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BanatiP, etal. BMJ Open 2024;14:e077533. doi:10.1136/bmjopen-2023-077533
Open access
Adolescent health and well- being
check- up programme in three African
cities (Y- Check): protocol for a
multimethod, prospective, hybrid
implementation- effectiveness study
Prerna Banati ,1 David Anthony Ross,2 Benedict Weobong,3 Saidi Kapiga,4,5
Helen Anne Weiss ,5 Valentina Baltag ,1 Farirai Nzvere ,5,6 Franklin Glozah,3
Mussa Kelvin Nsanya ,4 Giulia Greco,5 Rashida Ferrand,6,7
Aoife Margaret Doyle ,5,6 The Y- Check Research Programme Team
To cite: BanatiP, RossDA,
WeobongB, etal. Adolescent
health and well- being check- up
programme in three African
cities (Y- Check): protocol for
a multimethod, prospective,
hybrid implementation-
effectiveness study. BMJ Open
2024;14:e077533. doi:10.1136/
bmjopen-2023-077533
►Prepublication history for
this paper is available online.
To view these les, please visit
the journal online (https://doi.
org/10.1136/bmjopen-2023-
077533).
Received 07 July 2023
Accepted 15 May 2024
For numbered afliations see
end of article.
Correspondence to
Prerna Banati; banatip@ who. int
Protocol
© Author(s) (or their
employer(s)) 2024. Re- use
permitted under CC BY.
Published by BMJ.
ABSTRACT
Background During adolescence, behaviours are initiated
that will have substantial impacts on the individual’s short- term
and long- term health and well- being. However, adolescents
rarely have regular contact with health services, and available
services are not always appropriate for their needs. We co-
developed with adolescents a health and well- being check- up
programme (Y- Check). This paper describes the methods to
evaluate the feasibility, acceptability, short- term effects and
cost- effectiveness of Y- Check in three African cities.
Method This is a multi- country prospective intervention
study, with a mixed- method process evaluation. The
intervention involves screening, on- the- spot care and referral
of adolescents through health and well- being check- up visits.
In each city, 2000 adolescents will be recruited in schools
or community venues. Adolescents will be followed- up at
4 months. The study will assess the effects of Y- Check on
knowledge and behaviours, as well as clinical outcomes and
costs. Process and economic evaluations will investigate
acceptability, feasibility, uptake, delity and cost effectiveness.
Ethics and dissemination Approval has been received from
the WHO (WHO/ERC Protocol ID Number ERC.0003778); Ghana
Health Service (Protocol ID Number GHS- ERC: 027/07/22),
the United Republic of Tanzania National Institute for Medical
Research (Clearance No. NIMR/HQ/R.8a/Vol.IX/4199), the
Medical Research Council of Zimbabwe (Approval Number
MRCZ/A/2766) and the LSHTM (Approval Numbers 26 395
and 28312). Consent and disclosure are addressed in the
paper. Results will be published in three country- specic
peer- reviewed journal publications, and one multicountry
publication; and disseminated through videos, briefs and
webinars. Data will be placed into an open access repository.
Data will be deidentied and anonymised.
Trial registration number NCT06090006.
BACKGROUND
To unlock human potential and accelerate
progress towards achieving the Sustainable
Development Goals, it is essential to improve
the health and well- being of adolescents
(10–19 years).1 Health is an essential compo-
nent of human capital,2 yet adolescent invest-
ments have focused primarily on either
health or education services with little atten-
tion to synergies between these.3 Research
investments in the first 1000 days of life have
dramatically outweighed investments in the
subsequent 7000 days, leaving an evidence
gap on how to develop and sustain human
potential through adolescence and early
adulthood.4
Among adolescents in low- income and
middle- income countries (LMICs), HIV/
AIDS, road injury, diarrheal diseases, self-
harm, iron- deficiency anaemia and skin
diseases are among the top causes of
morbidity and mortality.5–7 Identifying
adolescents with poor health, health-
compromising behaviours or undiagnosed
disability is important given (a) the growing
STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒This study will utilise existing healthcare infrastruc-
ture in low- income and middle- income country
settings, assessing real- world implementation situ-
ations and therefore it will be relatively straightfor-
ward to directly apply the ndings to programmes.
⇒This is a relatively large study of 6000 adolescents in
three countries. The study takes the views of young
people centrally into the design of the intervention.
⇒Although the primary outcome is an implementation
science/programmatic outcome, the effectiveness
data is based on pre–post comparison.
⇒This study will have limited ability to assess sustain-
ability of effects over the longer term as the follow-
up period is 4 months.
⇒This study is operating in three African cities which
may limit generalisability to rural areas.
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number of adolescents and their low frequency of regular
contacts with health services,8 (b) the high proportion of
the total global burden of disease that occurs in adoles-
cence, (c) the fact that many key health conditions (eg,
mental health disorders) and behaviours (eg, tobacco
and alcohol use, unhealthy diet, low physical activity
and risky sexual behaviours) that predispose to prevent-
able serious conditions in later life start in adolescence,
(d) the negative impact of poor health on educational
attainment and employability and other transitions to
healthy adulthood and (e) gender- related vulnerabilities,
including violence, abuse, unintentional injury, sexual
and reproductive health (SRH) and gendered mental
health outcomes which may emerge or be exacerbated
during this period of life, setting negative trajectories to
lifetime and intergenerational health and well- being.4
Systematic reviews have identified individual inter-
ventions that are effective at improving various aspects
of adolescent health and/or well- being.4 However, most
adolescents only come into contact with health services
when they are ill, and services are not always appropriate
for their needs.9 This represents a missed opportunity for
early detection of health problems, for health promotion
and for the development of health- seeking behaviours.
Early and sustained engagement with health and social
services could reap a triple dividend for human develop-
ment by improving the health and well- being of adoles-
cents, their health and well- being in adulthood and the
health and well- being of their future offspring.2 4 10
Routine health and well- being check- up visits for
adolescents that screen for multiple conditions and risk
behaviours could provide an entry point into services
and be highly cost- effective.11 12 Obtaining evidence on
the optimum content, delivery, effectiveness and cost of
check- ups is a high priority for adolescent health research
so that governments can be informed by the evidence on
how to initiate or strengthen existing health and well-
being check- ups during adolescence.13 Many high- income
countries have national recommendations related to
adolescent health check- ups, which have been largely
based on expert opinion.14 15 In LMICs, if provided at all,
preventive and promotive health services for adolescents
are largely provided in schools and are usually limited
to deworming and vaccination campaigns. They do not
usually address other key conditions and risk factors such
as nutrition, mental health, SRH or disability.16 17 If a
system- wide approach to check- ups exists in adolescence,
in LMICs, it is often limited to a screening activity without
other components such as brief intervention or anticipa-
tory guidance.17
This paper describes the protocol for the Y- Check:
Evaluating the effects of adolescent health check- ups
study, a prospective hybrid implementation- effectiveness
study evaluating the feasibility, acceptability, short- term
effects, costs and cost- effectiveness of the Y- Check inter-
vention in three African cities. This study has received
approval from the World Health Organisation (WHO/
ERC Protocol ID Number ERC.0003778); Ghana Health
Service (Protocol ID Number GHS- ERC: 027/07/22),
the United Republic of Tanzania National Institute for
Medical Research (Clearance No. NIMR/HQ/R.8a/Vol.
IX/4199), the Medical Research Council of Zimbabwe
(Approval Number MRCZ/A/2766) and the London
School of Hygiene and Tropical Medicine (Approval
Numbers 26 395 and 28312) .
The Y-Check intervention
Y- Check is a novel intervention delivering a health and
well- being check- up and, where indicated, will provide
on- the- spot care and/or referral for common conditions
on two occasions in adolescence (in young adolescents
(10–14 year olds)—soon after the onset of puberty—and
in older adolescents (15–19 year olds)—when many
adolescents become, or are soon to become, sexually
active). It will also provide health promotion informa-
tion and materials to support positive behaviours and
healthy lifestyles during adolescence and beyond. The
intention is that in the context of a future routinely
delivered programme, every adolescent will have two
guaranteed contacts with the healthcare system. Adoles-
cents will only be screened for conditions that have
an accurate, low- cost, acceptable screening test and a
locally accessible, effective intervention. The conditions
selected for screening will be chosen to reflect the local
epidemiological contexts (eg, screening for malaria will
only take place in malaria endemic areas). Respecting
specific requests from the Ministries of Education in all
three cities, the study will only include SRH screening
and services at the community sites (which only include
older adolescents).
Figures 1 and 2 present the Theory of Change and
description of the intervention. Table 1 applies the
Template for Intervention Description and Replica-
tion (TIDieR) checklist18 to describe details of the
intervention.
Locally accessible services will be identified and
assessed in terms of their ability to provide the services
recommended by local and WHO guidelines, willingness
to accept referred adolescents, and the fees charged to
the project will be negotiated by the research team for
services provided to referred adolescents (where adequate
services are not covered by national health insurance
schemes, free NGO services or free public healthcare).
METHODS/DESIGN
Aims
The aim of the study is to develop and implement in
three African cities a potentially sustainable adolescent
health check- up programme, and evaluate the accept-
ability, feasibility, short- term effects and cost- effectiveness
of the programme to improve health and well- being. The
study was launched in September 2021 and will run until
June 2025.
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Objectives
1. To develop and pilot test a check- up programme for
adolescents that screens for important preventable
and treatable health conditions using accurate and ac-
ceptable screening tests and provides locally accessible
effective interventions.
2. Through a prospective intervention study in selected
schools and communities to:
– Estimate short- term impacts on adolescent health
and well- being outcomes: clinical outcomes, health-
related knowledge and behaviours, intentions,
agency and perceived social support for behaviour
change; engagement with health services.
– Understand, through process evaluation, the feasi-
bility and fidelity of implementation, the accepta-
bility and uptake and the influence of context.
– Estimate the cost- effectiveness of the programme in
reducing overall disease burden and improving ad-
olescent well- being
3. Obtain information on key parameters needed for
the planning of an evaluation study: prevalence
of health conditions and behaviours, acceptability
Figure 1 Theory of Change for Y- Check, an adolescent health and well- being check- up.
Figure 2 The Y- Check intervention package. *The intervention package may vary according to setting.
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of referral, feasibility of following- up programme
participants and delivering quality follow- up care,
initial estimates of the impact of the programme
on longer term health, educational and well- being
outcomes based on the short- term implementation
and effectiveness outcomes observed in this phase
of the research programme, and factors related to
the optimal implementation of the Y- Check inter-
vention.
4. To refine the programme and its Theory of Change,
and finalise optimal methods for the measurement of
the impact of the programme in future studies.
Table 1 Template for Intervention Description and Replication (TIDieR) checklist describing the Y- Check intervention
Item Item
Brief name
1 Evaluating the effectiveness of adolescent health check- ups (Y- Check)
Why?
2 Identifying adolescents with poor health, health- compromising behaviours or undiagnosed disability is important for
their health and well- being, and also for communities and nations
Most adolescents only come into contact with health services when they are ill, and services are not always
appropriate for their needs
Routine health and well- being check- up visits for adolescents that screen for multiple preventable and/or treatable
conditions and risk behaviours could provide an entry point into services and be highly cost- effective
What?
3 The intervention includes a comprehensive health check- up for priority conditions customised to national and local
contexts.
Where indicated, Y- Check will provide on- the- spot care and cover all clinical costs associated with referrals to further
care provided by the public health system or non- governmental organisations (NGOs).
During the check- up, adolescents will receive health promotion information and limited supplies of key health
commodities.
Clinical costs of services are covered by the study if accessed within 4 months of the check- up.
4 Adolescent- friendly services will be provided, as dened by WHO (2018). Nationally approved protocols will be
applied. Adolescent privacy and condentiality will be protected.
Who provided?
5 Y- Check teams will be staffed with health professionals trained to provide quality adolescent- friendly health services
in line with nationally approved protocols. Y- Check teams will also be trained in the use of the digital application which
will be used for data collection. Public and private not- for- prot care facilities providing referrals will meet national
accreditation guidelines.
How?
6 The Y- Check service will take place over a 60–90 min period face- to- face. Any referrals will only be subsidised by the
study if they take place within 4 months.
Where?
7 The Y- Check service will be provided in schools and community venues, in outdoor tents where required.
Referrals will be to public or private not- for- prot providers as close as possible to the adolescent’s home. Providers
will be vetted by the study team as being able to provide the necessary referral services to national and WHO-
recommended standards.
When and how much?
8 Within the current phase of the study, each adolescent will receive Y- Check once. Within a routine programme, the
intention would be that the intervention will be delivered twice during adolescence, once when the adolescent is
10–14 years old, and a second time when they are 15–19 years old.
Tailoring
9 The content of the intervention is tailored to local context. The exact set of conditions that will be assessed as part of
Y- Check will be adapted based on burden of disease, and availability of local tests and referral services.
Modications
10 Any modications will be reported in the article reporting the results of the study.
How well?
11 Intervention delity (adherence, integrity and quality) will be evaluated through a process evaluation including youth-
friendly health services quality.
12 Intervention delity will be reported in the article reporting the results of the study.
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Patient and public involvement
The intervention was designed following formative research
conducted in three African countries between 2019 and
2020.19–21 This formative research revealed that the proposed
adolescent health and well- being check- ups are likely to be
feasible to implement and acceptable to stakeholders in
Ghana, Tanzania and Zimbabwe, and are likely to meet the
perceived needs of key stakeholders including adolescents,
their parents and key policy makers in the health and educa-
tion sectors.22 Further, we showed that the programme is
likely to produce a substantial yield of important, previously
untreated, treatable conditions. Human- centred design tech-
niques were used alongside desk review to define elements
of objective and subjective importance to the health and
well- being of adolescents, identify facilitators and barriers to
adolescent health seeking, preferences for delivery of routine
health check- ups, and potential effects of interventions to
select the content and method of delivery of the Y- Check
intervention. Interviews and participatory workshops with
adolescents, parents of adolescents and key stakeholders from
the ministries of health and education, non- governmental
organisations, healthcare workers and teachers found that
there was overall support for the introduction of routine
health check- ups.19–21 To navigate potential barriers, stake-
holders suggested clear messaging, awareness building and
sensitisation campaigns to overcome disinterest in preven-
tative healthcare and, in some contexts, mitigate cultural or
religious messaging against healthcare engagement.19
Theory of Change
We hypothesise that a routine health and well- being
check- up visit for adolescents that screens for multiple
conditions and risk behaviours will have an immediate
and long- term positive impact on health and well- being
outcomes (figure 1).
Health seeking and promotion behaviours among adoles-
cents operate in complex environments and across ecolog-
ical levels,10 with determinants at individual, interpersonal
institutional/organisational, community and public policy
levels. Drawing from the health promotion literature,23 24 the
Theory of Change for Y- Check (figure 1) draws on thinking
that recognises predisposing, enabling and reinforcing
factors as capacities to be strengthened in order to achieve
adolescent well- being at the individual level; that respon-
sive parenting can support adolescents to meet their own
health and well- being goals; that systems- based approaches
(including stronger linkages between health and educa-
tion systems) can improve outcomes for adolescents, espe-
cially reaching the most vulnerable and those in need and
that an enabling environment (especially in schools and
communities) can support adolescents to take action towards
improving their health.
Study setting
Our study will be undertaken in three African cities: Cape
Coast in Ghana, Mwanza in Tanzania and Chitungwiza in
Zimbabwe. These cities are described in table 2.
Table 2 The study cities, schools and communities
Cape Coast, Ghana
Cape Coast Metropolis is located
on the coast of Ghana, 150 kms
west of the capital city, Accra. It has
a population of 169 894 with three
quarters of the households residing in
urban areas.
Literacy in 11–24 year olds is about
97%. In 2016, 11 233 (68.8%) of 12–14
year olds were enrolled in junior high
schools while 8407 (91.6%) of 15–17
year olds were enrolled in senior high
schools. For Ghana as a whole,
primary and secondary net enrolment
rates in 2019 were 86% and 57%,
respectively.38
There are 36 health facilities (26 public
and 10 private) in the metropolitan
area, including a regional hospital that
serves as a secondary referral facility.
The study will be conducted in eight
schools and local community venues
in four communities that include two
relatively afuent communities with
trading being the main source of
livelihood and two relatively poorer
communities where shing and farming
dominate, respectively.
Mwanza, Tanzania
Mwanza is located on the southern
shores of Lake Victoria in North-
Western Tanzania and is the second
largest city in Tanzania with a population
of over 900 000 and an annual growth
rate of 3%.39 Economic activities
in Mwanza include shing and sh
processing, subsistence agriculture and
support services to nearby gold and
diamond mines.
Adolescents make up 24.2% of the
population of the city (Tanzania National
Bureau of Statistics, 2016). As of
2020/2021, the primary and secondary
school net enrolment rates were 82%
and 39%, respectively.39
Available public health services include
26 dispensaries, 5 health centres, 2
district hospitals, 1 regional hospital and
1 tertiary/teaching hospital.39 40
The study will be conducted in 4–6
purposively selected communities
and in up to eight primary schools
and eight secondary schools within
the catchment area of health facilities
serving the selected communities in the
two districts within Mwanza city.
Chitungwiza, Zimbabwe
Chitungwiza is the third largest city in
Zimbabwe, located approximately 25 km
south of the capital city, Harare. It has a
population of about 456 000.41 The houses
are mostly high- density, single- story,
detached units with small yards that are
generally used for growing vegetables. Most
of the people work in Harare, as there is little
industry in Chitungwiza itself.
Zimbabwe has a school- going population
(8–18 years) of approximately 4.3 million.42
Net primary enrolment rate across Zimbabwe
is 94%; net secondary enrolment rate is
54%.41
In Chitungwiza, there is one tertiary hospital,
4 public primary healthcare facilities, 20
private medical facilities, 30 government
primary schools and 13 government
secondary schools (all mixed sex).
The study will be conducted in four distinct
communities which are representative of the
urban, peri- urban and rural populations of
Chitungwiza. Eligible schools must have a
student population of at least 200 learners in
grade 6 or at least 75 learners in Form 5; and
be located in or close to one of the selected
study communities.
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Study design
In this prospective hybrid implementation- effectiveness
study, 2000 adolescents per city who receive the Y- Check
intervention will be followed up at 4 months, and at
12 months (Zimbabwe only).
Stakeholder engagement
In each city, the research study is undertaken in partner-
ship with both the national and municipal Ministries of
Health and Education. Each country has a policy frame-
work that provides encouragement for the introduction
of health and nutrition education and promotion among
adolescents, including screening for communicable
and non- communicable diseases, immunisation, growth
monitoring and assessments and nutritional services.25–27
This study will build on stakeholder engagement, the
process for which was established in each research setting
during the formative phase. In each city, a Community
Advisory Committee (CAC) comprising key community
leaders and stakeholders will be reinforced or set up to facil-
itate input from, and feedback to, participating commu-
nities and a Youth Advisory Group (YAG) will provide a
forum for adolescents to input into the programme. The
YAG will meet with research staff at least four times per
year, be active participants in programme design and
dissemination workshops and help to ensure that the
programme meets the needs of adolescents. Community
engagement will be an ongoing process through regular
contacts with the CAC, the YAG and other stakeholders,
such as teachers, health workers, Community- Based
Organisations (CBOs), Non- Governmental Organisations
(NGOs) and religious leaders. In addition, a key aspect
for building confidence within communities is the knowl-
edge that the study has the support of the government.
Intervention development and pilot testing
Prior to implementation, preparatory activities will
include community engagement, participatory co- de-
sign, negotiating referral arrangements and pretesting of
screening tools, procedures and referral protocols. Pilot
studies in each setting will provide initial estimates of the
frequency of health and behavioural outcomes, and help
to refine the intervention model.
Pilot testing will involve the implementation of the
screening tools and procedures with approximately 200
adolescents in each of the three cities with revisions and
repeat pilot testing where required. Adolescents who
participate in the pilot study will be excluded from the
main study if the procedures change following the pilot.
There will be an opportunity for young people and stake-
holders to suggest additional client- centred outcomes
that may reflect some of their priority concerns or inten-
tions that should be captured.
Intervention implementation
The intervention will be delivered over a period of 2–6
months in each of the settings. The follow- up visits will
take place at the same school or community setting as the
initial check- up. In addition to covering all clinical costs,
the equivalent of US$5 will be given to each participant
who attends the follow- up to cover any transport costs
that they might have incurred. Additionally, health and
hygiene related items will also be provided for adoles-
cents to take home, including tooth cleaning kit (tooth-
brush and toothpaste), fruit, bottle of water, two pairs
of underpants and pack of reusable sanitary pads (girls
only).
Composition and training of Y-Check team
The Y- Check team will be trained to deliver adolescent-
responsive and age- appropriate services according to
national and WHO guidelines, recognising also the needs
for privacy and confidentiality.28 This includes providing
services that are attractive to adolescents, meet their
needs comfortably and responsively and that are atten-
tive to their privacy. These principles and approaches will
be embedded into each part of the Y- Check intervention.
Visual and auditory privacy will be prioritised, through
the use of separate tents, rooms or screens. Health
workers will employ standard gowning and draping for
clinical procedures.
For infection prevention and control, all study proce-
dures including interviews, physical examinations and
blood tests will take place in well- aerated tents or outdoors,
and will follow relevant nationally approved protocols for
all staff and participants.
The Y- Check team will be trained in good clinical prac-
tice, data protection and confidentiality and clinical staff
will be trained in counselling for participants testing posi-
tive for any of the conditions being screened for within
Y- Check as well as in general counselling skills.
Inclusion and exclusion criteria
To be included in the study, adolescents aged 10–19 years
must fall into one of the first three categories below and
fulfil category 4.
1. Be attending selected classes of year 5 of primary
school in Mwanza (median age 11 years); grade 5/6 of
primary school in Chitungwiza (median age 11 years)
or year 1 of Junior Secondary School in Cape Coast
(median age 12 years) OR
2. Be attending selected classes in year 3 of Secondary
School in Mwanza (median age 17 years), Form 3/4 in
Chitungwiza (median age 17 years) or year 2 of Senior
Secondary School in Cape Coast (median age 16 years)
OR
3. Be resident in a selected community during the time
of the Y- Check intervention, and be aged 16–19 years
AND
4. Have a completed and signed Informed Consent form,
or a signed Informed Assent Form and signed Paren-
tal/Guardian Informed Consent Form if the adoles-
cent is seen in the community and is below the nation-
al age of consent or is seen in a school, irrespective of
their age.
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Consent and assent procedures
Before the visit of the implementation team, informa-
tion on the Y- Check programme will be distributed to
parents/guardians through the schools and to community
members through an active communication campaign
in collaboration with the CAC and the YAG. School and
community meetings will allow parents and community
members to ask questions about the programme and give
their feedback.
In schools, adolescents will have a short introductory
meeting with a member of the Y- Check team typically
in a class or group setting. Parent meetings will then
be held in each of the schools, to which all the parents
and guardians of eligible learners will be invited. During
these sessions, information will be provided about the
study, its objectives and procedures, possible risks and
procedures that will be used to maintain confidenti-
ality. These meetings will provide an opportunity for the
adolescents, parents and guardians of eligible adoles-
cents to learn more about the Y- Check intervention and
the research linked to it and to have their questions
answered.
No participants will be screened, receive care or be
counselled or interviewed without their informed consent
(community participants who are above the national age
of consent), or, for minors, their assent and parental
consent, unless they are determined to be emancipated
minors.29 Following advice from Ministries of Education
in all three countries, all adolescents seen in schools will
be considered to be minors and require parental consent,
irrespective of their age.
Minor adolescents’ assent will be ascertained and
documented in an assent form. Parents or guardians
who would like their adolescent to receive the check- up
will be asked to provide their written consent. On the
day of the check- up visit, a verbal confirmation of their
previous written assent will be requested from the adoles-
cent. In Ghana and Tanzania, where the minimum age
for providing consent to medical and health- related
research is 18 years, clients of all ages under 18 will
provide completed parental consent forms and provide
written assent before proceeding through the check- up
visit regardless of whether the check- up is in schools or
communities. In Zimbabwe, a waiver of parental consent
has been given by the Medical Research Council of
Zimbabwe (MRC- Zimbabwe) so that participants aged
16 and 17 years who attend the check- ups in the commu-
nity venues will be allowed to provide written consent for
themselves.
The intervention will be conducted in private and not
in the presence of the parent or guardian. Contact details
of the study team will be shared with participants in case
they have questions at a later stage. All participants will be
reminded that participation is entirely voluntary and will
be told that they can opt out of the research or services
at any time.
Data collection
During the Y-Check intervention and follow-up
Data collection during baseline and follow- up visits will
include self- completed evaluation questionnaires, self-
reported screening tool responses and screening visit
consultations, measurements and specimen collection
and an exit interview. Data on the implementation
process and on adolescent outcomes will be collected in
digital and paper- based formats. A user- friendly digital
data collection app for the check- ups will be developed
and housed on a tablet computer for direct use by the
adolescent. Initial sections will include audio- assisted,
user- friendly self- completion questions for adolescents to
fill out. This will utilise engaging content and processes,
tailored to adolescents’ interests. The option of a face-
to- face interview will also be available if the adolescent
is unable to use the tablet or has low literacy level.
Health services registers and school registers will also be
reviewed to determine the number of adolescents of the
relevant age ranges, and school attendance by the classes
involved in Y- Check. To help build the referral process,
existing adolescent services will be mapped in the study
communities.
Process evaluation
The process evaluation is guided by the UK MRC’s Process
Evaluation framework to understand intervention imple-
mentation (including feasibility and fidelity), mechanisms
of impact (including acceptability and uptake) and the
influence of context.30 Key implementation outcomes of
interest are acceptability, adoption, appropriateness, feasi-
bility and fidelity. Data on contextual factors and barriers
and facilitators to programme implementation will be
gathered using routinely collected programme moni-
toring data. Qualitative data will be collected through (1)
observations of the Y- Check intervention and referrals,
as well as team meetings; (2) in- depth interviews with
eligible adolescents who received, adolescents who were
referred and adolescents who did not receive Y- Check,
as well as with school authorities and the Y- Check service
providers and (3) participatory workshops with teachers,
adolescents and parents. Quantitative programme moni-
toring data will be collected routinely within the Y- Check
visit, including through a participant exit interview.
Process evaluation data will be analysed iteratively and
thematically, through regular analytical discussions and
analytical memos to draw out the main themes emerging
from the data. Across the pilot and intervention studies,
data collection for the process evaluation will include
real- time feedback to the implementation team.
Economic evaluation
A costing study will be conducted to estimate the total
costs of developing, setting up and running the Y- Check
package, in school and community settings. A combi-
nation of top- down and ingredients- based costing
approaches will be used to generate cost estimates for the
whole package, and for each component/activity. All costs
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will be estimated from the perspectives of the adolescents,
the schools/community and implementing partners/
service providers. Financial and economic costs will be
calculated for all inputs. These inputs will be identified
and measured using process data, staff interviews and
observations, document review and accounting records.
Costs will be inputted and analysed in an Excel- based
costing tool. The cost analysis will describe the distribu-
tion of costs across different forms of inputs, and will esti-
mate the unit cost per adolescent reached, screened and
treated on the spot or referred; cost per unit of measure
for selected process and effect outcomes such as cost per
condition detected, cost per condition appropriately
treated on- the- spot or with a completed referral within 4
months, cost for a unit improvement in reported quality
of life and Disability Adjusted Life Years averted.
The cost and cost- effectiveness estimates will be
compared with other programmes in the region (eg,
human papillomavirus vaccination and deworming) and
will inform programme replication, scalability and finan-
cial sustainability.
Data protections
Data protection will be strictly observed. After study
completion, data will be stored in the LSHTM- curated
digital repository ‘Data Compass’ following General Data
Protection Regulation (GDPR) guidelines. Data and code
registered in LSHTM Data Compass will be made open
access following deposit. A Data Safety and Monitoring
Board (DSMB) has been constituted to assist in managing
adverse events, though we expect these to be very rare
since all treatment and care are standard with no novel
treatments.
Study outcomes
Outcomes will be ascertained during the check- up
screening visit and through collection of referral vouchers
from the referral health facilities, and, for outcomes
related to health and well- being impacts, through data
from the 4 month and, in Zimbabwe only, 12 month
follow- up visits. Outcomes related to completed referrals
will be triangulated against participants’ self- reports at
the 4 month and in Zimbabwe only, 12 month follow- up
visits. Review of school and health service registers will be
used to see whether attendance has increased during the
period when Y- Check is being implemented.
The primary outcome will be the proportion of those
screening positive for at least one condition who receive
appropriate on- the- spot care or complete appropriate
referral for all identified conditions within 4 months.
This will be measured using data collected at the initial
check- up visit and through recovery of referral vouchers
given to participants to allow them to access referral
services for free during the 4 months after the Y- Check
screening. Completed referral is defined as attending at
least the first referral appointment.
Secondary implementation outcomes will include the
proportion of those screening positive for each condition
who receive appropriate on- the- spot care or complete
appropriate referral for that condition within 4 months,
the yield of previously untreated conditions, clinical
outcomes at 4 months among those who had originally
screened positive for each condition, and intervention
acceptability, adoption, appropriateness, feasibility,
fidelity and cost. Secondary effectiveness outcomes will
include knowledge about health services and health
behaviours, self- reported agency and self- efficacy to make
decisions about their health, self- reported health- related
risk and protective behaviours, reported engagement
with health services, well- being, self- esteem and quality of
life, clinical outcomes and educational outcomes, which
will be collected within the Y- Check and follow- up visits.
The short- term cost- effectiveness of the intervention will
be estimated (calculated by a comparison of the costs
of the intervention against the primary and secondary
outcomes and including short- term changes in self-
reported quality of life). All outcomes for the study are
described in table 3.
Sample size
In each city, the intervention will be implemented for
10–14 year olds in up to six government primary schools
(n=500 for young adolescent girls, and n=500 for young
adolescent boys), and for 15–19 year- olds in up to eight
secondary schools and up to three community venues
(n=500 for older adolescent girls, and n=500 for older
adolescent boys), giving a total sample size of 2000 adoles-
cents (10–19 y).
The sample size provides specified precision around
the primary outcome. For example, for the primary
outcome, within each age group and gender, if 150 (30%)
of 500 participants screen positive for at least one condi-
tion, and 75% of those who screen positive are correctly
managed (n=112), the 95% CI for correct management
will be ±7%. The primary outcome used data from the
initial check- up visit and referrals and did not require the
4 month follow- up data.
Statistical analysis
All primary analyses will be conducted separately by
study city; Cape Coast, Chitungwiza and Mwanza. Where
comparable, secondary analyses will be conducted with
the data from all three cities combined.
In our study sites, a contemporaneous comparison
group is not required since no routine screening is
currently taking place, and as a result, assessments at base-
line will serve as the counterfactual for internal compar-
isons. Similarly, since there is no routine screening and
treatment provided to adolescents of the target ages in
the study population, a before–after comparison is appro-
priate since it is plausible to assume that reductions in the
prevalence of the chronic conditions between the orig-
inal Y- Check visit and the follow- up at 4 months will be
due to the interventions provided through Y- Check.
We will follow Strengthening the Reporting of Observa-
tional Studies in Epidemiology (STROBE) guidelines for
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Table 3 Study outcomes and means of verication
Outcome Sources of data
Primary outcome
Proportion of those screening positive for at least one condition who receive
appropriate on- the- spot care or complete appropriate referral for all identied
conditions within 4 months (ie, they attend a provider for referral care who has
been accredited by the study team and has been shown to be capable of providing
appropriate referral care).
►Programme monitoring data including records of attendance
for referrals.
►Screening tool (self- reported symptoms or conditions,
measurements and clinical actions).
Secondary outcomes
Implementation outcomes
Proportion of those screening positive for each condition who receive appropriate on-
the- spot care or complete appropriate referral for that condition within 4 months.
►Programme monitoring data including records of attendance
for referrals
►Screening tool (self- reported symptoms or conditions,
measurements and clinical actions).
The yield of previously untreated conditions. ►Programme monitoring data including records of attendance
for referrals.
►Screening tool (self- reported symptoms or conditions,
measurements and clinical actions).
Intervention acceptability (satisfaction): acceptability to adolescents and to other
stakeholders (eg, schools, parents and health workers).
►Programme monitoring data including records of attendance
for referrals.
►Screening tool (self- reported symptoms or conditions,
measurements and clinical actions).
►Self- completed evaluation questionnaire.
►Exit interviews.
►Observations of the Y- Check visits and of selected referrals.
►Interviews and workshops with adolescents, healthcare
providers, community members, teachers, parents and key
stakeholders.
Intervention adoption (uptake, utilisation): Y- Check uptake, referrals completed.
Intervention appropriateness (perceived t, perceived relevance and perceived
usefulness): perceived value of the intervention to adolescents and to other
stakeholders.
Intervention feasibility (actual t, practicability): Y- Check visits completed, referrals
completed, stakeholder support (including community).
Intervention delity (adherence, integrity, quality): completeness of training for and
delivery of intervention components; diagnostic accuracy; youth- friendly health
services quality assessment.
►Interviews and workshops with adolescents, healthcare
providers, community members, teachers, parents and key
stakeholders.
►Observations of the Y- Check visits and of selected referrals,
including youth friendly services.
►Self- reported screening tool
Economic outcomes
Cost of setting up and running the intervention. ►Y- Check documentation and nancial records
►Interviews with Y- Check staff and staff of the referral
facilities.
►Programme monitoring data including records of attendance
for referrals.
►Screening tool (self- reported symptoms or conditions,
measurements and clinical actions).
Cost per adolescent with a newly diagnosed condition (overall and by condition).
Cost per adolescent with a newly diagnosed condition who received appropriate on-
the- spot care or who completed an appropriate referral within 4 months (overall and
by condition).
Short- term (4 months) cost- effectiveness: cost per improvement in health or well-
being (eg, cost per case addressed or cured), cost per unit improvement in QALYs
and per DALY averted.
Client outcomes
Knowledge about health services and health behaviours. ►Programme monitoring data including records of attendance
for referrals.
►Screening tool (self- reported symptoms or conditions,
measurements and clinical actions).
►Self- completed evaluation questionnaire.
Intentions to adopt healthy behaviours.
Agency to make decisions about health and well- being.
Perceived social support for behaviour change.
Health- related risk and protective behaviours.
Improvement in previously diagnosed health and well- being conditions.
Engagement with health and other services within the past 4 months.
Self- esteem.
Self- perceived well- being.
Quality of life.
Clinical outcomes.
Educational outcomes (eg, school attendance). ►Self- completed evaluation questionnaire.
►School register review.
Client- dened outcomes (to be determined). ►Self- completed evaluation questionnaire.
►Exit interviews.
DALYs, Disability Adjusted Life Years; QALYs, Quality Adjusted Life Years.
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the reporting of cohort studies. Descriptive analyses will
be used to compare the community- level and school- level
characteristics of the study communities and schools.
Quantitative programmatic data, including screening
test results, services delivered and referrals made and
completed will be reported by age, sex and city. The
primary outcome is a single proportion which will be
presented with a 95% CI for each of the four target
groups: 10–14 year- old males, 10–14 year- old females,
15–19 year- old males 15–19 year- old females.
Secondary outcomes which are measured at a single- time
point will be presented in a similar way to the primary outcome.
For outcomes which are measured at two or more time
points, a before–after analysis will be conducted comparing
differences in measures between the time points. The unit
of analysis will be the individual. For clinical outcomes which
are measured at two or more time- points, the initial check- up
visit (baseline) will give the prevalence of untreated condi-
tions which will represent the counterfactual. The prevalence
of conditions at the 4 month follow- up visit will be formally
compared with this counterfactual to estimate the short-
term effects of the intervention in improving these clinical
outcomes. For analysis of outcomes measured at two time-
points, we will use mixed- effects logistic regression (binary
outcomes) or linear regression (continuous outcomes)
adjusting for individual- level clustering as a random effect
and school/community as a fixed effect. Health service and
client determinants of correct management of conditions at
4 months will be analysed using multivariable regression.
Ethics and dissemination
Ethics clearance has been received from WHO (WHO/
ERC.0003778) and from all country national ethics
bodies. Protocol modifications will be shared with the
WHO Ethics Review Committee and relevant national
ethics boards. Results will be published in at least three
country- specific peer- reviewed journal publications and
one multicountry publication. There will also be videos,
briefs, webinars and meetings to disseminate results. All
data will be placed into an open access repository after
deidentification and anonymisation to ensure confidenti-
ality and participant privacy.
DISCUSSION
Over the last decade, adolescent well- being has become a
global priority.5 School health is also a growing area of policy
interest.31 WHO guidelines on school health services note that
along with health promotion, health education, preventive
interventions (such as immunisations and mass drug admin-
istration), clinical assessment and health services manage-
ment, health screenings within school learners are one of
the key pillars in the delivery of comprehensive school health
services.16 Screening programmes such as Y- Check provide a
unique opportunity to detect easily treatable, high- burden
health conditions, refer those requiring medical attention,
treatment and care, as well as to advise and encourage adoles-
cents to engage in healthy behaviours.
In a 2015 review, school health services were found to exist
in at least 102 countries though their content varied consid-
erably across 16 areas including vaccinations, SRH education,
vision screening, nutrition screening and nutrition health
education.32 If all types of screening were combined, they
were the second most commonly reported intervention in
school health services, second only to immunisation. A later
systematic review found evidence of routine health check- ups
of school age children having been reported in 86 countries
worldwide.17 Despite their widespread existence, little quality
evidence exists on how to promote good health for adoles-
cents in educational settings,32 and even less for multicompo-
nent school health services,33 especially in LMICs.34
Good practices in conducting adolescent health or
well- being screenings are rarely reported. In 2024, WHO
released new guidance on well- child and well- adolescent
visits, which will recommend expanding routine screening
tests to also integrate other well- being dimensions through
a broader evaluation of social risks, emotional state and
individual and family resources delivered with context-
specific recommendations at key moments during the
first two decades of life.35 The successful implementation
of such guidance requires robust measurement of the
effectiveness of preventive interventions in adolescence.36
Evaluation of the Y- Check intervention will incorporate
implementation science and effectiveness research. Such
hybrid designs have important advantages over conducting
separate studies. These include the potential for quicker trans-
lation of intervention research findings into programmes,
the development and selection of more effective implemen-
tation strategies and more useful information for decision
makers.37
The process evaluation findings will provide guidance
for the next stage of the programme and for potential
future sustainable and scalable implementation by local
health authorities should it prove successful. Data on the
short- term changes in clinical and behavioural outcomes
will be used as inputs to model both short- term and long-
term health and social impacts and as inputs to sample
size and power calculations for a third phase of the
Y- Check research programme, which plans to undertake
a rigorous population level evaluation of the impact of
routine check- ups on adolescent health and well- being.
Through WHO’s advice to member states, findings from
the Y- Check study have the potential to shape the delivery of
adolescent health check- ups globally including identifying
the optimal number, content and delivery for these services.
Y- Check will advance the field by providing some of the first
rigorous information on the effects of a health screening
programme in three African cities, assessing implementa-
tion, effectiveness, cost and cost- effectiveness outcomes.
Author afliations
1World Health Organization, Geneva, Switzerland
2Stellenbosch University, Stellenbosch, South Africa
3University of Ghana, Legon, Ghana
4National Institute for Medical Research Mwanza Research Centre, Mwanza, United
Republic of Tanzania
5London School of Hygiene and Tropical Medicine, London, UK
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6Biomedical Research and Training Institute, Harare, Zimbabwe
7Department of Infectious Disease Epidemiology, London School of Hygiene and
Tropical Medicine, London, UK
X Farirai Nzvere @farrieafc and Aoife Margaret Doyle @aoife_md
Acknowledgements The authors thank our Programme Advisors: Professor Simon
Gregson, Dr Sachin Shinde, Professor Fred Binka, Dr Suzanne Petroni, Professor
Audrey Pettifor, Prof Shane Norris, Professor James Hargreaves, Patience Manhibi
and Aveneni Mangome. DSMB members are Professor David Mabey, Dr Andrew
Abassa, Prof Fred Binka and Dr Nothando Ngwenya. The authors thank adolescent
participants in three countries. The support of participating Ministry ofcials in
Ghana, Tanzania and Zimbabwe is gratefully acknowledged.
Collaborators The Y- Check Research Programme Team in alphabetical order
includes: Philip B Adongo, MA, PhD, Department of Social and Behavioural Sciences,
School of Public Health, University of Ghana; Kenneth S Adde, MPhil, Department
of Population and Health, University of Cape Coast; Evans Agbeno, FGCS, MPH,
MBCHB, Department of Obstetrics & Gynaecology, University of Cape Coast; Patricia
Akweongo, MA, PhD, Department of Health Policy Planning and Management,
School of Public Health, University of Ghana; Tsitsi Bandason MSc, The Health
Research Unit Zimbabwe/Biomedical Research and Training Institute; Sarah
Bernays, PhD MA, Global Health and Development, London School of Hygiene and
Tropical Medicine and School of Public Health, University of Sydney; Rudo Chingono
PhD, The Health Research Unit Zimbabwe/Biomedical Research and Training
Institute; Chido Dziva Chikwari PhD, MSc, BSc, The Health Research Unit Zimbabwe/
Biomedical Research and Training Institute and MRC International Statistics &
Epidemiology Group, Department of Infectious Disease Epidemiology, London
School of Hygiene & Tropical Medicine, London, UK; Ethel Dauya MPH, The Health
Research Unit Zimbabwe/Biomedical Research and Training Institute; Samuel Derry,
PhD, Department of Bio- Statistics, School of Public Health, University of Ghana; Eric
Koka, MPhil, PhD, Department of Sociology and Anthropology, University of Cape
Coast; Constance Mackworth- Young, PhD MSc, Global Health and Development,
London School of Hygiene and Tropical Medicine; Salome Manyau MSc, The
Health Research Unit Zimbabwe/Biomedical Research and Training Institute; Gerry
Mshana PhD, Mwanza Intervention Trials Unit (MITU)/National Institute for Medical
Research (NIMR); Bernard A Owusu, MPhil, Department of Population and Health,
University of Cape Coast; Yovitha Sedekia, MPHDC, PhD, Mwanza Intervention
Trials Unit (MITU)/National Institute for Medical Research (NIMR); Victoria Simms
PhD, MRC International Statistics & Epidemiology Group, London School of Hygiene
and Tropical Medicine, Hannah Taylor- Abdulai, MPH, MPhil, PhD, Department of
Physician Assistant Studies, University of Cape Coast; Mandi Tembo, PhD, The
Health Research Unit Zimbabwe/Biomedical Research and Training Institute and
Department of Global Health and Development, Faculty of Public Health and Policy,
London School of Hygiene and Tropical Medicine, London, UK.
Contributors PB, AMD and DAR conceived and drafted the paper. All authors
contributed to writing. BW, SK, AMD, FN, FG and MKN provided country- specic
inputs. GG contributed to the economic evaluation section. HAW contributed to the
study outcomes and statistical analysis sections. VB and RAF contributed to the
sections on consent, introduction and discussion.
Funding This work was supported by the Botnar Foundation grant number (RG21-
001) and UKRI (MR/T043156/1).
Competing interests PB and VB are WHO staff members. The opinions expressed
are theirs and do not necessarily represent the policies and positions of the WHO.
The other authors declared no competing interests.
Patient and public involvement Patients and/or the public were involved in the
design, or conduct, or reporting, or dissemination plans of this research. Refer to
the Methods section for further details.
Patient consent for publication Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits
others to copy, redistribute, remix, transform and build upon this work for any
purpose, provided the original work is properly cited, a link to the licence is given,
and indication of whether changes were made. See:https://creativecommons.org/
licenses/by/4.0/.
ORCID iDs
PrernaBanati http://orcid.org/0009-0003-2997-9224
Helen AnneWeiss http://orcid.org/0000-0003-3547-7936
ValentinaBaltag http://orcid.org/0000-0002-6766-0842
FariraiNzvere http://orcid.org/0000-0002-3260-6889
Mussa KelvinNsanya http://orcid.org/0000-0001-7653-4541
Aoife MargaretDoyle http://orcid.org/0000-0002-3305-7738
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