School-aged children (SAC; 5–9 years) remain understudied in global efforts to examine intervention effectiveness and scale up evidence-based interventions.
This review summarizes the available evidence describing the effectiveness of key strategies to deliver school-age interventions.
We searched Medline, PsycINFO, Campbell Collaboration, and The Cochrane Library during November 2020.
Systematic reviews and meta-analyses that: target SAC, examine effective delivery of well-established interventions, focus on low- and middle-income countries (LMICs), were published after 2010, and focus on generalizable, rather than special, populations.
Two reviewers conducted title and abstract screening, full-text screening, data extraction, and quality assessments.
Sixty reviews met the selection criteria, with 35 containing evidence from LMICs. The outcomes assessed and the reported effectiveness of interventions varied within and across delivery strategies. Overall, community, school, and financial strategies improved several child health outcomes. The greatest evidence was found for the use of community-based interventions to improve infectious disease outcomes, such as malaria control and prevention. School-based interventions improved child development and infectious disease-related outcomes. Financial strategies improved school enrollment, food security, and dietary diversity.
Relatively few LMIC studies examined facility, digital, and self-management strategies. Additionally, we found considerable heterogeneity within and across delivery strategies and review authors reported methodological limitations within the studies.
Despite limited research, available information suggests community-based strategies can be effective for the introduction of a range of interventions to support healthy growth and development in SAC. These also have the potential to reduce disparities and reach at-risk and marginalized populations.
The Problem, Condition, or Issue
Global efforts to examine intervention effectiveness and scale up evidence-based interventions have thus far largely focused on maternal and newborn health, children younger than 5 years, and, to a lesser extent, adolescents, whereas school-age children (SAC) (5–9 years) remain understudied.1 Interventions and delivery strategies designed for early childhood and adolescence may also improve some school-age outcomes, however, isolated early childhood or adolescent interventions often do not cover the length of the school-age period. Innovative intervention designs and delivery strategies can potentially address these gaps, encourage scale-up, and impact outcomes, but there is little consensus on their effectiveness beyond school feeding programs.2 Another important consideration is creating an enabling environment, which refers to those conditions that encourage the successful implementation and scale-up of effective intervention coverage. These often include national strategies that integrate multiple platforms (eg, health, education, and social protection) to enable widespread and sustainable implementation and uptake.
The Intervention
This review aims to synthesize the evidence base for key strategies that can be used to successfully deliver interventions to SAC, going beyond examining the effectiveness of the interventions themselves (Table 1).
Description of Delivery Strategies
| Delivery Strategy | Description and Examples |
|---|---|
| Community-based | Interventions delivered in the community through preexisting community facilities, programs, or activities. |
| Examples | • Education and behavior change campaigns delivered through mass participation events.3,4 |
| • Home safety interventions provided by community health workers, social care professionals, and lay workers.5 | |
| Facility-based | Interventions delivered through primary care health centers, and first-level and referral hospitals. |
| Examples | • Mental health and developmental assessment.6,7 |
| • Brief psychological interventions and active consultation with a mental health specialist.6 | |
| School-based | Interventions delivered in the school setting. These interventions often use the school’s health services, staff, amenities, or curriculum. |
| Examples | • School-based immunization programs.8 |
| • Peer support groups.9 | |
| Digital or technology | Interventions delivered through digital or technological devices, such as social media, phone apps, and mHealth. |
| Examples | • Internet-delivered cognitive behavioral therapy.10–13 |
| • Mass media campaigns to normalize healthy behaviors.14–16 | |
| Financial | Financial strategies, such as conditional and unconditional cash transfers, voucher schemes, and microcredit strategies. |
| Examples | • School fee reductions.17 |
| • Cash transfers conditional upon vaccinations.18 | |
| Self-management | Interventions that encourage individuals to take responsibility for their own care, which includes monitoring and managing symptoms. |
| Examples | • Self-monitoring through mHealth technologies.19 |
| • Brief guided self-help education.20,21 | |
| Integrated strategies | Interventions delivered through a combination of the aforementioned strategies. |
| Examples | • Integrated community- and school-based schistosomiasis drug delivery.22 |
| • Programs that communicate health education regarding salt intake through multiple channels, such as schools, communities, and health service providers.23 |
| Delivery Strategy | Description and Examples |
|---|---|
| Community-based | Interventions delivered in the community through preexisting community facilities, programs, or activities. |
| Examples | • Education and behavior change campaigns delivered through mass participation events.3,4 |
| • Home safety interventions provided by community health workers, social care professionals, and lay workers.5 | |
| Facility-based | Interventions delivered through primary care health centers, and first-level and referral hospitals. |
| Examples | • Mental health and developmental assessment.6,7 |
| • Brief psychological interventions and active consultation with a mental health specialist.6 | |
| School-based | Interventions delivered in the school setting. These interventions often use the school’s health services, staff, amenities, or curriculum. |
| Examples | • School-based immunization programs.8 |
| • Peer support groups.9 | |
| Digital or technology | Interventions delivered through digital or technological devices, such as social media, phone apps, and mHealth. |
| Examples | • Internet-delivered cognitive behavioral therapy.10–13 |
| • Mass media campaigns to normalize healthy behaviors.14–16 | |
| Financial | Financial strategies, such as conditional and unconditional cash transfers, voucher schemes, and microcredit strategies. |
| Examples | • School fee reductions.17 |
| • Cash transfers conditional upon vaccinations.18 | |
| Self-management | Interventions that encourage individuals to take responsibility for their own care, which includes monitoring and managing symptoms. |
| Examples | • Self-monitoring through mHealth technologies.19 |
| • Brief guided self-help education.20,21 | |
| Integrated strategies | Interventions delivered through a combination of the aforementioned strategies. |
| Examples | • Integrated community- and school-based schistosomiasis drug delivery.22 |
| • Programs that communicate health education regarding salt intake through multiple channels, such as schools, communities, and health service providers.23 |
Why It Is Important To Do This Review
The scope of this review was determined through an evidence scoping and mapping exercise that revealed gaps in the literature for interventions related to SAC. This review seeks to take a more comprehensive and systematic approach and provide an overview of existing systematic reviews and meta-analyses covering a diverse range of interventions delivered through different strategies.
Objectives
We reviewed the available evidence describing the effectiveness of key delivery strategies for optimizing the implementation and scale-up of a variety of evidence-based school-age (ages 5–9) interventions. The following strategies were explored: community-based, facility-based, school-based, digital or technological, financial, self-management, and integrated strategies.
Methods
Search Methods
This overview of reviews was conducted according to the recommendations and standards set by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. A subset of reviews was identified through an initial literature scoping exercise and in the reference lists for established World Health Organization (WHO) guidelines and documents. Targeted database searches were conducted for the delivery strategies for which limited high-quality evidence syntheses were found. A comprehensive search strategy (Supplemental Information) was developed according to PICO (population, intervention, comparison, outcomes) criteria and conducted in the following databases: Medline, PsycINFO, Campbell Collaboration, and The Cochrane Library. The final search date was November 26, 2020. Further details about our methodology are provided in the supplement (Supplemental Information).
Eligibility Criteria
We undertook a systematic review that included: (1) systematic reviews and meta-analyses that synthesized empirical studies using experimental or quasi-experimental study designs, and clearly stated the methodology used for searches, screening, data collection, and data synthesis; (2) greater than 50% of the included studies targeted SAC; (3) examined the effectiveness of strategies to deliver well-established interventions to SAC; (4) contained evidence from low- and middle-income countries (LMIC) (unless there were no such reviews, in which case evidence from high-income countries (HIC) was included); and (5) were published after 2010.
Reviews that examined the effectiveness of novel interventions delivered through the strategies were included separately and were not synthesized in this review because they do not examine the effectiveness of the delivery strategies (Table 2). Reviews that addressed enabling policies and intersectoral actions were also collected and were not synthesized in this review.
Selection Process
At least 1 reviewer screened the titles and abstracts of all identified reviews for relevance based on predefined eligibility criteria. Two reviewers independently screened all full texts of the selected reviews in duplicate based on predefined eligibility criteria. Disagreements were resolved through discussion and, if necessary, by a third reviewer.
Data Collection Process
Data abstraction was conducted independently by 2 reviewers into a predefined data abstraction form. Disagreements were resolved by discussion and, if necessary, by involving a third reviewer. Data items in the abstraction form included: review characteristics, study population description, delivery strategies, child health outcome, description of intervention, pooled outcomes and effect sizes, and quality assessment.
Outcomes
Outcomes reported in reviews were not used as a criterion for inclusion or exclusion. Examples of outcomes that were assessed included but were not limited to: morbidity and mortality in the school-age group, child development outcomes, mental health outcomes, burden of noncommunicable diseases (NCD) and communicable diseases, anthropometric outcomes, physical injuries, and sexual and reproductive health outcomes.
Quality Assessment
The included systematic reviews were critically appraised using the AMSTAR 2 tool. The overall confidence was rated as follows: high (0 or 1 noncritical weakness), moderate (more than 1 noncritical weakness), low (1 critical flaw with or without noncritical weakness), and critically low (more than 1 critical flaw with or without noncritical weakness).
Grading of Recommendations Assessment, Development, and Evaluation ratings for the overall quality of the evidence at the outcome level were abstracted from the reviews. In the cases where these ratings were not reported by review authors, we extracted information on individual study quality and the consistency of results to achieve an overall quality assessment.
Results
Syntheses
One hundred ninety-three reviews were included in Pathway 1, 66 reviews were included in Pathway 2, and 19 reviews examined enabling policies and intersectoral actions. These reviews are listed in the supplement (Supplemental Information).
Description of Pathways
| Pathway 1 | Priority Pathway 1 | Pathway 2 | Enabling Policies and Intersectoral Actions |
|---|---|---|---|
| This category included systematic reviews and meta-analyses that examined the effectiveness of strategies to deliver well-established interventions to school-age children. For example: reviews that compared community-based, school-based, and combined delivery strategies for mass drug administration programs. | The evidence in Pathway 1 was narrowed down based on several criteria to focus the narrative syntheses on reviews that best answered our research question. To ensure evidence focused on school-age children, we only included systematic reviews and meta-analyses where >50% of the included studies targeted school-age children. | This category included systematic reviews and meta-analyses that examined the effectiveness of strategies to deliver novel interventions to school-age children. For example: reviews that examined the effectiveness of exergames on fitness levels and weight management. | This category included resources that examined the effectiveness of enabling policies and intersectoral actions to scale-up interventions within the delivery strategies. For example: reviews that explored the effectiveness of the World Health Organization’s Health Promoting Schools framework. |
| Pathway 1 | Priority Pathway 1 | Pathway 2 | Enabling Policies and Intersectoral Actions |
|---|---|---|---|
| This category included systematic reviews and meta-analyses that examined the effectiveness of strategies to deliver well-established interventions to school-age children. For example: reviews that compared community-based, school-based, and combined delivery strategies for mass drug administration programs. | The evidence in Pathway 1 was narrowed down based on several criteria to focus the narrative syntheses on reviews that best answered our research question. To ensure evidence focused on school-age children, we only included systematic reviews and meta-analyses where >50% of the included studies targeted school-age children. | This category included systematic reviews and meta-analyses that examined the effectiveness of strategies to deliver novel interventions to school-age children. For example: reviews that examined the effectiveness of exergames on fitness levels and weight management. | This category included resources that examined the effectiveness of enabling policies and intersectoral actions to scale-up interventions within the delivery strategies. For example: reviews that explored the effectiveness of the World Health Organization’s Health Promoting Schools framework. |
Sixty reviews met the selection criteria and were included in the narrative synthesis and the accompanying tables. We present the results of reviews that examine delivery strategies and reviews that compare delivery strategies. We do not mean to make broad conclusions about the effectiveness of 1 strategy compared with another. The comparisons shared below and made within the included reviews pertain to specific interventions and outcomes. We have included reviews that compare delivery strategies because they are more likely to examine the effectiveness of the delivery strategy rather than the effectiveness of the intervention.
The characteristics of included studies, pooled effect estimates, quality assessments, and justification for exclusion are provided in the supplement (Supplemental Information). Table 3 presents the interventions that were found by our original scoping exercise and the interventions found by this systematic review. The table reveals which child health domains have been well-covered by the literature.
Community
Fifteen reviews of moderate to critically low quality explored the effect of community-based interventions on child health outcomes. Outside of school, SAC develop in the contexts of their home and community. Existing community programs and health workers can be leveraged to reach SAC and support positive health outcomes.
Summary Table
| Delivery Strategy | |||||||
|---|---|---|---|---|---|---|---|
| Child Health Domain | Community | Facility | School | Digital or Technology | Financial | Self-Management | Integrated Strategies |
| Child development | Surveillance of patients with neurologic consequences of Zika virus infection.a,24 | Specialized healthcare.a,6,24 | Curriculum for social and emotional learning.26 | Cash transfers conditional on17,27,28 : parent training, home visits, behavior management, social development, center-based parent-child programs, school enrollment and attendance. | Self-monitoring, administration, evaluation, goal setting.29 | Patient education, home visits, and schoolteacher training.33 | |
| Community health and social services.a,24 | Mental health and developmental assessment.a,6,7 | Unconditional cash transfers,17,27,28 school fee reduction.,17 and vouchers for school.17 | Computerized cognitive training programs.30 | ||||
| Family psycho-education and psychosocial interventions.7 | Executive functioning training.31 | ||||||
| Caregiver training.a,6,7,25 | Self-regulation31 : mindfulness meditation, biofeedback-induced relaxation, and direct teaching. | ||||||
| Self-directed parenting interventions.32 | |||||||
| Infectious diseases | Community event-based surveillance.a,24 | Viral hepatitis testing34 : provider- or practitioner-initiated, clinic, inpatient, and outpatient settings.a | Hygiene promotion through health promoters and activities.37–39 | Mass media to: promote viral hepatitis testing and targeted screening,34 advocate for dengue prevention and control,48 provide timely information on the spread of disease,24 and manage misinformation.a,24 | Incentives.38 | Installation of household sanitation (eg, clean drinking water, latrines).a,50 | Combination of hand hygiene marketing and health system change in healthcare settings.a,52 |
| Community delivered Hepatitis B and C testing.a,34 | Voluntary HIV testing and counseling routinely offered in clinical settings.a,46 | School-based immunization programs.8 | Online risk assessment.34 | Providing subsidies, facilities, or hardware.37 | Installation of insecticide-treated nets, repellents, and wearing protective clothing.a,51 | Integrated community- and school-based schistosomiasis drug delivery.22 | |
| Hygiene promotion:35–39 communication, social mobilization, community participation, social marketing, and advocacy. | Streamlined interventions7 : enhanced linkage with case management, support for HIV disclosure, patient tracing, training staff to provide multiple services, and streamlined services.a | School-based delivery of mass drug administration programs.22,44 | Prevention interventions through49 : voice landlines and mobile telephones. | Free insecticide-treated bednets and incentives to encourage bednet use.42 | Community-based combined with healthcare-based delivery of mass drug administration programs.22,44 | ||
| Distribution of insecticide treated nets, indoor residual spraying, and chemical and biological larvicides.40–42 | School-based leprosy screening.47 | Cash transfers conditional on18 ; vaccinations. | |||||
| Mass drug administration.22,43,44 | |||||||
| Home-based provision of antimalarials.45 | |||||||
| Healthy lifestyle and nutrition | Education and behavior change campaigns:3,4,53–57 community leaders, mass participation events, and linkages with community programs. | Routine contact, patient assessment, and counseling to3,4,53,58,59 : deliver preventive, services, monitor, and identify high-risk groups. | Promoting physical activity and healthy eating54–57,60–62 : curriculum, physical activity breaks, active play during recess, physical activity homework, counseling, and peer-modeling. | Information systems to strengthen monitoring and decision-making.a,3 | Financing structures that enable health professionals to dedicate more time to diet and physical activity.a,53 | Self-monitoring through mHealth technologies.19 | Mass media communication campaigns, linked with community-based programs.a,4 |
| Safe and well-maintained infrastructure, facilities, and public open spaces.a,3,4 | Communication through mass media for physical activity.a,3 | Conditional and unconditional cash transfers.28,67 | |||||
| Iron supplementation and point-of-use fortification.a,6,7 | Electronic media-based behavior change lessons.63 | Vouchers and subsidies.28,67,68 | |||||
| Vitamin A supplementation integrated into pre-existing nutrition interventions.a,35 | Smartphone interventions.64–66 | Income generation opportunities.68 | |||||
| Noncommunicable diseases | Organized sport groups and clubs, programs, and events.a,14,69 | Facility-based care:14,69 early detection, health counseling, consistent follow-up, person-centered care provided by a multidisciplinary team, referrals, and screening of complications. | Oral health promotiona: curriculum,72 dental screening,73,74 and skills-based activities.72,75 | Mass media campaigns to normalize healthy behaviors.14,16 | Tracking progress:20,77–80 educational sessions, daily diaries, homework assignments, and telemedicine. | Integrate health education througha,23 : schools, communities, and health providers. | |
| Urban planning and active transport policies.14,69 | Outreach: mobile clinics70 and specialist home-based nursing services.71 | Social media to augment risk-behavior change campaigns.16 | Motivational interviewing.a,77 | Media to increase participation in community campaigns.16 | |||
| Patient consultations via tele-communication.a,76 | Cognitive behavioral therapy to instruct home practice.79,81 | ||||||
| Electronic media-based behavior change lessons.63 | School self-management plans.82 | ||||||
| Computerized cognitive behavioral therapy for pain.10 | Family counseling and skill-based models.80,81,83 | ||||||
| Brief guided self‐help education.20,21 | |||||||
| Physical safety and injuries | Risk communication and safety education campaigns.a,5 | Education as part of the delivery of health care.a,5 | Physical safety education campaigns in schools.85–87 | Telephone information services after poisoning:5 prevention, counseling, and follow-up.a | Financial incentives or free distribution for: booster seats,a,88 seat belts,a,89 and helmets.a,86 | ||
| Home safety interventions provided by community health workers, social care professionals, and lay workers.5,84 | Home safety interventions delivered in healthcare settings.84 | Mass media to raise awareness of accident risks and prevention.a,5 | |||||
| Community-based helmet education.85 | Facility-based helmet education.85 | Electronic media-based behavior change lessons.63 | |||||
| Mental health | Mental health interventions delivered by community health workers.90 | Mental health specialistsa,6 : brief psychological interventions and active consultation. | School personnel providing mental health support.92 Peer support groups.9 | Digitally‐delivered cognitive behavioral therapy.10,12,13 | Nonspecialized health care facilities that collaborate with school-based life skills education.a,6 | ||
| Interventions before medication:a,6 parent training, cognitive behavioral therapy, and social skills training. | Coping and resilience skills development:93 mindfulness and stress management. | Internet-based modules, manuals, and activities.94 | |||||
| Mental health services integrated with primary care.91 | Telehealth for sleep behaviors.12,94 | ||||||
| Sexual and reproductive health | Sexuality education programsa,6 : skills-based interactive approaches and peer and outreach approaches. | Sexual and reproductive health services, without mandatory parental authorization.a,6 | Electronic media-based behavior change lessons.63 | Integrated programs focused on girls’ empowerment and economic incentives to prevent child marriage.96 | |||
| Brief sexuality-related communication in primary health services.a,6 | |||||||
| Cervical cancer screening and treatment. a,6,95 | |||||||
| Integrated domains | Promotion of HPV vaccination for cervical cancer preventiona,97 : outreach and counseling, community mobilization, and health education. | Joint TB and diabetes detection and management systems.a,98 | aIntegration of health services in schools:97 HPV vaccination, gatekeeper training, and facilitating access. | Microfinance programs.99–101 | Providing counseling to girls and parentsa,97 : HPV vaccination for girls screened for cervical cancer and health decision-making. | TB+diabetes programs, delivered through the integration ofa98 : clinical care at local and clinical level, mutual advocacy, communication, and social mobilization. | |
| Education activities to raise awareness about joint risk factors of TB+diabetes.a,98 | Hepatitis testing as part ofa,34 : mental health services, substance use services, and sexually transmitted infection services. | Cash transfers conditional on28,102 : health service usage, immunization, and other broad criteria. | Universal self-regulation interventions.103 | ||||
| Integrating hepatitis services in preexisting servicesa,34 : education, harm reduction, mental health services, medical services, and direct provision of referrals. | Primary-care settings for integration of servicesa,34,95 : testing, counseling, and multidisciplinary care. | Unconditional cash transfers for reducing poverty and other vulnerabilities.101,102 Vouchers, flat-rate subsidies, health insurance, and financial risk-protection measures.102 | |||||
| Delivery Strategy | |||||||
|---|---|---|---|---|---|---|---|
| Child Health Domain | Community | Facility | School | Digital or Technology | Financial | Self-Management | Integrated Strategies |
| Child development | Surveillance of patients with neurologic consequences of Zika virus infection.a,24 | Specialized healthcare.a,6,24 | Curriculum for social and emotional learning.26 | Cash transfers conditional on17,27,28 : parent training, home visits, behavior management, social development, center-based parent-child programs, school enrollment and attendance. | Self-monitoring, administration, evaluation, goal setting.29 | Patient education, home visits, and schoolteacher training.33 | |
| Community health and social services.a,24 | Mental health and developmental assessment.a,6,7 | Unconditional cash transfers,17,27,28 school fee reduction.,17 and vouchers for school.17 | Computerized cognitive training programs.30 | ||||
| Family psycho-education and psychosocial interventions.7 | Executive functioning training.31 | ||||||
| Caregiver training.a,6,7,25 | Self-regulation31 : mindfulness meditation, biofeedback-induced relaxation, and direct teaching. | ||||||
| Self-directed parenting interventions.32 | |||||||
| Infectious diseases | Community event-based surveillance.a,24 | Viral hepatitis testing34 : provider- or practitioner-initiated, clinic, inpatient, and outpatient settings.a | Hygiene promotion through health promoters and activities.37–39 | Mass media to: promote viral hepatitis testing and targeted screening,34 advocate for dengue prevention and control,48 provide timely information on the spread of disease,24 and manage misinformation.a,24 | Incentives.38 | Installation of household sanitation (eg, clean drinking water, latrines).a,50 | Combination of hand hygiene marketing and health system change in healthcare settings.a,52 |
| Community delivered Hepatitis B and C testing.a,34 | Voluntary HIV testing and counseling routinely offered in clinical settings.a,46 | School-based immunization programs.8 | Online risk assessment.34 | Providing subsidies, facilities, or hardware.37 | Installation of insecticide-treated nets, repellents, and wearing protective clothing.a,51 | Integrated community- and school-based schistosomiasis drug delivery.22 | |
| Hygiene promotion:35–39 communication, social mobilization, community participation, social marketing, and advocacy. | Streamlined interventions7 : enhanced linkage with case management, support for HIV disclosure, patient tracing, training staff to provide multiple services, and streamlined services.a | School-based delivery of mass drug administration programs.22,44 | Prevention interventions through49 : voice landlines and mobile telephones. | Free insecticide-treated bednets and incentives to encourage bednet use.42 | Community-based combined with healthcare-based delivery of mass drug administration programs.22,44 | ||
| Distribution of insecticide treated nets, indoor residual spraying, and chemical and biological larvicides.40–42 | School-based leprosy screening.47 | Cash transfers conditional on18 ; vaccinations. | |||||
| Mass drug administration.22,43,44 | |||||||
| Home-based provision of antimalarials.45 | |||||||
| Healthy lifestyle and nutrition | Education and behavior change campaigns:3,4,53–57 community leaders, mass participation events, and linkages with community programs. | Routine contact, patient assessment, and counseling to3,4,53,58,59 : deliver preventive, services, monitor, and identify high-risk groups. | Promoting physical activity and healthy eating54–57,60–62 : curriculum, physical activity breaks, active play during recess, physical activity homework, counseling, and peer-modeling. | Information systems to strengthen monitoring and decision-making.a,3 | Financing structures that enable health professionals to dedicate more time to diet and physical activity.a,53 | Self-monitoring through mHealth technologies.19 | Mass media communication campaigns, linked with community-based programs.a,4 |
| Safe and well-maintained infrastructure, facilities, and public open spaces.a,3,4 | Communication through mass media for physical activity.a,3 | Conditional and unconditional cash transfers.28,67 | |||||
| Iron supplementation and point-of-use fortification.a,6,7 | Electronic media-based behavior change lessons.63 | Vouchers and subsidies.28,67,68 | |||||
| Vitamin A supplementation integrated into pre-existing nutrition interventions.a,35 | Smartphone interventions.64–66 | Income generation opportunities.68 | |||||
| Noncommunicable diseases | Organized sport groups and clubs, programs, and events.a,14,69 | Facility-based care:14,69 early detection, health counseling, consistent follow-up, person-centered care provided by a multidisciplinary team, referrals, and screening of complications. | Oral health promotiona: curriculum,72 dental screening,73,74 and skills-based activities.72,75 | Mass media campaigns to normalize healthy behaviors.14,16 | Tracking progress:20,77–80 educational sessions, daily diaries, homework assignments, and telemedicine. | Integrate health education througha,23 : schools, communities, and health providers. | |
| Urban planning and active transport policies.14,69 | Outreach: mobile clinics70 and specialist home-based nursing services.71 | Social media to augment risk-behavior change campaigns.16 | Motivational interviewing.a,77 | Media to increase participation in community campaigns.16 | |||
| Patient consultations via tele-communication.a,76 | Cognitive behavioral therapy to instruct home practice.79,81 | ||||||
| Electronic media-based behavior change lessons.63 | School self-management plans.82 | ||||||
| Computerized cognitive behavioral therapy for pain.10 | Family counseling and skill-based models.80,81,83 | ||||||
| Brief guided self‐help education.20,21 | |||||||
| Physical safety and injuries | Risk communication and safety education campaigns.a,5 | Education as part of the delivery of health care.a,5 | Physical safety education campaigns in schools.85–87 | Telephone information services after poisoning:5 prevention, counseling, and follow-up.a | Financial incentives or free distribution for: booster seats,a,88 seat belts,a,89 and helmets.a,86 | ||
| Home safety interventions provided by community health workers, social care professionals, and lay workers.5,84 | Home safety interventions delivered in healthcare settings.84 | Mass media to raise awareness of accident risks and prevention.a,5 | |||||
| Community-based helmet education.85 | Facility-based helmet education.85 | Electronic media-based behavior change lessons.63 | |||||
| Mental health | Mental health interventions delivered by community health workers.90 | Mental health specialistsa,6 : brief psychological interventions and active consultation. | School personnel providing mental health support.92 Peer support groups.9 | Digitally‐delivered cognitive behavioral therapy.10,12,13 | Nonspecialized health care facilities that collaborate with school-based life skills education.a,6 | ||
| Interventions before medication:a,6 parent training, cognitive behavioral therapy, and social skills training. | Coping and resilience skills development:93 mindfulness and stress management. | Internet-based modules, manuals, and activities.94 | |||||
| Mental health services integrated with primary care.91 | Telehealth for sleep behaviors.12,94 | ||||||
| Sexual and reproductive health | Sexuality education programsa,6 : skills-based interactive approaches and peer and outreach approaches. | Sexual and reproductive health services, without mandatory parental authorization.a,6 | Electronic media-based behavior change lessons.63 | Integrated programs focused on girls’ empowerment and economic incentives to prevent child marriage.96 | |||
| Brief sexuality-related communication in primary health services.a,6 | |||||||
| Cervical cancer screening and treatment. a,6,95 | |||||||
| Integrated domains | Promotion of HPV vaccination for cervical cancer preventiona,97 : outreach and counseling, community mobilization, and health education. | Joint TB and diabetes detection and management systems.a,98 | aIntegration of health services in schools:97 HPV vaccination, gatekeeper training, and facilitating access. | Microfinance programs.99–101 | Providing counseling to girls and parentsa,97 : HPV vaccination for girls screened for cervical cancer and health decision-making. | TB+diabetes programs, delivered through the integration ofa98 : clinical care at local and clinical level, mutual advocacy, communication, and social mobilization. | |
| Education activities to raise awareness about joint risk factors of TB+diabetes.a,98 | Hepatitis testing as part ofa,34 : mental health services, substance use services, and sexually transmitted infection services. | Cash transfers conditional on28,102 : health service usage, immunization, and other broad criteria. | Universal self-regulation interventions.103 | ||||
| Integrating hepatitis services in preexisting servicesa,34 : education, harm reduction, mental health services, medical services, and direct provision of referrals. | Primary-care settings for integration of servicesa,34,95 : testing, counseling, and multidisciplinary care. | Unconditional cash transfers for reducing poverty and other vulnerabilities.101,102 Vouchers, flat-rate subsidies, health insurance, and financial risk-protection measures.102 | |||||
HIV, human immunodeficiency virus; HPV, human papillomavirus; TB, tuberculosis.
Identified from WHO guidance document.
Comparisons Made Within the Included Reviews
| Delivery Strategy | ||||||||
|---|---|---|---|---|---|---|---|---|
| Child Health Domain | Intervention | Community | Facility | School | Digital or Technology | Financial | Self-Management | Integrated Strategies |
| Child development | Parenting interventions | Parent-reported externalizing child behavior: no significant difference between strategies (SMD: −0.13; 95% CI: −0.49 to 0.24; P = .49)32 | Parent-reported externalizing child behavior: no significant difference between strategies (SMD: −0.13; 95% CI: −0.49 to 0.24; P = .49)32 | |||||
| Infectious diseases | Malaria control and prevention interventions (eg, training low-level health workers or mothers to give antimalarials, ITNs provided for free or at a subsidized cost) | Compared with facility-based:41,5 Prompt treatment with antimalarial ↑ (RR: 4.69; 95% CI: 1.00 to 22.07). All-cause mortality ↓ (RR: 0.58; 95% CI: 0.44 to 0.77). ITN ownership ↑ (RR: 1.24; 95% CI: 1.11 to 1.39). ITN usage ↑ (RR: 1.18; 95% CI: 1.03 to 1.34). Malarial incidence ↓ (RR: 0.70; 95% CI: 0.54 to 0.90). Malarial prevalence ↓ (RR: 0.42; 95% CI: 0.25 to 0.69). Parasitemia ↓ (RR: 0.39; 95% CI: 0.24 to 0.64). Splenomegaly ↓ (RR: 0.57; 95% CI: 0.50 to 0.65). Anemia prevalence ↓ (RR: 0.71; 95% CI: 0.53 to 0.97). Malaria-specific mortality ↓ (RR: 0.33; 95% CI: 0.20 to 0.55). ITN usage ↑42 | ITN ownership ↑42 | Compared with facility-based care41 : ITN ownership ↑ (RR: 5.05; 95% CI: 2.59 to 9.86). ITN usage ↑ (RR: 6.97; 95% CI: 3.10 to 15.69). Parasitemia ↓ (RR: 0.72; 95% CI: 0.53 to 0.99). All-cause mortality ↓ (RR: 0.79; 95% CI: 0.64 to 0.96) | ||||
| Helminthiasis control and prevention interventions (eg, mass drug administration) | STH prevalence ↓ (RR: 0.52; 95% CI: 0.41 to 0.67). STH intensity ↓ (SMD: −5.29; 95% CI: −9.22 to −1.36). Schistosomiasis prevalence ↓ (RR: 0.42; 95% CI: 0.31 to 0.57)44 | STH prevalence ↓ (RR: 0.49; 95% CI: 0.39 to 0.63). STH intensity ↓ (SMD: −0.22; 95% CI: −0.26 to −0.17). Schistosomiasis prevalence ↓ (RR: 0.50; 95% CI: 0.33 to 0.75). Mean Hemoglobin ↑ (SMD: 0.24; 95% CI: 0.16 to 0.32). Anemia prevalence ↓ (RR: 0.87; 95% CI: 0.81 to 0.94)44 | STH prevalence ↓ (RR: 0.30; 95% CI: 0.12 to 0.78). Schistosomiasis prevalence ↓ (RR: 0.24; 95% CI: 0.11 to 0.56). Birth wt ↓ (SMD: −9.52; 95% CI: −13.86 to −5.19). Very low birth wt ↓ (RR: 0.38; 95% CI: 0.16 to 0.87)44 | |||||
| Sanitation interventions (eg, subsidies, sanitation promotion) | Latrine coverage ↑ (absolute difference: 14 percentage points; 95% CI: 10 to 18). Latrine use ↑ (absolute difference: 13 percentage points; 95% CI: 5 to 21).37 Hand-washing with soap ↑. Latrine use ↑ (risk ratio: 2.63; 95% CI: 1.62 to 4.29). Open defecation ↑ (RR: 0.40; 95% CI: 0.37 to 0.44. Safe disposal practices ↑ (risk ratio: 2.07; 95% CI: 0.59 to 7.22)38 | Pupil per latrine ratio ↓37 | Behavior change outcomes: inconclusive results38 | |||||
| Mass drug administration programs for schistosomiasis | Percentage of SAC coverage: second highest coverage (53% to 85%; median 72%)22 | Percentage of SAC coverage: Lowest coverage (28% to 81%; median 49%)22 | Percentage of SAC coverage: Highest coverage (78% to 95%; median 89%)22 | |||||
| Leprosy screening | Identification of leprosy: inconclusive47 | Identification of leprosy ↑47 | ||||||
| Healthy lifestyle and nutrition | Obesity prevention interventions | Obesity-related outcomes: mixed results54,56 | Obesity-related outcomes ↓54,56 | |||||
| Physical activity interventions | Compared with school-based57 : Whole-day MVPA ↑ (MD: 2.67 mins/day; 95% CI: 2.05 to 3.28) | |||||||
| Nutritional environment interventions | Fruit and vegetable availability: little to no effect55 | Fruit and vegetable availability ↑55 | ||||||
| Noncommunicable diseases | Cystic fibrosis self-management interventions (eg, written materials, 1-to-1 or group educational sessions) | Compared with facility-based delivery20 : Pulmonary functioning: no effects. Wt: no effects. Dietary fat intake: no effects. Patients’ knowledge ↑. Self-management behaviors in caregivers ↑ | ||||||
| Physical safety and injuries | Home safety education and provision of safety equipment | Home compared with facility or community settings:84 Injury rates ↓ (IRR: 0.75; 95% CI: 0.62 to 0.91) | ||||||
| Nonlegislative interventions | Observed helmet use ↑ (OR: 4.30; 95% CI: 2.24 to 8.25)85 | Self-reported helmet use ↑ (OR: 2.78; 95% CI: 1.38 to 5.61)85 | Observed helmet use ↑ (OR: 1.73; 95% CI: 1.03 to 2.91). Self-reported helmet use ↑ (OR: 4.21; 95% CI: 1.06 to 16.74)85 | Observed helmet use ↑ (OR: 4.35; 95% CI: 2.13 to 8.89). Self-reported helmet use ↑ (OR: 7.27; 95% CI: 1.28 to 41.44). Self-reported helmet ownership ↑ (OR: 11.63; 95% CI: 2.14 to 63.16)85 | ||||
| Mental health | Cognitive behavioral therapy | Anxiety outcomes: no significant difference between strategies13 | Anxiety outcomes: no significant difference between strategies13 | |||||
| Sexual and reproductive health | Programs focused on girls’ empowerment and economic incentives | Knowledge and attitudes related to the negative consequences of child marriage ↑. Child marriage ↓96 . | ||||||
| Integrated domains | ||||||||
| Delivery Strategy | ||||||||
|---|---|---|---|---|---|---|---|---|
| Child Health Domain | Intervention | Community | Facility | School | Digital or Technology | Financial | Self-Management | Integrated Strategies |
| Child development | Parenting interventions | Parent-reported externalizing child behavior: no significant difference between strategies (SMD: −0.13; 95% CI: −0.49 to 0.24; P = .49)32 | Parent-reported externalizing child behavior: no significant difference between strategies (SMD: −0.13; 95% CI: −0.49 to 0.24; P = .49)32 | |||||
| Infectious diseases | Malaria control and prevention interventions (eg, training low-level health workers or mothers to give antimalarials, ITNs provided for free or at a subsidized cost) | Compared with facility-based:41,5 Prompt treatment with antimalarial ↑ (RR: 4.69; 95% CI: 1.00 to 22.07). All-cause mortality ↓ (RR: 0.58; 95% CI: 0.44 to 0.77). ITN ownership ↑ (RR: 1.24; 95% CI: 1.11 to 1.39). ITN usage ↑ (RR: 1.18; 95% CI: 1.03 to 1.34). Malarial incidence ↓ (RR: 0.70; 95% CI: 0.54 to 0.90). Malarial prevalence ↓ (RR: 0.42; 95% CI: 0.25 to 0.69). Parasitemia ↓ (RR: 0.39; 95% CI: 0.24 to 0.64). Splenomegaly ↓ (RR: 0.57; 95% CI: 0.50 to 0.65). Anemia prevalence ↓ (RR: 0.71; 95% CI: 0.53 to 0.97). Malaria-specific mortality ↓ (RR: 0.33; 95% CI: 0.20 to 0.55). ITN usage ↑42 | ITN ownership ↑42 | Compared with facility-based care41 : ITN ownership ↑ (RR: 5.05; 95% CI: 2.59 to 9.86). ITN usage ↑ (RR: 6.97; 95% CI: 3.10 to 15.69). Parasitemia ↓ (RR: 0.72; 95% CI: 0.53 to 0.99). All-cause mortality ↓ (RR: 0.79; 95% CI: 0.64 to 0.96) | ||||
| Helminthiasis control and prevention interventions (eg, mass drug administration) | STH prevalence ↓ (RR: 0.52; 95% CI: 0.41 to 0.67). STH intensity ↓ (SMD: −5.29; 95% CI: −9.22 to −1.36). Schistosomiasis prevalence ↓ (RR: 0.42; 95% CI: 0.31 to 0.57)44 | STH prevalence ↓ (RR: 0.49; 95% CI: 0.39 to 0.63). STH intensity ↓ (SMD: −0.22; 95% CI: −0.26 to −0.17). Schistosomiasis prevalence ↓ (RR: 0.50; 95% CI: 0.33 to 0.75). Mean Hemoglobin ↑ (SMD: 0.24; 95% CI: 0.16 to 0.32). Anemia prevalence ↓ (RR: 0.87; 95% CI: 0.81 to 0.94)44 | STH prevalence ↓ (RR: 0.30; 95% CI: 0.12 to 0.78). Schistosomiasis prevalence ↓ (RR: 0.24; 95% CI: 0.11 to 0.56). Birth wt ↓ (SMD: −9.52; 95% CI: −13.86 to −5.19). Very low birth wt ↓ (RR: 0.38; 95% CI: 0.16 to 0.87)44 | |||||
| Sanitation interventions (eg, subsidies, sanitation promotion) | Latrine coverage ↑ (absolute difference: 14 percentage points; 95% CI: 10 to 18). Latrine use ↑ (absolute difference: 13 percentage points; 95% CI: 5 to 21).37 Hand-washing with soap ↑. Latrine use ↑ (risk ratio: 2.63; 95% CI: 1.62 to 4.29). Open defecation ↑ (RR: 0.40; 95% CI: 0.37 to 0.44. Safe disposal practices ↑ (risk ratio: 2.07; 95% CI: 0.59 to 7.22)38 | Pupil per latrine ratio ↓37 | Behavior change outcomes: inconclusive results38 | |||||
| Mass drug administration programs for schistosomiasis | Percentage of SAC coverage: second highest coverage (53% to 85%; median 72%)22 | Percentage of SAC coverage: Lowest coverage (28% to 81%; median 49%)22 | Percentage of SAC coverage: Highest coverage (78% to 95%; median 89%)22 | |||||
| Leprosy screening | Identification of leprosy: inconclusive47 | Identification of leprosy ↑47 | ||||||
| Healthy lifestyle and nutrition | Obesity prevention interventions | Obesity-related outcomes: mixed results54,56 | Obesity-related outcomes ↓54,56 | |||||
| Physical activity interventions | Compared with school-based57 : Whole-day MVPA ↑ (MD: 2.67 mins/day; 95% CI: 2.05 to 3.28) | |||||||
| Nutritional environment interventions | Fruit and vegetable availability: little to no effect55 | Fruit and vegetable availability ↑55 | ||||||
| Noncommunicable diseases | Cystic fibrosis self-management interventions (eg, written materials, 1-to-1 or group educational sessions) | Compared with facility-based delivery20 : Pulmonary functioning: no effects. Wt: no effects. Dietary fat intake: no effects. Patients’ knowledge ↑. Self-management behaviors in caregivers ↑ | ||||||
| Physical safety and injuries | Home safety education and provision of safety equipment | Home compared with facility or community settings:84 Injury rates ↓ (IRR: 0.75; 95% CI: 0.62 to 0.91) | ||||||
| Nonlegislative interventions | Observed helmet use ↑ (OR: 4.30; 95% CI: 2.24 to 8.25)85 | Self-reported helmet use ↑ (OR: 2.78; 95% CI: 1.38 to 5.61)85 | Observed helmet use ↑ (OR: 1.73; 95% CI: 1.03 to 2.91). Self-reported helmet use ↑ (OR: 4.21; 95% CI: 1.06 to 16.74)85 | Observed helmet use ↑ (OR: 4.35; 95% CI: 2.13 to 8.89). Self-reported helmet use ↑ (OR: 7.27; 95% CI: 1.28 to 41.44). Self-reported helmet ownership ↑ (OR: 11.63; 95% CI: 2.14 to 63.16)85 | ||||
| Mental health | Cognitive behavioral therapy | Anxiety outcomes: no significant difference between strategies13 | Anxiety outcomes: no significant difference between strategies13 | |||||
| Sexual and reproductive health | Programs focused on girls’ empowerment and economic incentives | Knowledge and attitudes related to the negative consequences of child marriage ↑. Child marriage ↓96 . | ||||||
| Integrated domains | ||||||||
Arrows indicate the direction of the effect (ie, improved or reduced).
CI, confidence interval; IRR, incidence rate ratio; ITN, insecticide-treated nets; MD, mean difference; MVPA, moderate to vigorous physical activity; OR, odds ratio; RR, relative risk; SAC, school-age children; SMD, standardized mean difference; STH, soil-transmitted helminth.
Eight reviews examined the effects of infection control interventions delivered through the community compared with other strategies (Table 4).22,37,38,41,42,44,45,47 However, target populations were not exclusively SAC, and many studies focused on children (without reporting ages), households, or the general population. Community strategies significantly improved malaria control and prevention outcomes compared with facility care. For example, community-only interventions reduced malaria incidence (relative risk [RR]: 0.70; 95% confidence interval [CI]: 0.54 to 0.90) and prevalence (RR: 0.42; 95% CI: 0.25 to 0.69) compared with facility-only care.41 Community-only delivery of helminthiasis interventions reduced schistosomiasis prevalence, STH prevalence, and STH intensity. Community-based approaches that include sanitation components consistently improved handwashing with soap and sanitation outcomes, whereas incentives yielded mixed results.38 Community-based education interventions may increase usage of insecticide-treated nets (ITN).42 A review by Mbakaya and colleagues39 examined hand hygiene interventions delivered in the community and schools but did not compare the delivery strategies. The authors identified the following intervention types: training, funding, and policy, used alone or in combination. Interventions delivered through the community or school reduced respiratory conditions, gastro-intestinal problems, and school absenteeism.
Though the evidence on the effectiveness of community-based healthy lifestyle and nutrition interventions was limited and mixed, 1 review found that interventions delivered in community settings were more effective at maintaining moderate to vigorous physical activity than school settings.57
Two reviews conducted in HIC explored the effectiveness of physical safety and injury prevention interventions delivered through different strategies. Home safety interventions delivered in the child’s home (incidence rate ratio [IRR]: 0.75; 95% CI: 0.62 to 0.91) were more effective than interventions delivered in healthcare (IRR: 1.07; 95% CI: 0.99 to 1.17) or community settings (IRR: 0.77; 95% CI: 0.52 to 1.16).84 Community-based interventions improved the odds of observed helmet ownership (odds ratio [OR]: 4.30; 95% CI: 2.24 to 8.25).85
A review by Barnett and colleagues found that community health worker-involved mental health interventions are effective for improving mental health outcomes for underserved populations. However, the authors found significant differences between LMIC- and US-based trials. Trials conducted in LMICs tested evidence-based treatments more frequently, whereas trials conducted in the United States tested newer, community-developed interventions more frequently.90
Facility
Eight reviews of moderate to critically low quality explored the effectiveness of facility-based interventions. SAC regularly visit healthcare facilities, such as primary care centers.58 Thus, this strategy is uniquely positioned to manage child health and advocate for healthy behaviors. Likewise, specialized conditions require interventions delivered through health care facilities.
Several reviews categorized within other strategies included the facility strategy as a comparison group. Eight reviews used the facility strategy for the intervention group.
HIC studies reveal that the facility strategy improves self-reported helmet wearing (OR: 2.78; 95% CI: 1.38 to 5.61) compared with other strategies.85
Evidence from HIC settings reveal that primary care provider-delivered interventions improve healthy lifestyle and nutrition outcomes (eg, improve nutrition and dietary behavior, increase physical activity, reduce screen time, improve anthropometric and metabolic outcomes, and reduce sedentary behavior).58,59
There is insufficient evidence supporting primary care-feasible or -referable interventions for child maltreatment.25 However, partnerships with primary care facilities and nonembedded specialty mental health providers were most effective when they included strong communication among providers, timely availability, reliability of services, additional support beyond 1-time consultation, and standardized care algorithms.91
School
Seventeen reviews of high to critically low quality examined the effect of school-based interventions. The school setting is an ideal environment to deliver interventions to SAC because of the amount of time SAC spend at school. The school setting may alleviate the disparities in accessibility and use that are present in interventions delivered through other strategies. For example, more than half of young people who seek mental health services receive them in schools.92
School-based child development and mental health interventions significantly improved social competence, emotional competence, behavioral self-regulation, and early learning skills, and reduced behavioral and emotional challenges.26 School-based mental health programs were also associated with a moderate effect on externalizing problems, a small effect on internalizing and attention problems, and nonsignificant effects on substance use.92
School-based interventions improved several infectious disease outcomes. School-based delivery of helminthiasis interventions reduced schistosomiasis prevalence, STH prevalence, and STH intensity. School-based delivery also improved hemoglobin levels and reduced anemia prevalence (RR: 0.87; 95% CI: 0.81 to 0.94).44 Mbakaya and colleagues found that interventions delivered through the school and community strategies reduced respiratory conditions, gastro-intestinal problems, and school absenteeism.39 One review found that school-based screening is effective for early detection of leprosy cases, and for identification of cases through household contacts. However, most studies detected the largest number of leprosy cases through screening of the 10 to 14 age group.47
HIC studies revealed that school-based interventions improve physical safety outcomes (eg, observed helmet ownership and self-reported helmet wearing).85
School-based interventions improved healthy lifestyle and nutrition outcomes (eg, reduced body mass index [BMI] and improved fruit and vegetable availability) compared with community-based interventions. Interventions that included a physical exercise component in isolation (0.13 kg/m2; 95% CI: 0.04 to 0.22) or in combination with nutrition interventions (0.17 kg/m2; 95% CI: 0.06 to 0.29) were especially beneficial for reducing the BMI of overweight or obese children.61 Authors reported that school-based obesity prevention interventions were most effective when they included a secondary home element, combined diet and physical activity components, and were implemented for the entire school year or longer. Randomized controlled trials with positive results reported BMI or BMI z-score outcomes.54
Our search yielded limited evidence for the nutrition aspect of the healthy lifestyle and nutrition domain. Most interventions addressed diet and physical activity together, instead of focusing on nutrition-only interventions, such as food provision. However, according to a recent scoping review and WHO guidance document, the school strategy has great potential to effectively deliver nutrition interventions to improve health and educational outcomes in SAC. In particular, the following components were supported by the evidence: multicomponent interventions, involving parents, education, healthy school food environments through healthy food provision, and school-based growth monitoring.2,104
Self-Management
Twelve reviews ranging from critically low to moderate quality examined the effectiveness of self-management interventions. It has been suggested that self-management interventions (eg, self-regulation and self-direction) contribute to healthy development and the maintenance of health and wellbeing in SAC and across the lifespan.103
One of 12 reviews included LMIC evidence. This review found that computerized cognitive training programs had a small-to-moderate effect on cognitive and behavioral outcomes in typically and atypically developing children. The greatest and most significant effect was on visuo-spatial skills (Hedges’ g: 0.44; 95% CI: 0.18 to 0.71).30
Most HIC reviews examined child development and NCD interventions. Self-management interventions were effective for children with autism in natural, clinical, and mixed settings.29 Implicit executive functioning training through self-regulation strategies (eg, biofeedback-enhanced relaxation and strategy teaching programs) were more effective than explicit training, as well as more enjoyable and easily integrated into children’s everyday activities.31 However, a review that compared self-directed and therapist-directed interventions for externalizing child behavior found no significant differences between delivery methods.32
Four reviews assessed the effectiveness of self-management strategies in children with chronic conditions, such as asthma, cystic fibrosis, diabetes, epilepsy, and physical disabilities. Although reviews varied in the types of self-management interventions used, successful interventions aimed to increase condition-related knowledge, facilitated communication between parents and caregivers and health professionals, and involved parents in some capacity.80–83
Pandey and colleagues found that self-regulation interventions such as curriculum-based, yoga and mindfulness, social and personal skills-based, and exercise-based interventions improved health and social measures (eg, academic achievement, social skills, and mental health) (Cohen’s d: 0.42; 95% CI: 0.32 to 0.53).103
Digital
Nine reviews of moderate to critically low quality explored the effect of digital and technological interventions. Digital strategies have the potential to improve the uptake and accessibility of well-established interventions, particularly for children and adolescents who frequent digital spaces.
Two of the 9 reviews included LMIC evidence. LMIC evidence reveals that digitally delivered cognitive behavioral therapy (CBT) reduces anxiety compared with no treatment (Hedges’ g: 1.410; 95% CI: 0.375 to 2.444), though no significant differences were found between digital and standard CBT.13
The remaining reviews did not include LMIC evidence. Studies from HIC settings reveal that telehealth interventions improve sleep outcomes, though outcomes (eg, sleep onset latency) did not always reach typical levels.94
Text-messaging interventions significantly improved behavioral and clinical disease management outcomes, particularly when interventions were personalized.65 Digitally delivered CBT was associated with clinically significant reductions in pain compared with waitlist or computerized educational program controls (standardized mean difference [SMD]: 6.03; 95% CI: 2.67 to 13.62).10
Digital nutrition websites and apps that targeted parents improved nutrition outcomes, self-efficacy, and knowledge in children and parents.66 Electronic media-based interventions significantly improved at least 1 health and safety behavior change outcome (eg, fruit and vegetable consumption, physical activity, asthma self-management, and safety skills).63
Financial
Thirteen reviews of high to critically low quality examined financial strategies. Financial interventions address the effect of household socioeconomic disparities and poverty on SAC outcomes (eg, educational attainment and health and wellbeing). However, most of the included reviews focused on households, and the specific applicability to SAC is unclear.
Evidence revealed that free or subsidized provision can improve infectious disease and physical safety outcomes (eg, household ITN ownership, observed and self-reported helmet ownership, and self-reported helmet wearing).42,85 However, the evidence for improvements in physical safety is from HIC.
Consistent evidence suggests that participating in conditional cash transfer (CCT) and unconditional cash transfer (UCT) programs positively impacts child development outcomes (eg, school enrollment [OR: 1.36; 95% CI: 1.24 to 1.48] and attendance [OR: 1.59; 95% CI: 1.35 to 1.87]).17,27,28 Additionally, CCTs significantly improve the uptake of healthcare services.18
Consistent evidence showed that financial incentives improved household food security and dietary diversity.28,67,68 Demand- and supply-side financial incentives improved nutritional status and child growth indicators, and reduced child mortality and HIV prevalence.102
Two reviews found that microfinance programs had the potential to be both beneficial and detrimental. Programs had a positive impact on the overall health, food security, and nutrition of poor people and their children. However, these interventions can increase poverty and reduce levels of children’s education.100,101
Integrated Strategies
Four reviews of low to critically low quality examined integrated strategies. Integrated strategies employ more than 1 strategy to deliver interventions to SAC.
Three reviews examined the effectiveness of integrated strategies to deliver infectious disease interventions. Community integrated with facility strategies were found to significantly improve malaria control and prevention outcomes compared with facility-only care.41 Integrated community- and school-based delivery of mass drug administration programs for schistosomiasis were able to achieve higher coverage rates than both community-only and school-only delivery.22 Community strategies integrated with facility-based care had a significant effect on STH prevalence, schistosomiasis prevalence, birth weight, and very low birth weight.44
One systematic review addressed sexual and reproductive health interventions delivered through integrated strategies and the authors reported methodological limitations of the included studies. Integrated programs that focused on girls’ empowerment and offered economic incentives were reasonably successful at delaying child marriage and improving knowledge and attitudes toward child marriage. The findings highlight the importance of working through the education system and providing incentives that alleviate poverty.96
Discussion
Summary of the Evidence
Most of the evidence in favor of the community strategy examined infectious disease interventions. Community strategies significantly improved several infectious disease outcomes (eg, malaria control and prevention) compared with facility-only care. Additionally, interventions delivered at home or in community settings improved physical safety outcomes (eg, odds of observed helmet ownership), and community health worker-involved interventions improved mental health outcomes for underserved populations.
Facility-based interventions improved physical safety outcomes (eg, self-reported helmet wearing), and healthy lifestyle and nutrition outcomes (eg, nutrition and dietary behavior and physical activity).
School-based interventions improved several infectious disease outcomes (eg, reduced schistosomiasis prevalence). The strategy also delivered effective healthy lifestyle and nutrition interventions that improved BMI and BMI Z scores in overweight and obese children. School-based interventions improved physical safety (eg, self-reported helmet wearing) and child development (eg, social and emotional competence) outcomes.
Self-management interventions have shown promising effects on child development outcomes and can be easily integrated into SAC’s everyday activities. Interventions have also improved health and social measures, such as social skills and academic achievement.
Digital interventions improved NCD (eg, behavioral and clinical disease management and pain outcomes), healthy lifestyle and nutrition (eg, nutrition outcomes, self-efficacy, and knowledge), and integrated outcomes.
Financial interventions that provided free or subsidized ITNs and helmets showed improvements in ownership, though not necessarily usage. CCT and UCT programs improved child development outcomes (eg, school enrollment). Financial interventions also improved food security, dietary diversity, nutritional status, and child growth indicators.
Integrated strategies that incorporated community and facility improved malaria control and prevention outcomes, STH prevalence, schistosomiasis prevalence, birth weight, and very low birth weight. Integrated community- and school-based strategies achieved high coverage of mass drug administration for schistosomiasis. Programs that integrated girls’ empowerment in schools and offered economic incentives were reasonably successful at delaying child marriage and improving knowledge and attitudes toward child marriage.
Limitations
Our search yielded a paucity of evidence from LMIC settings (35 of 60 reviews), particularly for facility-based, digital, and self-management interventions.
Additionally, the focus of our review was SAC. However, several reviews covered wide age ranges or did not report the age of participants.
Some of the reviews in the community strategy defined community broadly and included home-based and school-based interventions under the definition. Thus, it is difficult to disentangle the effects of community-, home-, and school-based interventions.
We found considerable heterogeneity in intervention types, outcomes measured, and findings within and across delivery strategies.
Several reviews recommended further high-quality research and rigorous evaluations because of methodological limitations in the included studies.
Key Evidence Gaps
Little to no evidence was found for several child health interventions delivered through the facility, digital, financial, and self-management strategies. Overall, very few reviews examined facility-based interventions. Instead, this setting was often used as a comparison group. The few digital reviews included showed promise; however, results were limited by low-quality and methodological issues. The vast majority of studies that examined facility-based, digital, and self-management interventions were conducted in HIC. Moving forward, interventions that showed promise in HIC should be studied in LMIC settings.
Across several delivery strategies, limited evidence was found for sexual and reproductive health and nutrition interventions. For sexual and reproductive health, most reviews were excluded because of their focus on adolescents, young adults, and adults. Likewise, most nutrition interventions targeted children under 5. However, in the case of nutrition, this is likely due to our search approach and not a true gap in the evidence. A recent scoping review and WHO guidance document found evidence supporting school-based nutrition interventions. However, authors also found that few interventions addressed the nutrition domain alone, without the presence of physical activity components. Little evidence was found for interventions such as nutrition supplementation, growth monitoring, deworming, or school health services, such as nutrition counseling. School-based delivery of these interventions holds promise and more research is required.2,104
In addition to improving the health of SAC, effective delivery strategies must improve the distribution of health. Target 8 under Sustainable Development Goal 3 asks for the achievement of universal health coverage in response to the low access to affordable and quality healthcare worldwide. Universal health coverage is an essential step toward meeting several of the Sustainable Development Goals, particularly under goal 3. Moving forward, strategies that aim to deliver child health interventions must support the transition to universal health coverage by reaching underserved and marginalized children who are often missed in our intervention efforts. Further research is required to examine innovative strategies to improve the coverage of child health interventions worldwide.
Dr Zulfiqar and Mr Vaivada conceptualized and designed the study; Ms Sharma and Ms Asaf screened the search results, screened the retrieved articles against the inclusion criteria, appraised the quality of articles, extracted the data, completed data tabulation and synthesis, and drafted the initial manuscript; and all authors reviewed, revised, and approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.
FUNDING: This work was supported by a grant from the International Development Research Centre (#109010-001), as well as the World Health Organization. The funders did not participate in the work. Core funding support was also provided by the SickKids Centre for Global Child Health in Toronto.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no financial relationships relevant to this article to disclose.
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