Evaluation of a Comprehensive School Health Programme in Zambia

Testing for the presence of P. falciparum, non-falciparum species, or a mixed infection. The tests are performed using a rapid diagnostic test (RDT) on the sample of children taking part in the health diaries (testing will occur at the end of the period).

Haemoglobin concentration measured using a HemoCue photometer in the sample of children taking part in the health diaries (testing will occur at the end of the period). Anemia severity categories will be based on the WHO classification which depends on the age and sex of the child. Haemoglobin is first adjusted for elevation using the WHO (2024) continuous adjustment, defined in g/L as 0.0056384 times elevation in metres plus 0.0000003 times elevation squared, evaluated at each school's recorded GPS elevation and subtracted from the measured value. Moderate-to-severe anaemia is considered when adjusted haemoglobin is below 11.0 g/dL, a threshold common to all age bands represented in the sample.

Incidence of diarrhoea - carer report of the child experiencing three or more loose or watery stools.

An indicator for incidence of haematuria (blood in urine) reported by the caregiver.

The share of days on which the child was reported to have any symptom, over the eight week symptom diary recording period (0 days if no symptoms recorded).

Proportion of completed health-diary days on which the child reported one or more symptoms. Computed per child as (diary days with ≥1 reported symptom) ÷ (completed diary days). Defined for all children in the diary sub-sample; no conditioning on illness status.

Mean number of consecutive symptom-days per illness episode, among episodes in children who reported illness during the diary window. Estimated from a discrete-time hazard model for symptom resolution: episodes still ongoing at the end of the observation window contribute their observed (censored) days rather than being dropped; episodes already symptomatic on the first diary day are excluded (start date unobservable / left-truncated). Reported as a restricted mean over the eight-week observation window.

As for the all-episodes duration outcome, restricted to episodes classified as serious.

A serious illness episode is one during which a child's ill-health symptoms are severe enough to require medical care, either immediately or the next day. This classification is based on WHO tools (c-IMCI and IMAI): Care is needed when (i) a child experiences any red-flag symptom (e.g. difficulty breathing, convulsions); (ii) has symptoms suggestive of certain conditions (e.g. measles, malaria); (iii) has experienced mild symptoms for a long time (coughing for 14 days, etc).

Mean consecutive symptom-days per serious episode, estimated from the same discrete-time hazard model, with ongoing episodes contributing observed (censored) days and day-1 episodes excluded as left-truncated. Reported as a restricted mean over the eight-week window.

Share of correct responses across three menstrual health knowledge items. The item set is the final items retained after in-country piloting for comprehension and relevance, from a pre-specified pool adapted from validated instruments. Computed per respondent as (correct responses) / (items answered), averaged within the relevant sub-sample: girls grade 5 or above who have heard of menstruation. Higher values indicate greater knowledge.

Share of responses indicating good menstrual management across the practices items. Item set is the final 5 items pilot-retained from a pre-specified pool adapted from the same validated instruments. Computed per respondent as (good-management responses) / (items answered), averaged across girls who have reached menarche in the sub-sample. Higher values indicate better practices.

First principal component of a PCA over the menstrual health stigma items (final 4 items pilot-retained from a pre-specified pool adapted from the same validated instruments; construction rule fixed prior to piloting). Loadings estimated on the pooled sample; scores standardised to the control-group mean and standard deviation. Oriented so that higher values indicate lesser stigma; a beneficial programme effect corresponds to a reduction. Constructed for girls grade 5 or above who have heard of menstruation.

Item-response-theory (IRT) ability score in literacy, estimated over per-item responses from the grade-banded exam blocks (lower-, middle-, and upper-grade versions) placed on a common within-domain scale via shared anchor items. Standardised to the control-group mean and standard deviation. Higher values indicate greater literacy ability.

IRT ability score in numeracy, estimated over per-item responses from the grade-banded exam blocks (lower-, middle-, upper-grade versions) linked to a common within-domain scale via shared anchor items. Standardised to the control-group mean and SD. Higher values indicate greater numeracy ability.

IRT ability score in science and health knowledge, estimated over per-item responses from the grade-banded exam blocks (lower-, middle-, upper-grade versions) linked to a common within-domain scale via shared anchor items. Standardised to the control-group mean and SD. Higher values indicate greater ability.

Composite learning score, defined as the mean of the three control-standardised domain scores (literacy, numeracy, science), each an IRT ability score placed on a common within-domain scale across grade bands via anchor items and standardised to the control-group mean and SD. Domains enter with equal weight. Higher values indicate greater overall learning ability.

Students' working memory and attention is measured using the Digit Span task, a widely used short-term memory and working memory assessment. Enumerators orally present a sequence of digits at a rate of one per second, and students are asked to repeat the digits in the same order (Digit Span Forward) and then in reverse order (Digit Span Backward). The task measures students' auditory attention, concentration, and working memory capacity, which are foundational components of general cognitive functioning and predictive of academic achievement. Scores are recorded as the total number of correct sequences reproduced, following standard administration and scoring procedures.

Proportion of children confirmed present in class on the day of the visit, out of the total number of children enrolled at the school at baseline and still alive. This measure effectively treats children who may have transferred to another study school as 'absent', dropped out, or temporarily relocated.

Proportion of children confirmed present in class on the day of the visit either in their original school or in another school to which they have transferred if that school is one of the study schools, out of the total number of children enrolled at baseline and still alive. Analysis will follow Intention-to-Treat principle, treating participants as assigned to their original treatment arm, even if they moved to a different study arm school.

From the diary's daily records, caregivers flag whether the child attended school each day and records the reason for each absent day. The reasons are: illness (1), was menstruating (2), farming (3), school closure or school event (4), bad weather (5), religious reasons (6), market day (7), public holiday (8), fishing (9), mining (10), working with parents (11), no uniform/shoes/books (12), and other (-97). A day missed is considered caused by an illness or menstruation-related absence when the reason is (1) or (2). The sample is restricted to school days by dropping weekends and public holidays. This measure is the share of the child's school days in the diary window lost to health-related absence: health-related absence days divided by total school days observed.