Journal Article

School eHealth Education Program Pakistan (eSHEPP) to improve NCDs awareness in adolescents from urban Pakistan: a mixed method design protocol

Zimmerman, Kanecia Obie, Ali, Tazeen Saeed, Samad, Zainab, Almas, Aysha, Khan, Muhammad Shahid

2025

Overview

Background Non-communicable diseases (NCDs) pose a significant health threat, particularly among adolescents in low- and middle-income countries (LMICs) such as Pakistan. Unhealthy habits, including poor diet, physical inactivity, and substance use, often begin in childhood. These behaviors not only increase the risk of NCDs later in life but can also cause serious health problems during adolescence or early adulthood. This protocol aims to assess the feasibility and potential efficacy of the School eHealth Education Program Pakistan (eSHEPP) in improving the knowledge, attitudes, and practices (KAP) of school students in Karachi regarding NCDs and their risk factors. Methods and analysis A sequential mixed-methods design will be used, combining qualitative and quantitative approaches. In Phase 1, focus group discussions (FGDs) and interviews with stakeholders will identify barriers and facilitators to implementation, as well as gather perspectives on the eHealth application’s design and content. In Phase 2, a pilot cluster randomized controlled trial (cRCT) will assess the program’s feasibility and potential efficacy in improving participants’ KAP regarding NCDs. In Phase 3, FGDs with intervention participants will explore the program’s usability, acceptance, and task–technology fit. Participants The study will engage a diverse group of stakeholders across three phases. Phase 1 will involve four FGDs, two with students and two with teachers (eight participants per FGD), and ten key informant interviews (five with parents and five with school administrators). In Phase 2, 272 secondary and higher secondary school students aged 13–18 years will be recruited from selected schools in Karachi. Phase 3 will include two FGDs with students (eight participants per FGD). Written assents and consents will be obtained from all participants. Intervention The eSHEPP will deliver digital health education via an interactive eHealth application to raise awareness about NCDs and their risk factors among adolescents. Students in the intervention group will attend health-promoting sessions in the classroom for over two months, while the control group will receive no intervention and continue with the routine teaching schedule. Outcomes Phase 1 will identify barriers and facilitators to implementing the eSHEPP in secondary and higher secondary schools and explore stakeholders’ perceptions of its design and content. Phase 2 will assess feasibility, defined as achieving recruitment, retention, and treatment fidelity rates above 70%, and potential efficacy, indicated by a ≥ 25% improvement in KAP after two months. Phase 3 will evaluate the program’s acceptability, perceived usefulness, and task–technology fit to determine how well it meets students’ needs and expectations in the school setting. Ethics and dissemination Ethical approval has been obtained from the Aga Khan University Ethical Review Committee (Ref: 2023-9277-27367) and the National Bioethics Committee Pakistan (Ref: 4–87/NBCR-1089/23/1896). Findings will be disseminated through peer-reviewed journals and national and international conferences. Trial registration number NCT06674798. Strengths and limitations of this study The sequential mixed-methods design will enhance understanding and credibility of the eSHEPP through data triangulation. The pilot cRCT will rigorously evaluate the program while controlling for confounders, strengthening internal validity. Diverse stakeholder perspectives will enrich the data by highlighting barriers, facilitators, and potential efficacy. Findings may not be generalizable to educational settings or cultural contexts beyond Karachi, Pakistan. The small number of clusters ( N  = 4) limits statistical power; therefore, analyses are exploratory, and results should be interpreted with caution.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Acceptability / Administrators / Adolescents / Attitudes / Barriers / Beliefs, opinions and attitudes / Bioethics / Childhood / Children / Chronic diseases / Classrooms / Clinical Nutrition / Clinical trials / Colleges & universities / Committees / Consents / Credibility / Cultural factors / Design / Diet / Digital health / E-health / Education / Educational aspects / Educational programs / Effectiveness / Efficacy / EHealth / Epidemiology / Ethical standards / Ethics / Evaluation / Feasibility / Feasibility studies / Habits / Health aspects / Health attitudes / Health education / Health literacy / Health problems / Health promotion / Health Promotion and Disease Prevention / Health risks / Infectious Diseases / Interest groups / International conferences / Internet access / Intervention / Interviews / Knowledge / Low income groups / Maternal and Child Health / Medicine / Medicine & Public Health / Methods / Mixed methods research / Non-communicable diseases / Pilot cluster randomized controlled trial / Prevention / Public Health / Qualitative analysis / Recruitment / Registration / Risk factors / School-based intervention / School-based Interventions to Prevent Childhood Overweight and Obesity / Schools / Secondary school students / Secondary schools / Student attitudes / Students / Study and teaching / Study Protocol / Substance abuse / Substance use / Teachers / Teaching / Technology / Teenagers / Triangulation / Urban youth / Will