WHO guideline on school health services: web annex G: survey of expert opinion on school health services: methodology and select findings

In partnership with WHO guideline on school health services Web Annex G. Survey of expert opinion on school health services: methodology and select findings In partnership with WHO guideline on school health services Web Annex G. Survey of expert opinion on school health services: methodology and select findings WHO guideline on school health services. Web Annex G. Survey of expert opinion on school health services: methodology and select findings ISBN 978-92-4-003072-5 (electronic version) © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non- commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/). Suggested citation. Web Annex G. Survey of expert opinion on school health services: methodology and select findings. In: WHO guideline on school health services. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/ bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. This publication forms part of the WHO guideline entitled WHO guideline on school health services. It is being made publicly available for transparency purposes and information, in accordance with the WHO handbook for guideline development, 2nd edition (2014). Contents Acknowledgements iv Abbreviations vi Web Annex G. Survey of expert opinion on school health services: methodology and select findings 1 G.1 Survey methodology 2 G.2 Select survey findings 3 G.3 Survey conclusions 5 Table G.1. Sociodemographic characteristics of respondents in the survey of expert opinion on SHS 4 iii Drafting of the guideline Mary Louisa Plummer, Child and Adolescent Health Consultant, United States of America, and David A. Ross, Department of Maternal, Newborn, Child and Adolescent Health and Ageing, WHO headquarters. GRADE methodologist Nandi Siegfried, Public Health Medicine Specialist, South Africa. Steering Group (WHO staff unless otherwise noted) Coordination David Ross and Kid Kohl, Department of Maternal, Newborn, Child and Adolescent Health and Ageing. Members Jamela Al-Raiby, WHO Regional Office for the Eastern Mediterranean; Wole Ameyan, Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes; Valentina Baltag, Department of Maternal, Newborn, Child and Adolescent Health and Ageing; Faten Ben-Abdelaziz, Department of Health Promotion; Paul Bloem, Department of Immunization, Vaccines and Biologicals; Sonja Caffe, WHO Regional Office for the Americas; Marie Clem Carlos, Department of Noncommunicable Diseases; Shelly Chadha, Department of Noncommunicable Diseases; Venkatraman Chandra-Mouli, Department of Sexual and Reproductive Health and Research; Katrin Engelhardt, Department of Nutrition and Food Safety; Kaia Engesveen, Department of Nutrition and Food Safety; Regina Guthold, Department of Maternal, Newborn, Child and Adolescent Health and Ageing; Joanna Herat, United Nations Educational, Scientific and Cultural Organization (UNESCO); Symplice Mbola Mbassi, WHO Regional Office for Africa; Rajesh Mehta, WHO Regional Office for South-East Asia; Denise Mupfasoni, Department of Control of Neglected Tropical Diseases; Martina Penazzato, Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes; Marina Plesons, Department of Sexual and Reproductive Health and Research; Leanne Riley, Department of Noncommunicable Diseases; Chiara Servili, Department of Mental Health and Substance Use; Stéphanie Shendale, Department of Immunization, Vaccines and Biologicals; Marcus Stahlhofer, Department of Maternal, Newborn, Child and Adolescent Health and Ageing; Howard Sobel, WHO Regional Office for the Western Pacific; Martin Weber, WHO Regional Office for Europe; and Juana Willumsen, Department of Health Promotion. Evidence review and synthesis Systematic overview of systematic reviews of comprehensive school health services Julia Levinson, Kid Kohl, Valentina Baltag and David Ross. Systematic reviews of the effectiveness and acceptability of comprehensive school health services Paul Montgomery, University of Birmingham, United Kingdom; Jacoby Patterson, Independent Senior Research Consultant, United Kingdom; and Anders M. Bach-Mortensen, University of Oxford, United Kingdom. Review of global WHO health service interventions for 5–19-year-olds Mary Plummer, Kid Kohl and David Ross. Survey of expert opinion on school health services Mary Plummer; Ace Chan, Stigma and Resilience Among Vulnerable Youth Centre (SARAVYC), School of Nursing, University of British Columbia, Vancouver, Canada; Kid Kohl; Ashley Taylor (SARAVYC); Elizabeth Saewyc (SARAVYC); and David Ross. Acknowledgements iv Brief exploratory review of school health services globally Mary Plummer, Kid Kohl and Valentina Baltag. Guideline Development Group Rima Afifi, University of Iowa, United States of America; Habib Benzian, New York University, United States of America; Harriet Birungi, Population Council, Kenya; Rashida Ferrand, Biomedical Research and Training Institute, Zimbabwe; Jorge Gaete, Universidad de los Andes, Chile; Najat Gharbi, Ministry of Health, Morocco; Murthy Gudlavalleti Venkata Satyanarayana, Indian Institute of Public Health, India; Henrica J. M. Fransen, University of Tunis El Manar, Tunisia; Julia Levinson, Boston University, United States of America; Erin D. Maughan, National Association of School Nurses, United States of America; Ella Cecilia Naliponguit, Department of Education, Philippines; Atif Rahman, University of Liverpool, United Kingdom; Elizabeth Saewyc (Chair), University of British Columbia, Canada; Susan Sawyer, University of Melbourne, Australia; Hui-Jing Shi, Fudan University, China; and Sharlen Vigan, World Bank, Togo. External Review Group Bruce Dick, Adolescent Health Consultant, Switzerland; Chris Kjolhede, Bassett Health Care Network, United States of America; Regina Lee, Professor of Nursing, University of Newcastle, Australia; Maziko Matemvu, Her Liberty, Malawi; Antony Morgan, Glasgow Caledonian University, United Kingdom; Blanca Pianello Castillo, International Federation of Medical Students’ Associations, Spain. Financial support The United Kingdom Department for International Development, the Bill and Melinda Gates Foundation and the United States Agency for International Development. v Abbreviations GDG Guideline Development Group HPS health-promoting school PA procedure or activity SARAVYC Stigma and Resilience Among Vulnerable Youth Centre (University of British Columbia, Canada) SHS school health services A glossary of terms used throught the guidance and its web annexes is provided in the guidance document. Glossary vi Survey of expert opinion on school health services: methodology and select findings Web Annex G G.1 Survey methodology G.1.1 Development of the questionnaire and survey protocol Global WHO publications were reviewed to identify recommended health service procedures or activities (PAs) for 5–19-year-olds. A working master list of 405 PAs was used to develop a comprehensive shortlist of 86 potential SHS interventions in 16 health areas – health promotion, health education, other aspects of a health-promoting school (HPS), assessment, screening, mass drug administration and immunization, health counselling to promote well-being, health counselling to prevent problems, sexual and reproductive health preventive care, general care, communicable diseases, noncommunicable conditions, injury and violence, sexual and reproductive health, mental health and substance use. The online questionnaire asked respondents to categorize the 86 health service interventions as essential, highly suitable, suitable or unsuitable for inclusion within SHS and whether this was applicable everywhere or in certain geographic areas only. These questions were mandatory, meaning that respondents needed to answer each question on a page of 2–6 questions (even if only to select “Do not know”) before moving on to the next page sequentially. Respondents also had the option to write in up to three additional interventions that they believed were essential to include in SHS, again with qualification of whether each should be included everywhere or in certain geographic areas only. Finally, respondents were asked to answer seven optional questions about their sociodemographic background. The only multiple-choice questions in the questionnaire were some of these respondent sociodemographic questions, relating to nationality, geographic area of expertise, health area of expertise and profession. The survey was designed to be closed and confidential. Each pre-selected expert was sent an email invitation with a unique link to the online questionnaire. Early drafts of the questionnaire were developed in English and administered by WHO using the programme LimeSurvey. The survey was pre-tested with WHO staff (n = 3) in April 2019 and then pilot-tested with SHS Guideline Steering Group members and Guideline Development Group (GDG) members at the May 2019 GDG meeting (n = 18). At the GDG meeting, participants reviewed the planned survey protocol, the draft questionnaire and the results of the pilot test and instructed WHO on revisions that should be made prior to finalization of the questionnaire. At the May 2019 meeting, the GDG requested that, if feasible, the three main questionnaire sections (A. promotion, B. prevention and C. care and treatment) be randomly ordered so that respondents might receive any of six versions of the questionnaire (ABC, ACB, BAC, BCA, CAB, CBA). The intention was to reduce the chance of bias related to answer order if, for instance, respondents only completed early questions fully, meaning all three sections would have an equal chance of full completion. However, at this meeting the GDG also requested WHO to administer the questionnaire in all six WHO languages. With the need for six different questionnaires to accommodate six languages, it became too difficult to also randomize sections, so section order randomization was not done. G.1.2 Selection of experts for the global survey on SHS WHO employed multiple approaches to compile a list of email addresses of experts who would be invited to participate in the survey of expert opinion, including the following. 1. A search of journal article databases using the key term “school health”, followed by review of the article lists to identify relevant titles and abstracts and then search for and inclusion of one author’s email address per article. The databases and numbers of expert email addresses broke down as follows: a. PubMed (2016–April 2019) (n = 307); b. African Index Medicus (2016–2018, because none after 2018) (n = 12); c. Africa Journals Online (2018–April 2019) (n = 35); d. Eastern Mediterranean Region Index Medicus (2018–April 2019) (n = 30); e. Pan American Health Organization Index Medicus (2018–April 2019) (n = 26); f. South-East Asia Region Index Medicus (2014–2016, none after 2016) (n = 28); and g. Western Pacific Region Index Medicus (2018–April 2019) (n = 23). In July–August 2019, a global survey of expert opinion was conducted on the relative suitability of interventions for inclusion within school health services (SHS). Web Annex G summarizes the methods and results of that survey. WHO guideline on school health services. Web Annex G. Survey of expert opinion on school health services: methodology and select findings 2 2. Addition of the email addresses of: a. all GDG members (n = 18); b. all GDG candidates (people who had been considered for GDG membership) (n = 64); and c. all Steering Group members and select WHO or United Nations Educational, Scientific and Cultural Organization headquarters and regional staff (n = 23). 3. Addition of names and email addresses contributed by 20 Steering Group members or GDG members from their professional networks (n = 745). Duplicates were removed from this list of 1311, resulting in a final list of 1293 expert email addresses. G.1.3 Survey administration and data cleaning The Stigma and Resilience Among Vulnerable Youth Centre (SARAVYC ) at the University of British Columbia, Canada, administered the survey using the Qualtrics programme (Qualtrics, Provo, UT). Translation of the English questionnaire into Arabic, Chinese, English, French, Spanish and Russian was carried out by Qualtrics staff directly into the programmed questionnaire. A check of the accuracy of those translations was carried out by GDG members and/or WHO staff who spoke those languages, before University of British Columbia SARAVYC staff made final edits to each questionnaire version. In July 2019, 1293 experts were emailed invitations to participate in the survey. The questionnaire took approximately 45 minutes to complete and could be completed within two weeks of receipt of the email. G.1.4 Quantitative and qualitative data analysis For quantitative data analysis, a partial completion cut-off was established for inclusion within the final dataset. This cut-off was set at > 6% of the mandatory questions (the first page of questions or five of 86 mandatory intervention questions). Of the 1293 experts who were emailed invitations to the survey, 442 (34%) completed at least the first page of five questions, of whom 417 (94%) completed all 86 mandatory questions. One hundred and eighty-eight respondents (44%) wrote at least one suggestion in response to the optional questions about additional essential interventions. In total there were 378 suggestions, approximately three fifths (63%) of which were in English and one fifth (22%) in French, followed by 7% Spanish, 6% Chinese, 2% Arabic and none in Russian. Quantitative data analysis focused on the 20 interventions that ranked most highly as: (a) “Essential everywhere” (both for all 86 interventions and for the 67 clinical interventions only); (b) “Essential in certain geographic areas only”; and (c) “Unsuitable everywhere” within SHS. “Clinical” interventions were defined as (a) needing to be delivered by or supervised by a health worker (n = 60) or (b) possibly being delivered by a health worker or delegated to a teacher with health- worker support or supervision (n = 7). Similarities and differences across WHO regions and the respondents’ professions were examined. The two categories of top 20 “Essential everywhere” interventions (all and clinical only) were mapped to the specific WHO PAs that support them. The 378 write-in interventions were translated into English, if needed, then organized under the 16 health areas. Suggestions that entirely repeated one of the interventions detailed in the first 86 questions were removed, unless multiple respondents stressed that they were extremely important. The interventions were organized under the 16 questionnaire health areas. Subgroups were created to reflect emergent themes and interventions were highlighted if they had been suggested by many (6–8) or several (4–5) respondents. G.2 Select survey findings G.2.1 Respondent sociodemographic information Survey respondents’ ages ranged from 25 to 81 years, with a mean and median age of 51 years. Respondents represented 81 nationalities, the 12 most common being: the Philippines (n = 56), United States of America (42), China (38), United Kingdom (26), Australia (18), Canada (13), India (13), South Africa (13), Tunisia (13), Germany (10), Jordan (9) and Sweden (9). Table G.1 details other self-reported sociodemographic characteristics of survey respondents. 3 Table G.1. Sociodemographic characteristics of respondents in the survey of expert opinion on SHS Region of nationality Main profession Area of expertise • 29% Western Pacific Region • 23% European Region • 18% Region of the Americas • 14% African Region • 12% Eastern Mediterranean Region • 4% South-East Asia Region • 30% researcher/academic • 27% health practitioner • 15% programme manager • 14% teacher or other educational professional • 8% policy-maker • 5% other • 28% child and adolescent health and development • 16% nutrition and/or physical activity • 14% noncommunicable diseases • 13% mental health (including self- harm) and/or substance use • 13% sexual and reproductive health • 11% communicable diseases • 6% unintentional injury and violence G.2.2 Interventions ranked as essential in SHS everywhere Overall, the interventions that were ranked most highly by survey respondents as essential in SHS everywhere were in the general health areas of health promotion and health education. The top five specific interventions were: promotion of personal hygiene and handwashing with soap (80%); provision of sexual and reproductive health education (75%); promotion of health literacy (73%); health education about nutrition (73%); and promotion of oral health care (70%). However, five of the top seven interventions in this category were among the first six questions of the questionnaire, so the possibility of some bias in response patterns (such as an initially affirmative response to all questions, followed by more subtle distinctions in later responses) cannot be ruled out. To address this possibility, “Essential everywhere” rankings of clinical interventions were also examined separately. Clinical interventions that were ranked most highly by survey respondents as essential in SHS everywhere were in the areas of immunization, screening, assessment and general care. The top five specific interventions were: administration of immunizations recommended for all children (68%); screening for vision problems (67%); provision of first aid (66%); screening for hearing problems (64%); and identification of developmental difficulties and disabilities (60%). G.2.3 Interventions ranked as essential in SHS in certain geographic areas only The interventions that were ranked most highly by survey respondents as essential in SHS in certain geographic areas only address diverse conditions that have limited geographic range due to disease prevalence, population, resources, ecology and/ or climate. The interventions that were ranked most highly in this category were in the areas of immunization, mass drug administration and health promotion, followed by screening and referral for communicable and noncommunicable diseases. The top five specific interventions were: administration of immunizations recommended for children residing in certain regions (49%); provision and promotion of use of insecticide-treated bed nets (48%); administration of immunizations recommended for children in some high-risk populations (44%); mass drug administration (38%); and promotion of use of sunscreen to prevent sunburn and skin cancer (27%). G.2.4 Interventions ranked as unsuitable in SHS anywhere The interventions that were ranked most highly by survey respondents as being UNSUITABLE IN SHS ANYWHERE mainly fell under the category of noncommunicable disease screening, although specific interventions from other health-care categories (general care, sexual and reproductive WHO guideline on school health services. Web Annex G. Survey of expert opinion on school health services: methodology and select findings 4 health preventive care, mental health, injury and immunization) also ranked highly. The top five specific interventions were: screening for hypertension (14%); administration of over-the- counter and prescribed medications (13%); and screening for diabetes (12%), scoliosis (12%) and other chronic conditions that may be undiagnosed (12%). Notably, the five interventions that were ranked most highly as “Unsuitable everywhere” were categorized in this way by only 12–14% of respondents and 2–3 times that proportion of respondents ranked each of these same interventions as “Essential everywhere” or “Essential in certain geographic areas only”. Four fifths (81%) of the interventions in the questionnaire were only ranked “Unsuitable everywhere” by 0–4% of respondents. There were no important differences in the results either by WHO region or by the profession of the respondent. G.2.5 Additional essential intervention suggestions Approximately half of the 378 write-in suggestions were in the categories of health promotion, health education and other aspects of HPS, with most in the latter category. Most of the remaining suggestions related to assessment, general care, noncommunicable conditions and mental health care. Six interventions were suggested by many (6–8) respondents: health education about safe use of technology/Internet; collaboration with school staff in multidisciplinary health services and classroom work; support for adequate and safe water and sanitation; early screening of students’ physical, behavioural, developmental and learning needs; occupational therapy at all levels of the support continuum; and specific nutrition interventions, such as referral, support and management for moderate and severe acute malnutrition or for overweight and obesity. G.3 Survey conclusions The survey of expert opinion succeeded in collecting meaningful data on the suitability of potential SHS interventions from a large and diverse sample of experts. Responses to all of the interventions listed in the questionnaire generally were favourable and there were no interventions that received an overwhelmingly negative response. The high overall ranking of health promotion and education interventions as “Essential everywhere” indicates that these are considered to be very important roles for health workers to perform within a school setting. The clinical interventions that ranked most highly as “Essential everywhere” were in the areas of immunization and mass drug administration, screening, assessment and general care. Similarly, the most common write-in suggestions were in the areas of health education, other aspects of HPS and screening and care for noncommunicable conditions. 5 For more information, please contact: mncah@who.int