Nutritional, Water, Sanitation and Hygiene Related Education Intervention to Address Malnutrition of Early Adolescents in Pakistan: A School Based Study: Protocol

This study is a Cluster Randomized Control Trial. Two stage sampling technique will be done. The sample size was calculated by using PASS software. Sample sizes was estimated to change in nutritional status of the early adolescent boys and girls. Sample size of 360 adolescents (180 in each intervention and control group) will achieve 80% power assuming 42% malnutrition among students in control arm and at least 6% reduction in the intervention arm having 90 students from each school at a two-sided 5% level of significance.

To assess the micronutrient levels (Iron, Zinc, Calcium, Complete Blood Count ) through blood sample, a subset of 108 adolescents 6-8 grade school going adolescents (54 intervention group,54 control group) from this total sample size (360) will be selected through random selection.

Data will be collected through adopted and adapted self-administered, structured questionnaire from 6,7, and 8 grade school going adolescents at base line and at end line.

To approach to 6, 7, and 8 grade adolescents, informed consent will be first taken from their mothers/immediate caretaker and school management. Before collecting the data, a written informed assent will also be taken from the participants available in Urdu and . Study participants will be briefed about purpose of the study and assured about anonymity and confidentiality of information shared. Finally, the survey questionnaire will be completed . In case, participants have any queries related to the questionnaire, explanation will be provided to them. Physical assessment will be done by the principal investigator which will take almost 10 minutes/ individual. For the biochemical markers assistance from local Aga Khan Laboratory will be sought. Phlebotomist /lab assistance from Aga Khan laboratory will go to the concerned educational institute and draw blood samples from the participants who have given their consent for the test.

Data analysis plan Quantitative variables will be described by means and standard deviations whereas median with interquartile range will be mentioned for qualitative variables. Frequencies and percentages will be calculated for knowledge, attitude and practices of adolescents regarding nutrition and WASH. The comparison between intervention and control at base line and end line will be performed by using paired t-test and Chi-square. For the variables that are not normally distributed, nonparametric test McNamara will be used. Binary logistic regression and multiple linear regression will be used to assess the effect of intervention. All the statistical analysis will be conducted using SPSS version 23. P value less than 0.05 will be considered statistically significant.