difference in health knowledge
      post-test scores will be obtained using a multivariable linear mixed model. All P-values will
      be 2-tailed and significance will be set at P<0.05.

      To study implementation, process outcomes will be obtained via a series of descriptive
      analysis. Coverage rates for individual health interventions and performance evaluations
      scores expressed as means and standard deviations will be obtained. In consultation with the
      project team, the research study team will define benchmarks for reach and fidelity, prior to
      analysis of data.

      Qualitative data will be integrated with quantitative data via a process of triangulation.
      This data was obtained from parents and teachers in focus groups and lay fieldworkers in
      semi-structured interviews. Coding and analysis of the qualitative data will begin with a
      deductive coding method. Common themes, including important contrary opinions, will be
      identified and illustrative quotes will be selected.

      All quantitative analysis will be done in SPSS and qualitative analysis completed in CATMA.
      The reporting and presentation of this trial will be in accordance with the Transparent
      Reporting of Evaluations with Nonrandomized Designs (TREND) guidelines.
    

Intervention name(s): Comprehensive Health & Hygiene Improvement Program (CHHIP)
Intervention type(s): Behavioral
Intervention description(s): CHHIP is an intense, multi-component holistic school health program based on the WHO Health Promoting School framework and designed for implementation by lay fieldworkers.
Allocation: Non-Randomized
Intervention model: Crossover Assignment
Intervention model description: We will use a stepped-wedge cluster controlled model to reflect the pragmatic enrollment and crossover of schools between intervention arms.
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: School Health Services; Health Education; Primary Schools; Republic of India