Lay Field-worker–Led School Health Program for Primary Schools in Low- and Middle-Income Countries

Abstract

BACKGROUND AND OBJECTIVES: School health programs are frequently attempted in low- and/or middle-income countries; however, programmatic scope and reach is limited by human resource constraints. We sought to determine if trained community members could implement a school health program that improved outcomes in rural primary schools in India. METHODS: This was a mixed-methods, stepped-wedge, cluster-controlled study of schools pragmatically assigned to receive a multicomponent, comprehensive school health program delivered by lay field-workers. RESULTS: All students in 22 primary schools (9 government schools and 13 low-cost private schools) participated in this study. A total of 3033 student-years were included in the analysis (2100 student-years in the intervention period and 933 student-years in the control period). Qualitative feedback was collected from 38 teachers, 49 parents, and 4 field-workers. In low-cost private schools, the diarrhea incidence was lower in students receiving the intervention (incidence rate ratio 0.58; 95% confidence interval [CI] 0.47 to 0.71; P < .001). There was no difference in diarrhea incidence for students in government schools (incidence rate ratio 0.87; 95% CI 0.68 to 1.12; P = .29). Health-knowledge acquisition was higher in intervention schools (mean difference 12.6%; 95% CI 8.8 to 16.4; P < .001) and similar in both school types. Intervention coverage rates were high (mean 93.9%; SD 2.0%), and performance assessment scores indicated fidelity (mean 3.45; SD 0.69). Stakeholders revealed favorable perceptions of the field-workers and high levels of perceived impact. CONCLUSIONS: Lay field-worker–led school health programs offer a promising alternative for improving school health delivery in resource-constrained settings.