Delivery Strategies Supporting

School-Age Child Health: A Systematic

Review
Naeha Sharma, MPH,a Ayesha Asaf, MPH,a Tyler Vaivada, MSc,a Zulfiqar A Bhutta, PhD, MBBS, FRCPCH, FAAPa,b,c

School-aged children (SAC; 5–9 years) remain understudied in global efforts to

CONTEXT: abstract
examine intervention effectiveness and scale up evidence-based interventions.
This review summarizes the available evidence describing the effectiveness of key
OBJECTIVE:
strategies to deliver school-age interventions.
We searched Medline, PsycINFO, Campbell Collaboration, and The Cochrane
DATA SOURCES:
Library during November 2020.
Systematic reviews and meta-analyses that: target SAC, examine effective
STUDY SELECTION:
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
DATA EXTRACTION:
extraction, and quality assessments.
RESULTS: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.
LIMITATIONS: 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.
CONCLUSIONS: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.

a
Centre for Global Child Health, The Hospital for Sick Children (SickKids), Toronto, Canada; bDepartment of Nutritional Sciences, University of Toronto, Toronto, Canada; and cCenter of
Excellence in Women and Child Health, Institute for Global Health & Development, Aga Khan University Hospital, Karachi, Pakistan

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.
DOI: https://doi.org/10.1542/peds.2021-053852L
Accepted for publication Feb 16, 2022

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 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).
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
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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,
SHARMA et al
 FIGURE 1
PRISMA flow diagram.

delivery strategies, child health inclusion or exclusion. Examples of
outcome, description of intervention, outcomes that were assessed
pooled outcomes and effect sizes, included but were not limited to:
and quality assessment. morbidity and mortality in the
school-age group, child
Outcomes development outcomes, mental
Outcomes reported in reviews health outcomes, burden of
were not used as a criterion for 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

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 TABLE 1 Description of Delivery Strategies comparisons shared below and
Delivery Strategy Description and Examples made within the included reviews
pertain to specific interventions and
Community-based Interventions delivered in the community through preexisting community
facilities, programs, or activities. outcomes. We have included reviews
Examples
Education and behavior change campaigns delivered through mass that compare delivery strategies
participation events.3,4 because they are more likely to

Home safety interventions provided by community health workers, examine the effectiveness of the
social care professionals, and lay workers.5
delivery strategy rather than
Facility-based Interventions delivered through primary care health centers, and first-
level and referral hospitals. the effectiveness of the
Examples
Mental health and developmental assessment.6,7 intervention.

Brief psychological interventions and active consultation with a mental
health specialist.6 The characteristics of included
School-based Interventions delivered in the school setting. These interventions often studies, pooled effect estimates,
use the school’s health services, staff, amenities, or curriculum.
quality assessments, and
Examples
School-based immunization programs.8

Peer support groups.9 justification for exclusion are
Digital or technology Interventions delivered through digital or technological devices, such as provided in the supplement
social media, phone apps, and mHealth. (Supplemental Information). Table 3
Examples
Internet-delivered cognitive behavioral therapy.10–13 presents the interventions that were

Mass media campaigns to normalize healthy behaviors.14–16
found by our original scoping
Financial Financial strategies, such as conditional and unconditional cash transfers,
voucher schemes, and microcredit strategies. exercise and the interventions found
Examples
School fee reductions.17 by this systematic review. The table

Cash transfers conditional upon vaccinations.18 reveals which child health domains
Self-management Interventions that encourage individuals to take responsibility for their have been well-covered by the
own care, which includes monitoring and managing symptoms.
literature.
Examples
Self-monitoring through mHealth technologies.19

Brief guided self-help education.20,21
Integrated strategies Interventions delivered through a combination of the aforementioned
Community
strategies. Fifteen reviews of moderate to
Examples
Integrated community- and school-based schistosomiasis drug critically low quality explored the
delivery.22

Programs that communicate health education regarding salt intake
effect of community-based
through multiple channels, such as schools, communities, and health interventions on child health
service providers.23 outcomes. Outside of school, SAC
develop in the contexts of their
home and community. Existing
AMSTAR 2 tool. The overall RESULTS
community programs and health
confidence was rated as follows:
Syntheses workers can be leveraged to reach
high (0 or 1 noncritical weakness),
SAC and support positive health
moderate (more than 1 noncritical One hundred ninety-three reviews
outcomes.
weakness), low (1 critical flaw were included in Pathway 1, 66
with or without noncritical reviews were included in Pathway 2, Eight reviews examined the effects
weakness), and critically low and 19 reviews examined enabling of infection control interventions
(more than 1 critical flaw with or policies and intersectoral actions. delivered through the community
without noncritical weakness). These reviews are listed in the compared with other strategies
supplement (Supplemental (Table 4).22,37,38,41,42,44,45,47
Grading of Recommendations Information). However, target populations were
Assessment, Development, and not exclusively SAC, and many
Evaluation ratings for the overall Sixty reviews met the selection studies focused on children (without
quality of the evidence at the criteria and were included in the reporting ages), households, or the
outcome level were abstracted from narrative synthesis and the general population. Community
the reviews. In the cases where accompanying tables. We present strategies significantly improved
these ratings were not reported by the results of reviews that examine malaria control and prevention
review authors, we extracted delivery strategies and reviews that outcomes compared with facility
information on individual study compare delivery strategies. We do care. For example, community-only
quality and the consistency of not mean to make broad conclusions interventions reduced malaria
results to achieve an overall quality about the effectiveness of 1 strategy incidence (relative risk [RR]: 0.70;
assessment. compared with another. The 95% confidence interval [CI]: 0.54 to

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 TABLE 2 Description of Pathways
Pathway 1
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.
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
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Priority Pathway 1 Pathway 2
The evidence in Pathway 1 was narrowed This category included systematic
down based on several criteria to reviews and meta-analyses that
focus the narrative syntheses on examined the effectiveness of
reviews that best answered our strategies to deliver novel
research question. To ensure interventions to school-age
evidence focused on school-age children. For example: reviews that
children, we only included systematic examined the effectiveness of
reviews and meta-analyses where exergames on fitness levels and
>50% of the included studies weight management.
targeted school-age children.
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
Enabling Policies and Intersectoral
Actions
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.
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
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TABLE 3 Summary Table
Delivery Strategy

Child Health
Domain Community Facility School Digital or Technology Financial Self-Management Integrated Strategies
Child development Surveillance of patients Specialized Curriculum for social and Cash transfers conditional Self-monitoring, Patient education,
with neurologic healthcare.a,6,24 emotional learning.26 on17,27,28: parent administration, home visits, and
consequences of Zika training, home visits, evaluation, goal schoolteacher
virus infection.a,24 behavior management, setting.29 training.33
social development,
center-based parent-
child programs, school
enrollment and
attendance.
Community health and Mental health and Unconditional cash Computerized
social services.a,24 developmental transfers,17,27,28 school cognitive training
assessment.a,6,7 fee reduction.,17 and programs.30
vouchers for school.17
Family psycho-education Executive functioning
and psychosocial training.31
interventions.7
Caregiver training.a,6,7,25 Self-regulation31:
mindfulness
meditation,
biofeedback-
induced relaxation,
and direct teaching.
Self-directed parenting
interventions.32

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Infectious diseases Community event-based Viral hepatitis testing34:
surveillance.a,24 provider- or
practitioner-initiated,
clinic, inpatient, and
outpatient settings.a
Community delivered Voluntary HIV testing and
Hepatitis B and C counseling routinely
testing.a,34 offered in clinical
settings.a,46
Hygiene promotion Mass media to: promote Incentives.38 Installation of Combination of hand
through health viral hepatitis testing household hygiene marketing
promoters and and targeted sanitation (eg, and health system
activities.37–39 screening,34 advocate clean drinking change in
for dengue prevention water, latrines).a,50 healthcare
and control,48 provide settings.a,52
timely information on
the spread of
disease,24 and manage
misinformation.a,24
School-based Online risk assessment.34 Providing subsidies, Installation of Integrated
immunization facilities, or insecticide-treated community- and
programs.8 hardware.37 nets, repellents, school-based
and wearing schistosomiasis
protective drug delivery.22
clothing.a,51

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TABLE 3 Continued
Delivery Strategy

Child Health
Domain Community Facility School Digital or Technology Financial Self-Management Integrated Strategies
Hygiene Streamlined School-based delivery of Prevention interventions Free insecticide-treated Community-based
promotion:35–39 interventions7: mass drug through49: voice bednets and incentives combined with
communication, enhanced linkage with administration landlines and mobile to encourage bednet healthcare-based
social mobilization, case management, programs.22,44 telephones. use.42 delivery of mass
community support for HIV drug
participation, social disclosure, patient administration
marketing, and tracing, training staff programs.22,44
advocacy. to provide multiple
services, and
streamlined services.a

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Distribution of School-based leprosy Cash transfers conditional
insecticide treated screening.47 on18; vaccinations.
nets, indoor
residual spraying,
and chemical and
biological
larvicides.40–42
Mass drug
administration.22,43,44
Home-based provision of
antimalarials.45
Healthy lifestyle Education and behavior Routine contact, patient Promoting physical activity Information systems to Financing structures that Self-monitoring Mass media
and nutrition change assessment, and and healthy strengthen monitoring enable health through mHealth communication
campaigns:3,4,53–57 counseling to3,4,53,58,59: eating54–57,60–62: and decision-making.a,3 professionals to technologies.19 campaigns, linked
community leaders, deliver preventive, curriculum, physical dedicate more time to with community-

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mass participation services, monitor, and activity breaks, active diet and physical based
events, and linkages identify high-risk play during recess, activity.a,53 programs.a,4
with community groups. physical activity
programs. homework, counseling,
and peer-modeling.
Safe and well- Communication through Conditional and
maintained mass media for unconditional cash
infrastructure, physical activity.a,3 transfers.28,67
facilities, and public
open spaces.a,3,4
Iron supplementation Electronic media-based Vouchers and
and point-of-use behavior change subsidies.28,67,68
fortification.a,6,7 lessons.63
Vitamin A Smartphone Income generation
supplementation interventions.64–66 opportunities.68
integrated
into pre-existing
nutrition
interventions.a,35

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TABLE 3 Continued
Delivery Strategy

Child Health
Domain Community Facility School Digital or Technology Financial Self-Management Integrated Strategies
14,69 a
Noncommunicable Organized sport groups Facility-based care: Oral health promotion : Mass media campaigns to Tracking Integrate health
diseases and clubs, programs, early detection, health curriculum,72 dental normalize healthy progress:20,77–80 education
a,14,69
and events. counseling, consistent screening,73,74 and behaviors.14,16 educational througha,23:
follow-up, person- skills-based sessions, daily schools,
centered care provided activities.72,75 diaries, homework communities, and
by a multidisciplinary assignments, and health providers.
team, referrals, and telemedicine.
screening of
complications.
Urban planning and Outreach: mobile clinics70 Social media to augment Motivational Media to increase
active transport and specialist home- risk-behavior change interviewing.a,77 participation in
policies.14,69 based nursing campaigns.16 community
services.71 campaigns.16
Patient consultations via Cognitive behavioral
tele-communication.a,76 therapy to instruct
home practice.79,81
Electronic media-based School self-
behavior change management
lessons.63 plans.82
Computerized cognitive Family counseling and
behavioral therapy for skill-based
pain.10 models.80,81,83
Brief guided self-help
education.20,21

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Physical safety and Risk communication and Education as part of the Physical safety education Telephone information Financial incentives or
injuries safety education delivery of health campaigns in services after free distribution for:
campaigns.a,5 care.a,5 schools.85–87 poisoning:5 prevention, booster seats,a,88 seat
counseling, and follow- belts,a,89 and
up.a helmets.a,86
Home safety Home safety interventions Mass media to raise
interventions delivered in healthcare awareness of accident
provided by settings.84 risks and prevention.a,5
community health
workers, social
care professionals,
and lay workers.5,84
Community-based Facility-based helmet Electronic media-based
helmet education.85 education.85 behavior change
lessons.63

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TABLE 3 Continued
Delivery Strategy

Child Health
Domain Community Facility School Digital or Technology Financial Self-Management Integrated Strategies
Mental health Mental health Mental health School personnel Digitally-delivered Nonspecialized health
interventions specialistsa,6: brief providing mental health cognitive behavioral care facilities that
delivered by psychological support.92 therapy.10,12,13 collaborate with
community health interventions and Peer support groups.9 school-based life
workers.90 active consultation. skills education.a,6
Interventions before Coping and resilience Internet-based modules,
medication:a,6 parent skills development:93 manuals, and
training, cognitive mindfulness and stress activities.94
behavioral therapy, and management.
social skills training.

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Mental health services Telehealth for sleep
integrated with primary behaviors.12,94
care.91
Sexual and Sexuality education Sexual and reproductive Electronic media-based Integrated programs
reproductive programsa,6: skills- health services, without behavior change focused on girls’
health based interactive mandatory parental lessons.63 empowerment
approaches and peer authorization.a,6 and economic
and outreach incentives to
approaches. prevent child
marriage.96
Brief sexuality-related
communication in
primary health
services.a,6
Cervical cancer screening

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and treatment. a,6,95
a
Integrated domains Promotion of HPV Joint TB and diabetes Integration of health Microfinance Providing counseling TB1diabetes
vaccination for detection and services in schools:97 programs.99–101 to girls and programs,
cervical cancer management HPV vaccination, parentsa,97: HPV delivered through
preventiona,97: systems.a,98 gatekeeper training, vaccination for the integration
outreach and and facilitating access. girls screened for ofa98: clinical care
counseling, cervical cancer and at local and
community health decision- clinical level,
mobilization, and making. mutual advocacy,
health education. communication,
and social
mobilization.
Education activities to Hepatitis testing as part Cash transfers conditional Universal self-
raise awareness ofa,34: mental health on28,102: health service regulation
about joint risk services, substance use usage, immunization, interventions.103
factors of services, and sexually and other broad
TB1diabetes.a,98 transmitted infection criteria.
services.

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 1-time consultation, and
Integrated Strategies standardized care algorithms.91

Two reviews found no significant

differences between outreach and
facility-based interventions for
asthma-related outcomes (eg,
symptom-free days and urgent care
Self-Management

use) and other acute and chronic

illness outcomes (eg, utilization of
health care and adverse
outcomes).70,71

School
insurance, and financial
transfers for reducing

vulnerabilities.101,102

Seventeen reviews of high to

poverty and other

subsidies, health
Unconditional cash

Vouchers, flat-rate

critically low quality examined the

Financial

risk-protection
measures.102

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.
Digital or Technology

The school setting may alleviate the

disparities in accessibility and use
Delivery Strategy

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

School

mental health interventions

significantly improved social
competence, emotional competence,
behavioral self-regulation, and early
learning skills, and reduced
Primary-care settings for

multidisciplinary care.
servicesa,34,95: testing,

HIV, human immunodeficiency virus; HPV, human papillomavirus; TB, tuberculosis.

behavioral and emotional

challenges.26 School-based mental
counseling, and
Facility

integration of

health programs were also

associated with a moderate effect on
externalizing problems, a small
effect on internalizing and attention
problems, and nonsignificant effects
and direct provision

on substance use.92
reduction, mental
Integrating hepatitis

medical services,
education, harm

health services,
Community

of referrals.
servicesa,34:
preexisting
services in

Identified from WHO guidance document.

School-based interventions
improved several infectious disease
outcomes. School-based delivery of
helminthiasis interventions reduced
schistosomiasis prevalence, STH
TABLE 3 Continued

prevalence, and STH intensity.

School-based delivery also improved
Child Health

hemoglobin levels and reduced

Domain

anemia prevalence (RR: 0.87; 95%

CI: 0.81 to 0.94).44 Mbakaya and
a

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TABLE 4 Comparisons Made Within the Included Reviews
Delivery Strategy

Child Health Digital or

Domain Intervention Community Facility School Technology Financial Self-Management Integrated Strategies
Child Parenting Parent-reported Parent-reported
development interventions externalizing child externalizing
behavior: no child behavior:
significant no significant
difference between difference
strategies (SMD: between
0.13; 95% CI: strategies (SMD:
0.49 to 0.24; 0.13; 95% CI:
P = .49)32 0.49 to 0.24;
P = .49)32

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Infectious Malaria control and Compared with facility-based:41,5 ITN ownership "42 Compared with
diseases prevention Prompt treatment with facility-based
interventions (eg, antimalarial " (RR: 4.69; 95% care41: ITN
training low-level CI: 1.00 to 22.07). All-cause ownership " (RR:
health workers or mortality # (RR: 0.58; 95% CI: 5.05; 95% CI: 2.59
mothers to give 0.44 to 0.77). ITN ownership " to 9.86). ITN usage
antimalarials, ITNs (RR: 1.24; 95% CI: 1.11 to 1.39). " (RR: 6.97; 95%
provided for free or ITN usage " (RR: 1.18; 95% CI: CI: 3.10 to 15.69).
at a subsidized 1.03 to 1.34). Malarial Parasitemia #
cost) incidence # (RR: 0.70; 95% CI: (RR: 0.72; 95% CI:
0.54 to 0.90). Malarial 0.53 to 0.99). All-
prevalence # (RR: 0.42; 95% CI: cause mortality #
0.25 to 0.69). Parasitemia # (RR: 0.79; 95% CI:
(RR: 0.39; 95% CI: 0.24 to 0.64). 0.64 to 0.96)
Splenomegaly # (RR: 0.57; 95%

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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
Helminthiasis control STH prevalence # (RR: 0.52; 95% STH prevalence # (RR: STH prevalence #
and prevention CI: 0.41 to 0.67). STH intensity 0.49; 95% CI: 0.39 to (RR: 0.30; 95% CI:
interventions # (SMD: 5.29; 95% CI: 9.22 0.63). STH intensity # 0.12 to 0.78).
(eg, mass drug to 1.36). Schistosomiasis (SMD: 0.22; 95% CI: Schistosomiasis
administration) prevalence # (RR: 0.42; 95% CI: 0.26 to 0.17). prevalence # (RR:
0.31 to 0.57)44 Schistosomiasis 0.24; 95% CI: 0.11
prevalence # (RR: 0.50; to 0.56). Birth wt
95% CI: 0.33 to 0.75). # (SMD: 9.52;
Mean Hemoglobin " 95% CI: 13.86 to
(SMD: 0.24; 95% CI: 5.19). Very low
0.16 to 0.32). Anemia birth wt # (RR:
prevalence # (RR: 0.87; 0.38; 95% CI: 0.16
95% CI: 0.81 to 0.94)44 to 0.87)44

S11
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TABLE 4 Continued

S12
Delivery Strategy

Child Health Digital or

Domain Intervention Community Facility School Technology Financial Self-Management Integrated Strategies
Sanitation Latrine coverage " (absolute Pupil per latrine Behavior change
interventions (eg, difference: 14 percentage ratio #37 outcomes:
subsidies, points; 95% CI: 10 to 18). inconclusive
sanitation Latrine use " (absolute results38
promotion) 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
Mass drug Percentage of SAC coverage: Percentage of SAC Percentage of SAC
administration second highest coverage (53% coverage: Lowest coverage: Highest
programs for to 85%; median 72%)22 coverage (28% to coverage (78% to
schistosomiasis 81%; median 95%; median
49%)22 89%)22
Leprosy screening Identification of leprosy: Identification of
inconclusive47 leprosy "47
Healthy lifestyle Obesity prevention Obesity-related outcomes: mixed Obesity-related
and nutrition interventions results54,56 outcomes #54,56
Physical activity Compared with school-based57:
interventions Whole-day MVPA " (MD: 2.67
mins/day; 95% CI: 2.05 to 3.28)

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Nutritional Fruit and vegetable availability: Fruit and vegetable
environment little to no effect55 availability "55
interventions
Noncommunicable Cystic fibrosis self-management Compared with
diseases interventions (eg, written facility-based
materials, 1-to-1 or group delivery20:
educational sessions) Pulmonary
functioning: no
effects. Wt: no
effects. Dietary fat
intake: no effects.
Patients’ knowledge ".
Self-management
behaviors in
caregivers "

SHARMA et al
by guest
TABLE 4 Continued
Delivery Strategy

Child Health Digital or

Domain Intervention Community Facility School Technology Financial Self-Management Integrated Strategies
Physical safety Home safety education Home compared with facility or
and injuries and provision of community settings:84 Injury
safety equipment rates # (IRR: 0.75; 95% CI: 0.62
to 0.91)
Nonlegislative Observed helmet use " (OR: 4.30; Self-reported helmet Observed helmet use Observed helmet
interventions 95% CI: 2.24 to 8.25)85 use " (OR: 2.78; " (OR: 1.73; 95% CI: use " (OR: 4.35;
95% CI: 1.38 to 1.03 to 2.91). Self- 95% CI: 2.13 to
5.61)85 reported helmet 8.89). Self-
use " (OR: 4.21; reported
95% CI: 1.06 to helmet use "

PEDIATRICS Volume 149, number s6, June 2022

16.74)85 (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 Anxiety outcomes: no Anxiety outcomes:
therapy significant no significant
difference between difference
strategies13 between
strategies13
Sexual and Programs focused on Knowledge and

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reproductive girls’ empowerment attitudes related to
health and economic the negative
incentives 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 differ-
ence; STH, soil-transmitted helminth.

S13
 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
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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
A large proportion of reviews found
evidence to support self-
management interventions delivered
through digital devices.19,21,30,32
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
SHARMA et al
 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
Several reviews highlighted the
paucity of studies and the need for
further, high-quality
evidence.12,49,63–66
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
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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).
S15
 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
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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.
SHARMA et al
 ABBREVIATIONS
CBT: cognitive behavioral
therapy
CCT: conditional cash transfers
HIC: high-income countries
ITN: insecticide-treated nets
LMIC: low- and middle-income
countries
NCD: noncommunicable diseases
SAC: school-aged children
STH: soil-transmitted helminth
infections
UCT: unconditional cash
transfers

Address correspondence to Zulfiqar A. Bhutta, PhD, MBBS, FRCPCH, FAAP, Centre for Global Child Health, The Hospital for Sick Children (SickKids), 686 Bay St, 11th floor, Suite 11.9731,
Toronto, Ontario M5G 0A4. E-mail: zulfiqar.bhutta@sickkids.ca
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2022 by the American Academy of Pediatrics
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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