Overview

Introduction:

AHI HPS model was designed based on Professor Wagner Marcenes translatable extensive collaborative research portfolio on addressing health inequities. Under international copyright law, the creator of a work owns the copyright to the work. Study protocols, including e-questionnaires were developed at the Affordable Health Research Centre and are available under request (GET INVOLVED). A copyright transfer agreement to publishers and a licence enabling to implement and assess the impact of AHI HPS model can be easily obtained by request to the copyright owner of the AHI HPS model, Professor Wagner Marcenes.

The copyrighted material in the realms of this AHI research project include the AHI HPS operational model, protocols (including questionnaires), articles in academic journals, contributions to anthologies and collections, monographs and newspaper articles, presentations and scientific/conference posters, photos, examination papers such as dissertations and theses for diplomas, Bachelor’s and Master’s degrees, and post-doctoral courses. A comprehensive transfer of all the rights or part of them rather than of the whole is negotiable and always done by signing a copyright transfer agreement or a licence, under which ownership is retained by the AHI CIO but the other party is enabled to implement and assess the impact of AHI HPS model. Under the criminal law, certain uses of copyright or registered research material, without the owner's permission can amount to a criminal offence. These are often referred to as piracy or a copyright infringement.

The assignment of a licence must be in writing signed by or on behalf of the assignor and will include:

  • AHI CIO understand that the researcher Parties have in common the desire to encourage and facilitate the advance, dissemination and application of new knowledge through exchange of materials and information as part of the Project entitled “Assessment of the implementation and impact of the Affordable Health Initiative Health Promoting School model.”

  • The Parties acknowledge that the Project is contemplated as a global network of researchers with mutual research interests and that it is anticipated that new Co-investigators may want to join after the Project has been established and others may want to leave.

  • During the course of the Project, Co-investigators may propose leading a specific publication. A draft copy of all scientific communication arising from the Project shall be given to the Project Director for approval before submission. If not approved, the Co-investigator may work with the Project Director to address the publication weakness before submitting the potential publication to a scientific journal for peer review.

  • In the event that any graduate student completes a dissertation or thesis, or an internal report relating to the Project, the student has the right to use the results in the thesis and/or its defence and the Collaborating Institution shall have the right to use those results for the evaluation of the academic progress of such student in accordance with its policies and procedures. If a scientific article is produced; this is without prejudice of approval before submission by the Project Director Professor Wagner Marcenes.

  • The Parties are abided by all applicable rules, regulations, terms of conditions in the World Health Organisation the Code of Conduct for responsible Research (LEARN MORE>), and by all Affordable Health Initiative CIO policies (LEARN MORE>), code of ethics (LEARN MORE>) and governance code of conduct (LEARN MORE>).

  • All parties agree to comply with the STROBE (Strengthening the Reporting of Observational Studies; (LEARN MORE>) and GATHER (Guidelines for Accurate and Transparent Health Estimates Reporting) statements. (LEARN MORE>) Note that GATHER considers open access to data inputs and access to analytical or statistical source code to be best practice in reporting.

  • The Parties shall use reasonable efforts to carry out the Project. The Project may from time to time be modified by mutual consent of the Parties. The philosophy among collaborators within and between centres is consensus.

  • The AHRC Director, Professor Wagner Marcenes (LEARN MORE>), provides support on technical matters that may arise during the course of the Project.

Organisation of the study:

A multi-centre study was designed to assess the implementation and impact of the Affordable Health Initiative (AHI) Health Promoting School (HPS) model. Currently, the Affordable Health Research Centres is piloting the AHI HPS model in Distrito Federal, Brasil, and assessing the intention to transform schools in HPS in several countries in Africa and Latin America. Nearly 50 academics have became an AHRC associate researcher; six PhD candidates and five MSc students are using the AHRC data in their PhD projects. Several undergraduate students are participating as initiation to research contributors and helping running the interventions. Click HERE to see samples of associated researchers projects.

Study centres and researcher associates will continually be recruited to provide a data on a large sample of schools from a number of countries and all continents. The recruitment of centres and co-investigators is based on dedication and commitment in a team effort to achieve goals that cannot be reached by a single centre effort. The philosophy among collaborators within and between centres is consensus. Research centres will continually be recruited to provide a data on a large sample of schools from a number of countries and all continents. The multi-centre study will generate a heterogeneous range of subjects and settings in order to obtain generalising valid conclusions. Including subjects from different countries with different cultures strengthens the generalisability (external validity) of the investigation; and the large sample size provides sufficient statistical power to detect clinically significant intervention effects. Analysis of the concerted efforts of multiple leaders from varying backgrounds and with diverse expertise serves as a platform to identify and solve a wide range of potential implementation barriers, identify implementation facilitators more efficiently, learn how to promote large-scale use of AHI HPS model and maintain its sustainability.

Rationality

WHO and UNESCO have launched a new initiative “Making Every School a Health Promoting School” (LEARN MORE>) through the development and promotion of Global Standards for Health Promoting Schools. The initiative will serve over 2.3 billion school-age children and will contribute to the WHO's 13th General Programme of Work’ target of achieving “1 billion lives made healthier” by 2023. The World Health Organisation (WHO) definition of a health promoting school is one that constantly strengthens its capacity as a healthy setting for living, learning and working (LEARN MORE>).

There is evidence to suggest that a number of individual health promoting school interventions can produce improvements in certain areas of health, in particular to reduce obesity, increase physical activity and fitness levels, improve fruit and vegetable consumption, decrease cigarette use, and reduce reports of being bullied [3]. However, health promotion intervention have little impact on low-income communities because the social conditions of its members prevent adopting a healthy lifestyle. Socio-economic resources are essential to avoid risk (Prevention of diseases) and minimise the consequences of diseases (Healthcare). Moreover, social conditions affect disease outcomes through multiple factors that are highly prevalent in low-income communities. Furthermore, the effect of social conditions reproduces over generations because low-income communities are not well equipped to benefit from new knowledge [4]. Therefore, it is relevant to carry out a real-world assessment of the AHI HPS model, identify the factors affecting its implementation, in particular the barriers and facilitators during the processes of implementation in a challenging environment characterised by high levels of social deprivation. It is also important to assess the viewpoint of stake holders to transform schools in health promoting schools, in particular the view of school teachers because their motivation and agreeability are central to the successful implementation of health promoting school programmes and more information about the view of headteachers is needed to successfully implement HPS models in their schools. To assess the views of children and their parents are similarly important, and this information is scarce in the scientific literature. Although it is likely that the individual interventions included in the AHI HPS model will have a synergic effect, it is unclear whether the efficacy of this combination of interventions would be effective in realistic settings.

The findings of this study will bring evidence-based knowledge that can inform health policies makers on implementation barriers and facilitators to transform schools in HPS at a large scale, as well as on the effectiveness of a number of individual interventions in school settings at a large scale. Despite the fact that the concept of Health Promoting Schools was articulated by WHO, UNESCO and UNICEF back in 1992, only few countries have successfully implemented Health Promoting Schools at scale. Affordable Health Initiative (AHI) developed and offers (GET INVOLVED) a simple, scalable and sustainable operational model for the WHO’s Health Promoting School (HPS) concept.

The Intervention

The AHI HPS model is a novel school intervention designed to reduce inequities between and within countries in the burden of diseases through promotion of good behaviour, good physical and mental health and quality education in low-income localities. The table below presents a summary of the model (individual interventions and its desirable outcomes). The theoretical framework adopted to developing the AHI HPS model includes the fundamental cause theory, the life course framework and the salutogenic approach (LEARN MORE>)

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Title of study 1: Assessment of the intention to transforming schools in HPS and factors affecting the implementation of the AHI HPS model.

Aim: The overall aim of this study is to assess whether stakeholders would transform the school in a health promoting school, as well as to assess whether they would implement the Affordable Health Initiative Health Promoting School model. In addition, to identify determinants of stakeholders’ behaviour towards transforming schools in a health promoting schools, and to monitor the process of implementation of AHI HPS model and identify barriers, facilitators and potential solutions to challenges affecting implementation of the initiative in schools serving low-income communities.

Specific objectives are:

  • To assess the intention of stakeholders to transform their school in a health promoting school;

  • To identify determinants of stakeholders behaviour towards transforming schools in health promoting schools;

  • To assess the acceptability of the Affordable Health Initiative Health Promoting School model;

  • To assess the adoption of the Affordable Health Initiative Health Promoting School model;

  • To assess the appropriateness of the Affordable Health Initiative Health Promoting School model;

  • To assess the feasibility of the Affordable Health Initiative Health Promoting School model;

  • To assess the fidelity of the Affordable Health Initiative Health Promoting School model;

  • To assess the implementation cost of the Affordable Health Initiative Health Promoting School model;

  • To assess the coverage of the Affordable Health Initiative Health Promoting School model;

  • To assess the sustainability of the Affordable Health Initiative Health Promoting School model.

  • To assess the capacity of the AHI HPS model to turn schools into health promoting schools.

Methods:

The implementation research conceptual framework adopted in this study was described by Proctor et all in 2010 [1]. Implementation research [2] attempts to identify in order to solve a wide range of implementation problem. Implementation research can consider any aspect of implementation, including the factors affecting implementation, the processes of implementation, including how to introduce potential solutions into a health promotion strategy or how to promote their large-scale use and sustainability. Implementation research design is appropriate  to understand what, why, and how interventions work in “real world” settings and to test approaches to improve them. The domains proposed to assess the factors affecting the implementation of the AHI HPS model are acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, coverage and sustainability [1].

While recommending Randomised Clinical Trials (RCTs) to ascertain intervention’s effectiveness, attention must also be paid to the challenges of implementing an effective intervention in the real world. Mixed methods research designs that permit assessment of the implementation of health promotion interventions in their natural settings for longer periods provide evidence of the effectiveness as important as evidence from RCTs carried out in optimal circumstances.

Prior to run the AHI HPS model, researchers assess the stake holders intention towards transforming the school in a health promoting school. AHI recommends a mixed-methods implementation research design to assess the intention to transform the school in a health promoting school and to identify the determinants of stakeholders’ behaviour towards transforming schools in a health promoting schools. AHI researchers use a cross-sectional survey design to assess the domains of implementation research acceptability, adoption, appropriateness and feasibility (intention to implement) of each of the AHI HPS model individual interventions and to assess school teachers’ health and health related behaviour. The subjects of the former are stack holders and of the latter are school teachers. This study design uses a systematic approach to collect data from survey respondents in a way that allows one to compare data collected in a wide range of environments. Cross-sectional surveys assess the view of respondents and related information in groups of individuals at one point in time. The reason to include only four domains to assess whether school teachers would support implementing the AHI HPS model in their schools is because the four domains not included are related to the experience in running the AHI HPS model.

Following, researchers carry out focus group studies in an appropriate locality to assess the implementation research domains acceptability, adoption, appropriateness and feasibility. Data on current school policies, curriculum, social environment and community relationship is collected using a validated health promoting status assessing tool to assess the current HPS status of the school.

Finally, researchers interview the headteacher and carry out a “walkabout” around the school to establish the stage of development of the school towards becoming a HPS. assess the built environment. A questionnaire was developed to guide the interview with the headteacher and an “walkabout” check list was developed to the assess the school facilities and identify aspects of the built environment that needs improvement (e.g. source of water, condition of bathrooms, number of sinks and showers) to implement the AHI HPS model.

The subjects in this study are stakeholders and schools serving low-income localities.

The outcome variable adopted to assess the intention to transform schools in HPS and factors affecting the implementation of the AHI HPS model includes eight domains:

Acceptability (questionnaire) to assess the perception among stakeholders (i.e. consumers, providers, managers, policy makers) that AHI intervention is acceptable.

Adoption (questionnaire) to assess the intention, initial decision-making process, and subsequent action involved in embracing and employing the AHI intervention.

Appropriateness (questionnaire) to assess the perceived fit, relevance or problems of the AHI intervention in the school setting as perceived by providers and consumers.

Feasibility (questionnaire) to assess the extent to which the AHI intervention can be carried out in a school setting.

Fidelity (questionnaire) to assess the degree to which the AHI intervention was implemented as it was originally designed and constructed.

Implementation cost (questionnaire and records) to assess the incremental costs of the implementation of AHI model. The total cost of implementation will also include the cost of the AHI intervention itself.

Coverage (records) to assess the degree to which the population that is eligible to benefit from the AHI intervention actually receives it.

Sustainability (questionnaire) to assess the extent to which the AHI intervention is maintained and institutionalised in a school setting.

The outcome variable adopted to monitor progress towards transforming schools in HPS includes five domains:

  • School Formal and Informal Curriculum (questionnaire): to assess the extent to which the school teach and carry out health promotion.

  • School Policies: to assess the extent to which the school policies are conducive to good health.

  • School Community Relations: to assess the extent to which the school health promotion activities reach the local community.

  • School Interpersonal Relationship Issues: to assess the extent to which the school manages social behaviour between pupils.

  • School Physical Environment to assess the extent to which the school physical environment is conducive to health.

The three Stars WASH Award:

In addition, the study assess the capacity of the AHI model to transform schools into UNICEF three stars WASH schools.

Title of study 2: Assessment of the effectiveness of the AHI HPS Model in promoting behaviour, health and education.

Aim: The overall aim of this study is to assess the effectiveness of the AHI HPS model in health and education outcomes of children 6-10 years old enrolled in schools serving low-income communities across the world.

It is hypothesised that, in early life good education and family functioning balance against the harmful effects of poor social condition throughout the development of sound psychological attributes such as resilience, confidence and self-esteem and foster adopting healthy behaviours, which in turn, lead to an improvement in health capital and education achievement in adolescence, and later in life to better job opportunities and upward social mobility. AHI acknowledges that the genetic endowment plays an important role in having a good health capital. As this is not modifiable, AHI focusses on identifying key modifiable risk and protective factors to promote health.

Specific objectives are: 

  • To assess the effectiveness of the AHI HPS model in well being outcomes in school children aged 6-10 years enrolled in schools serving low-income communities; 

  • To assess the effectiveness of the AHI HPS model in health outcomes in school children aged 6-10 years enrolled in schools serving low-income communities; 

  • To assess the effectiveness of the AHI HPS model in well being outcomes in school teachers in schools running the AHI HPS model;

  • To assess the effectiveness of the AHI HPS model in health outcomes in school teachers in schools running the AHI HPS model; 

  • To assess the effectiveness of the AHI HPS model in education outcomes in school children aged 6-10 years enrolled in schools serving low-income communities; 

  • To monitor progress towards becoming a health promoting school in schools running the AHI HPS model

Methods:

In order to assess effectiveness of the AHI HPS model in the real world, a controlled before-after study is proposed. In this study design observations are made before and after the implementation of an intervention, both in a group that receives the intervention and in a control group that does not or in an active control group, in which participants engage in some task during the intervention period. [5]. To produce evidence-based reform in health and education experimental studies must include a control group. As it would be unethical to withhold treatment from a control group, this study will use an active treatment concurrent control group, which serves as a benchmark. In this type of study design, one group is given the intervention and the other group is given an existing treatment. Parents of schoolchildren in the control group will be notified if their children have a health condition needing treatment. AHI organises the referral for treatment at local primary health care units and monitors the process to assure they will receive treatment. This study will also use a “delayed intervention” design in which the control group gets the intervention after the study is over. If the study demonstrates that the AHI HPS model is effective, training and materials to implement will be provide and the AHI HPS model will be implemented in the control group three years after the schools in the experimental group received the intervention. In this way, having been in the control group in the short term may serve to improve the school in the long run. Finally, it is important to note that this study is testing a novel intervention, thus it is not proved to be more effective than the current model adopted by schools, and it is not widely used that not to use the intervention in the control group would be unethical. In fact, it would be unethical to widely implement an intervention that was not tested in a sound experimental study design.

The subjects in this study are school children enrolled in a school implementing the full AHI HPS model (intervention group) and in schools implementing the health care intervention only (active control group). Alternatively, an uncontrolled before-after study may be carried out; in which observations are made before and after the implementation of an intervention in a group that receives the intervention without including a control group. This alternative research design serves as an exploratory study and provide only weak evidence on the impact of the AHI HPS model.

THE OUTCOME VARIABLES ADOPTED TO ASSESS THE IMPACT OF THE AHI HPS MODEL ON BEHAVIOUR ARE AS FOLLOWS:

Health related risk behaviours (questionnaire data) to assess the capacity of the AHI model to develop and maintain healthy behaviours, in particular hygiene practices, diet, physical activities and use of health services.

Bullying Episodes (logbook) to assess the capacity of AHI HPS model to reduce violence and improve social behaviour at school.

Fights Episodes (logbook) to assess the capacity of AHI HPS model to reduce violence and improve social behaviour at school.

Violent Events involving Police (logbook data), including bullying, to assess the capacity of the AHI model to reduce violence and anti-social behaviour.

THE OUTCOME VARIABLES ADOPTED TO ASSESS THE IMPACT OF THE AHI HPS MODEL ON HEALTH ARE AS FOLLOWS:

Height, Weight and Body mass index (clinical data) to assess the capacity of the AHI model to improve children’s growth rate and prevent children from being either underweight or overweight.

General Health State (health assessment questionnaire and stool analysis data) to assess the capacity of the AHI model to monitor and improve general health.

Dental Health State (clinical examination and questionnaire data) to assess the capacity of the AHI model to monitor and improve dental health and prevent the occurrence of new gingival bleeding, dental decay and experience of dental pain.

Vaccinations and Referrals (logbook data) to assess the capacity of AHI HPS model for screening schoolchildren for common diseases and organise referrals for treatment, and to monitor vaccination programmes and organise referrals for vaccination.

THE OUTCOME VARIABLES ADOPTED TO ASSESS THE IMPACT OF THE AHI HPS MODEL ON EDUCATION ARE AS FOLLOWS:

School Absenteeism among School Children (logbook) to assess the capacity of AHI HPS model to reduce school sickness absenteeism.

School Absenteeism among School Staff (logbook) to assess the capacity of AHI HPS model to reduce school sickness absenteeism.

School Performance Rank Position (National test in language and mathematics) to assess the capacity of AHI HPS model to improve school performance.

References:

  1. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health2010; 38:65-76.

  2. Peters DH, Tran N, Adam T. Implementation research in health: a practical guide. Alliance for Health Policy and Systems Research, World Health Organization, 2013.

  3. Langford R, Bonell CP, Jones HE, Pouliou T, Murphy SM, Waters E, Komro KA, Gibbs LF, Magnus D, Campbell R. The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD008958. DOI: 10.1002/14651858.CD008958.pub2.

  4. Phelan JC, Link BG, Tehranifar P. Social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications. J Health Soc Behav. 2010;51 Suppl: S28-40. doi: 10.1177/0022146510383498.

  5. Cochrane Centre. Non-randomised controlled study (NRS) designs. https://childhoodcancer.cochrane.org/non-randomised-controlled-study-nrs-designs