PLOS ONE

STUDY PROTOCOL

Health promotion intervention to prevent risk

factors of chronic diseases: Protocol for a
cluster randomized controlled trial among
adolescents in school settings of Chandigarh
(India)
Sandeep Kaur1, Manmeet Kaur ID1*, Rajesh Kumar ID1,2,3
a1111111111
1 Department of Community Medicine and School of Public Health, Post-Graduate Institute of Medical
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Education and Research, Chandigarh, India, 2 Department of Epidemiology and Population Health, London
a1111111111 School of Hygiene and Tropical Medicine, London, United Kingdom, 3 School of Public Health and
a1111111111 Community Medicine, University of New South Wales, Sydney, Australia
a1111111111
* [email protected]

OPEN ACCESS
Abstract
Citation: Kaur S, Kaur M, Kumar R (2022) Health
promotion intervention to prevent risk factors of
chronic diseases: Protocol for a cluster randomized Background
controlled trial among adolescents in school Chronic diseases like diabetes, cardiovascular diseases and cancers are on the rise. Most
settings of Chandigarh (India). PLoS ONE 17(2):
of the risk factors of these diseases commence in Adolescence. Therefore, a cluster rando-
e0263584. https://doi.org/10.1371/journal.
pone.0263584 mised controlled trial is designed to evaluate the effect of school-based health promotion
intervention on the risk factors of chronic diseases.
Editor: Rosely Sichieri, State University of Rio de
janeiro, BRAZIL

Received: May 28, 2021 Methodology

Accepted: January 18, 2022 Considering school as a cluster, twelve schools will be randomly selected from the public
Published: February 17, 2022 schools of Chandigarh, a city in India. After baseline assessment, six schools will be ran-
domly allocated to intervention and six to the control arm. Study participants will be stu-
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review dents of 8th grade (age 10–16 years), their parents and teachers. A sample of 360
process; therefore, we enable the publication of students (12 clusters x 30 students) has been estimated to provide statistically valid
all of the content of peer review and author
inference. The PRECEDE PROCEED Model will be used to develop health promotion
responses alongside final, published articles. The
editorial history of this article is available here:
interventions to prevent the use of an unbalanced diet, physical inactivity, alcohol, and
https://doi.org/10.1371/journal.pone.0263584 tobacco. Interventions will be implemented for six-months in the school setting. For
Copyright: © 2022 Kaur et al. This is an open
students, the intervention will comprise interactive learning sessions of 30 minutes dura-
access article distributed under the terms of the tion per week and physical activity sessions of 30 minutes duration four times every
Creative Commons Attribution License, which week. Educational sessions will be conducted for parents and teachers for 30 minutes,
permits unrestricted use, distribution, and
four times during the intervention period. Primary outcomes will be changes in the preva-
reproduction in any medium, provided the original
author and source are credited. lence of behavioural risk factors from pre- to post-intervention. Changes in anthropomet-
ric, physiological, and biochemical measures will be the secondary outcomes. The
Funding: Partial funding was awarded to MK with
project ID 5562 for undertaking laboratory tests, difference-in-difference (DID) method will be used to measure the net change in the
from The George Institute for Global Health, outcomes.

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PLOS ONE Health promotion intervention to prevent risk factors of chronic diseases

Hyderabad, India. The funders had no role in the Discussion

larger study design, data collection and analysis,
decision to publish, or preparation of the It is essential to understand whether health promotion interventions implemented in the
manuscript. school setting simultaneously targeting adolescents, teachers, and parents are effective.
Competing interests: The authors have declared Using the PRECEDE-PROCEED model for planning, implementing, and evaluating the
that no competing interests exist. intervention as part of a cluster Randomized Controlled Trial design with DID analysis, could
objectively assess the impact.

Introduction
Technological advancements have improved the living conditions of people all over the world.
However, this transition has shifted dietary behaviours from traditional home-cooked meals to
processed food high in sugar, salt, and fat and low in fruits and vegetables. It has also increased
the sedentary behaviours of individuals. Moreover, the growing availability and early expo-
sures have led to increased tobacco and alcohol-related products early in life [1, 2].
Unbalanced diets, physical inactivity and tobacco and alcohol use, are the behavioural risk
factors leading to chronic diseases. Currently, about 50% of total deaths globally are caused by
chronic diseases. Low- and middle-income countries like India face a similar situation wherein
40% of all deaths are caused by chronic diseases [3]. Many of these deaths occur at a young age
in India, leading to further loss of potentially productive life years [4].
Several health promotion interventions consisting of behaviour change strategies and activ-
ities have been recommended, and these are being implemented to reduce risk factors for
chronic diseases [5]. However, most intervention trials have been conducted in high-income
countries [6–8] and few in the low- and middle- income countries [9–13]. The trials carried in
high-income countries may not be effective in low- and middle- income countries, specially
India, as interventions need to be developed considering diverse cultural, socio-demographic
and economic factors [14]. Most of the studies carried out in low- and middle-income coun-
tries in the school settings among adolescents have either focussed on one of the risk factors
[9, 10] or have implemented interventions of shorter duration [11, 12]. Most of these studies
also lack any theoretical basis for the intervention development and implementation [15, 16].
Evidence suggests that interventions should be based on behaviour change theories or models
to be more effective in the targeted populations [17–19].
As chronic diseases of adulthood result from behavioural risk factors that usually begin dur-
ing early Adolescence [20–22], interventions should target adolescents. However, only a few
randomised controlled trials (RCT) have been carried out among adolescents in the school set-
tings of Low-middle Income countries [9, 12]. Moreover, none of these studies have included
parents and teachers even though both school and home environments may influence adoles-
cents [9, 12]. Hence, we have designed a study to evaluate the effectiveness of a school-based
health promotion intervention package in improving behavioural risk factors among adoles-
cents, their teachers, and parents.
The null hypothesis of the study is: School-based health promotion intervention will not
lead to any change in dietary intake of salt (g/day), sugar (g/day), fruits (g/day) and vegetables
(g/day), physical inactivity (%), tobacco and alcohol use (%), anthropometric (height, weight,
waist circumference, hip circumference, mid-upper arm circumference, subscapular and tri-
ceps skinfold thickness), physiological (blood pressure) and biochemical (fasting plasma glu-
cose and urinary sodium excretion levels) measures among adolescents.

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PLOS ONE Health promotion intervention to prevent risk factors of chronic diseases

The alternate hypothesis of the study is: School-based health promotion intervention will
lead to change in dietary intake of salt (g/day), sugar (g/day), fruits (g/day) and vegetables (g/
day), physical inactivity (%), tobacco and alcohol use (%), anthropometric (height, weight,
waist circumference, hip circumference, mid-upper arm circumference, subscapular and tri-
ceps skinfold thickness), physiological (blood pressure) and biochemical (fasting plasma glu-
cose and urinary sodium excretion levels) measures among adolescents.

Materials and methods

Study area
The study will be carried out in public schools of Chandigarh city in India. Chandigarh is a
Union Territory (UT) and capital of two states—Punjab and Haryana. It has a total population
of around one million. Out of 188 schools, 115 are public, and 73 are private [23]. The school
timings are from 8 AM to 2 PM in most public schools, with each subject period of 35 minutes
duration. Most schools have a ’zero period’ in a day, which is free time for adolescents. The
’zero periods’ are a good time for intervention implementation without disturbing the overall
school routine of the adolescents.

Study design
A cluster randomised controlled trial (cRCT) design will be used in which 12 schools will be
randomly selected from the list of 115 public schools. The randomly selected twelve schools
(clusters) will be stratified based on the household income of the study participants. Using
stratified random sampling equal number of clusters from each of the income strata will be
randomly allocated to the intervention and control arms. This stratified random sampling will
be employed to balance the potential confounders and reduce between-cluster variance for
estimating the true effect of the intervention [24]. The second author (MK) will conduct ran-
domisation procedures to assign the schools and participants to the intervention and control
arms. Whereas, First Author (SK) will enrol the participants.
Formative research will also be carried out to understand the social environment and other
contextual factors. Study design features, participant’s enrolment, intervention period, and
study variables at baseline and end-line analysis are summarised in Fig 1. The study was regis-
tered under the Clinical Trial Registry of India (CTRI/2019/09/021452; 30/09/2019).

Study participants
The study participants will include school students of 8th grade (age range 10–16 years), their
parents and teachers. The purpose of selecting adolescents in this age group is to catch them
’young’, when behavioural risk factors of chronic diseases start to emerge [18]. Either of the
parents (mother or father) or guardian will be recruited into the study based on adolescent
choice, parents’ consent and their time availability. The teachers who have direct interaction
with study adolescents for a more extended time, such as class teachers, subject teachers, physi-
cal education teachers, counsellors, or the person in charge of the mid-day meal or medical
assistant, will also be selected for the study.

Inclusion and exclusion criteria

Public schools of UT Chandigarh will be eligible for participation in the study. Consenting
participants residing in the study area and not intending to leave that area in the next year
from the time of recruitment will be included in the study. Only adolescents studying in 8th
grade and their parents and teachers below 65 years will be enrolled.

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PLOS ONE Health promotion intervention to prevent risk factors of chronic diseases

Fig 1. Study flow design.

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PLOS ONE Health promotion intervention to prevent risk factors of chronic diseases

Sample size
A total of 12 clusters (schools) are sampled based on the formula mentioned below:

π0 Þ=m þ π1 ð1 π1 Þ=m þ k2 ðπ20 þ π21 Þ�=ðπ0 π1 Þ

2
c ¼ 1 þ f ½π0 ð1

Where c is the number of clusters required, f = 7.84 for 5% type I error and 80% power, π1 is
the expected proportion of the risk factor in the intervention arm, π0 is the expected propor-
tion of risk factor in the control arm, m is the number of individuals in each cluster (assumed
equal in all clusters), and k is the coefficient of variation in the (true) rates or proportions
between clusters in each treatment arm. As most of the schools have a class strength of about
30 students in 8th grade, the size of the cluster (m) is taken to be 30 students.
The c value for each primary outcome is calculated separately using data from the previous
studies, as shown in Table 1 [25–29]. The maximum c value, out of all four risk indicators, is
considered the sample size for the study.
Thus, a sample size of 360 students (12 clusters x 30 students per cluster); 180 each in the
intervention and control arm is estimated to provide valid statistical inference about the
impact of the intervention. As one of the selected student’s parents will also participate in the
study, the sample size for parents will also be 360. Lastly, it is observed that on average about
seven teachers are in direct interaction with the students of 8th grade; therefore, the sample
size of teachers will be 84 (12 clusters x 7 teachers).
For the formative research, about ten Focus Group Discussions (FGDs) will be carried out
with participants from the study area. Out of ten FGDs, four will be with the students (2 male,
two female), four with their parents (2 fathers, two mothers), and two with teachers (1 male,
one female). Each of the FGDs will include a minimum of 5 and a maximum of 8 participants.

Sampling method
Twenty-four schools (double the required number of twelve schools) will be randomly chosen
by using a random number table from the list of 115 public schools in Chandigarh city [30].
Administrators of these 24 schools will be approached from the list sequentially for obtaining
their consent. For each refusal, the next school on the list will be approached. After receiving
approval from the first twelve schools, the list will be closed. From within the 12 selected
schools, 12 clusters will be selected randomly using the following procedure.
As each school has four eighth grade sections, namely, A, B, C and D, a number will be
assigned on folded paper slips for all the sections of the 8th-grade class. Later, a slip will be ran-
domly selected from the shuffled lot by a person other than the researcher. The section number
in the slip will then be selected as the cluster for the study. The method mentioned above will
be applied to choose a section of 8th grade in each of the selected twelve schools. Adolescents
studying in 8th grade are between 10–16 years of age. It is known from the literature that; six-
month intervention is sufficient to bring out the desired behaviour change. But the

Table 1. Sample size estimation based on the prevalence of risk factors of chronic diseases among adolescents.
Risk Factor π0 π1 K C
Inadequate fruits and vegetable intake 0.852 0.596 0.025 12.2
High salt intake 0.223 0.162 0.094 12.1
High sugar intake 0.48 0.34 0.041 12.5
Physical inactivity 0.232 0.162 0.099 12.1
Tobacco use 0.049 0.034 0.163 11.4
Alcohol use 0.345 0.242 0.057 12.4
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PLOS ONE Health promotion intervention to prevent risk factors of chronic diseases

biochemical measures are not impacted, which has been the basis for developing the study’s
outcomes [31, 32].

Outcomes
The primary outcomes of the study will be the change in dietary intake (g/day) of sugar, salt,
fruits and vegetables, physical activity (metabolic equivalent/minute/week), current tobacco
and alcohol use (%) among adolescents, pre-and post- health promotion intervention imple-
mentation in both the intervention and control arms.
Secondary outcomes will include changes in body mass index (kg/m2) blood pressure
(mmHg), and urinary sodium excretion (mg/day)) among adolescents of both intervention
and control arms before and after the delivery of the intervention package.

Intervention development
The intervention is based on the PRECEDE-PROCEED model (PPM) to increase the likeli-
hood of effectiveness [33, 34]. This model will inform the development, implementation, and
evaluation of the health promotion intervention as described in the Fig 2. The intervention
design will be developed by systematically using various phases of the PPM, as described below.
Phase 1 social diagnosis. Formative research will be conducted to understand partici-
pants’ social environment and their level of awareness regarding behavioural risk factors for
chronic diseases.
Phase 2 epidemiological and behavioural diagnosis. Epidemiological diagnosis will
focus on specific health issues like the prevalence of chronic diseases, and behavioural diagno-
sis will deal with risk factors such as unbalanced diet, physical inactivity, tobacco and alcohol
use. These factors will be assessed through a cross-sectional survey. The end-line survey will be
carried in both arms using the same methods, tools, apparatus and following the same study
participants as the cross-sectional survey. So, this cross-sectional survey will also form the
baseline for the present study.
Phase 3 educational and ecological diagnosis. In this phase, social and environmental
factors leading to specific behaviours will be identified from the data collected through forma-
tive research and baseline assessment. The prevalence of behavioural risk factors among the
participants from baseline data will help frame the objectives and inform the intervention
development.
Phase 4 intervention alignment. This phase will involve consultation with adolescents,
parents, and teachers to develop the intervention. To strengthen the intervention, findings
from focus group discussions will be utilised to understand ’participants’ requirements and
suggestions regarding the intervention. Additionally, a consultation workshop will be held,
where teachers of all the selected schools will participate. The study objectives and a draft of
the intervention plan will be presented to them, and their suggestions for improving the inter-
vention plan will be sought. An intervention module for both adolescents, parents and teachers
will be prepared.
The intervention package will consist of:
1. Interactive Learning Sessions: In the classroom settings, lecture and discussion sessions will
be conducted with all participants on behavioural risk factors of chronic diseases. These
will be focused on primarily the importance of a balanced diet, especially about the intake
of adequate amount of seasonal fruits and vegetables, and recommended levels of salt and
sugar as per WHO guidelines, ways to measure salt and sugar in home-cooked food using
measuring tea-spoons, calculating amounts of salt and sugar in processed foods by reading

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PLOS ONE Health promotion intervention to prevent risk factors of chronic diseases

Fig 2. PRECEDE-PROCEED model adapted from Green and Kreuter (1999) [34].
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labels, harmful effects of tobacco and alcohol use, the importance of physical activity, and
secondarily on the ways to manage hypertension and diabetes including adherence to medi-
cine. Activities such as poster making for a balanced diet debates on processed food, salt
and sugar consumption, and tobacco and alcohol use will also be conducted.
2. Physical Activity Sessions: Students will participate in physical activities such as sports and
athletics under the supervision of a physical training instructor for 30 minutes 4 times per
week.
3. Peer to Peer Sessions: Students will be encouraged to share their experiences of avoiding
tobacco and alcohol use [35].
Besides this, a pamphlet containing information on chronic diseases’ risk factors will be
given to all study participants. As outlined in Table 2, a ’Behaviour Change ’Communication’

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PLOS ONE Health promotion intervention to prevent risk factors of chronic diseases

Table 2. Behaviour change communication matrix for health promotion interventions to reduce chronic disease risk factors in public schools in Chandigarh, India.
Communication Audience Barriers Opportunities Activities Person Frequency & Channel of
objectives responsible time in one communication
cluster
(six month)
• To promote the Teachers: Different class School hours are the Educational Researcher Four sessions of Verbal (2-way
recommended levels of Teachers in schedules of best time to interact Sessions with thirty minutes communication)
salt, sugar, fruits and direct the teachers with teachers in teachers keeping during
vegetable intake, and interaction with groups communication intervention
physical activity and randomly objectives in focus period
reduction in the use of selected clusters
tobacco and alcohol (sections of 8th
grade)
Parents of Not all parents • Utilising home Educational Researcher Four sessions of Verbal (2-way
adolescents from are available at environment for Sessions with thirty minutes communication)
randomly the time of the promoting healthy parents keeping during
selected clusters parents- diets by educating communication intervention
teachers parents (as mostly, objectives in focus period
meeting in mothers are the food
schools makers of the house)
on the harmful effects
of excessive intake of
salt & sugar and less
consumption of fruits
and vegetables
• The Parents Teacher
Association (PTA)
meetings may be used
to interact with
parents in school
settings
• To manage Primary • Vendors • To catch adolescents Educational classes Researcher 30 minutes Verbal (2-way
hypertension and audience: outside school before risky and classroom session every communication) &
diabetes by discussing Adolescents of premises behaviours start discussions week Digital audio-visual
the importance of the randomly developing method (PowerPoint
medicine adherence selected clusters presentation using
(sections of 8th the laptop)
grade)
Secondary • Unhealthy • Using schools as a Physical activity Researcher/ Four sessions Verbal (2-way
audience: food options in platform for sessions physical every week with communication)
Parents & the school promoting healthy education each session of
teachers of canteens behaviours teachers 30 minutes
adolescents • Study load Other interactive Researcher Two sessions Verbal (2-way
(tuitions after activities: Poster during communication)
school hours & making intervention
homework) competition & period with
grow your own each session of
herbs about 45
minutes
• Stringent Peer-to-peer Researcher One session Verbal (2-way
school time- education for every month communication)
table reduction in the use with each
of tobacco and session of 15
alcohol minutes
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PLOS ONE Health promotion intervention to prevent risk factors of chronic diseases

(BCC) Matrix will be prepared for deciding on the messages, channels, modes of communica-
tion, and indicators for change before implementing the intervention. The channel of commu-
nication will be inter-personal two-way communication, including audio-visual and digital
communication. This matrix will be one of the crucial highlights of the present study as most
of the earlier studies lacked this kind of micro-planning before implementing the intervention
in the school settings [36].
Phase 5—Intervention implementation. Intervention arm. The intervention will focus
on building adolescents’ self-efficacy at the micro-level and that of parents and teachers at the
meso level.
Intervention implementation strategies, presented below, will be based on three compo-
nents: Capability, Opportunity and Motivation as per the Behaviour Change Wheel [5].
1. Parents and teachers are involved in providing a supportive environment for adolescents at
home and at school to promote positive behaviour change early in life.
2. Creating awareness by providing information on healthy dietary habits, the importance of
physical activity, and the harmful effects of tobacco and alcohol use.
3. Promotion of consumption of less expensive and more nutritious seasonal fruits and
vegetables.
4. Avoiding food high in sugar and salt content and refraining from tobacco and alcohol use.
5. Substituting snacks with fruit and vegetable salads.
6. Motivating the participants in reducing salt and sugar consumption by using measuring
spoons while cooking as per the WHO recommendations.
7. Promoting kitchen gardening encourages participants to grow herbs and spices in earthen
pots as herbs can reduce salt usage. Herbs and spices also add flavours and enhance the
taste of food in places of salt.
8. Highlighting potential cost savings for individuals by creating awareness among participants
regarding the benefits of eating more fruits and vegetables, eating less sugar and salt, increasing
physical activity, and reducing or stopping the use of tobacco and alcohol to prevent chronic
diseases, which in turn will help to reduce medical expenses related to chronic diseases.
9. Providing opportunities for playground activities in school to increase the level of physical
activity among adolescents.
10. Encouraging peer to peer learning for motivation and support for not using tobacco and
alcohol.
A micro plan will be prepared to ensure intervention adherence. It includes providing mea-
suring tea-spoons of 5g to all the participants to promote the recommended amount of salt
and sugar in their daily routine. For physical activity, four outdoor game sessions of 30 min-
utes each will be carried with the help of the respective physical education teachers in all six
schools every week. For tobacco and alcohol, peer-to-peer sessions will also be held once every
month to create awareness among adolescents regarding the harmful effects of alcohol and
tobacco consumption.
Interventions will be implemented by the researcher (SK) in a school setting over six
months. For adolescents, interventions will comprise interactive learning sessions of 30 min-
utes duration per week and a physical activity session of 30 minutes four times per week. Edu-
cational sessions will be conducted for parents and teachers for 30 minutes four times during

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the intervention period. Besides the lecture and discussion, at least fifty percent of the time will
be allocated to poster making, debates, and experience sharing.
Control arm. Participants of the control arm will be provided with a pamphlet in the local
language so that all study participants, especially parents, can understand the information eas-
ily. This pamphlet will be based on the dietary recommendations of the National Institute of
Nutrition (NIN), India [37]; the levels of physical activity for both adolescents and adults, salt
and sugar consumption, and consequences of tobacco and alcohol as per World Health Orga-
nization recommendations [38–42]. Study participants will be requested to read the informa-
tion in the pamphlet in their own time and convey the same information to their family
members. The same pamphlet will also be provided to the participants in the intervention arm.
Phase 6 process and impact evaluation. Process evaluation to be initiated at the time of
intervention implementation to assess whether the intervention is being implemented as per
the plan, to analyse the factors facilitating and hindering the use of the health promotion inter-
vention, and for identifying processes that require improvement. Information regarding the
uptake of intervention, changes incorporated in behaviours, the number of adolescents follow-
ing the behaviours and the number of them conveying the same to their family members will
be collected in writing. This information will be recorded by interviewing the adolescents once
in the intervention arm.
Outcome evaluation will be done after six months to examine the impact of the intervention
on the outcome indicators. The Difference-in-Differences (DID) method will be used to assess
net changes after implementing the health promotion intervention in both the control and the
intervention arm [43, 44].

Data collection
The dietary behaviour assessment will be through the Multiple-Pass Method by using two
24-hour dietary recalls on non-consecutive days during weekdays. After a thorough explana-
tion of the dietary tool, all the adolescents in the same cluster will fill their forms themselves
(self-administration). Whereas in-person interviews will be carried out with parents and teach-
ers. The first 24-hour dietary recall collection will be during the first interaction with all the
participants in the schools. The second 24-hour dietary recall collection will be a week later.
The researcher will carry out all the interviews with parents and teachers and explain the tool
to adolescents [45].
Data collected through the 24-hour dietary recall will be analysed using the PURE study
software [46]. This software uses National Institute of Nutrition (NIN) dietary guidelines for
Indians to calculate the quantity of various macro and micronutrients from the quantity of
various food items consumed by a person in a day. Using this software daily intake of sugar
(g), salt (g), fruits (g), and vegetable (g) will be estimated. The participants’ nutrient intake will
also be compared against the recommended dietary allowances according to NIN dietary
guidelines [35]. Validated physical activity tools based on a seven-day recall period will be
used. Physical Activity Questionnaire for Adolescents (PAQ-A) will be used, and for parents
and teachers, Short International Physical Activity Questionnaire for Adults (IPAQ) will be
used [47, 48]. The data on adults’ physical activity level will be converted into Metabolic equiv-
alent (MET) using the manual of IPAQ [48]. Physical activity will be further categorised using
the scale provided in the user manual [48]. For adolescents, the PAQ-A user manual will be
used to compute a composite physical activity score. It will be categorised into mild, moderate
and high according to the scale provided in the PAQ-A manual [47]. Previous and current use
of tobacco and alcohol among adolescents and adults (parents and teachers) will be assessed
using WHO’s GSHS and STEPS tool guidelines, respectively [49, 50].

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Standard equipment and procedures will be used for anthropometric, physiological and
biochemical measures. Standard operating procedures will be developed to maintain unifor-
mity and standardisation in sample collection and analysis.
For anthropometric measurements, ’ ’UNICEF’s standardised anthropometer will be used
to measure the height to the nearest 0.1 cm. The portable electronic weighing scale will be used
to measure the weight to the nearest 0.1 kg with minimum clothing and no shoes. Similarly,
hip circumference (HC), waist circumference (WC), and Mid Upper Arm Circumference
(MUAC) will be measured to the nearest 0.1 cm by using a fibreglass measuring tape. Further,
triceps Skinfold Thickness (TST) and Sub Scapular Skinfold Thickness (SSFT) will be mea-
sured to the nearest 0.1 mm using Lange’s skinfold calliper. Hand Dynamometer will be used
to measure the maximum grip strength (average of three readings with a gap of one minute
between each reading). Blood pressure (average of three readings) will be recorded for all par-
ticipants using a digital sphygmomanometer (Omron). These instruments will be regularly cal-
ibrated as per standard requirements. The portable digital weighing scale will be checked for
needle at 000 zero’ and calibrated after every 20th reading. ’ ’Lange’s skinfold calliper will also be
checked for needle at 000 zero’ before every reading, and it will be calibrated using calibration
block after every 20th reading.
Similarly, the hand dynamometer and digital sphygmomanometer will also be calibrated by
following the instruction in their standard manual after every 100th reading. Also, fibreglass
tape will be used for measuring hip, waist and mid-upper-arm-circumference as it is resilient
to any wear and tear and does not expand in warm weather conditions as an ordinary measur-
ing tape. Body Mass Index (BMI) will be calculated from the formula: weight (kg) divided by
height (m2). The calculated BMI will be categorised into underweight, normal, overweight,
and obese as per the World Health Organization (WHO) cut-offs for adults (parents and
teachers). For adolescents, their age and the gender-specific WHO growth reference chart will
be used to categorise their BMI into severe thinness, thinness, normal, overweight, and obese.
For biochemical measures, blood samples (2 ml in Fluoride vial and 3 ml plain vial) will be
obtained to estimate plasma glucose (mg/dL), total serum cholesterol (mg/dL), high density
lipoprotein (mg/dL), low density lipo-protein (mg/dL) and triglycerides (mg/dL). Twenty-
four-hour-urine and spot urine sample also will be collected to estimate the level of urinary
sodium excretion (mg/day).
Explicit instruction on fasting will be given to all participants a day before collecting fasting
blood samples. Similarly, they will also receive instructions regarding the process of 24-hour
urine and spot urine collection. And urine collection containers will also be provided to them.
They will be instructed to discard the first void of the morning and then start collecting the
subsequent voids for the next 24 hours. They will also be advised to note down the time of
their voids and whether they have collected each void in the collection container or not for the
24 hours period using a structured proforma. Blood samples for fasting plasma glucose and
lipid profile and 24-hour and spot urine samples for urinary sodium excretion (mg/day),
potassium, and chloride will be analysed using standard laboratory methods. Standard cut-offs
will be used for adolescents and adults, respectively.
A team of three members, including the first author (SK) and two field investigators, will be
involved in data collection. The field investigators will be qualified up to the graduation level
and receive training for data collection. One of the investigators will be a laboratory technician
for blood collection. Neither the investigator nor the data collectors will be blinded to the
intervention.
After obtaining written informed consent of the study participants, questionnaires will be
provided to them for writing their responses to questions in the classroom setting after that,
anthropometric and blood pressure measurements will be taken. Finally, instructions for the

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PLOS ONE Health promotion intervention to prevent risk factors of chronic diseases

collection of blood and urine samples will be provided. Specific days will be fixed for the collec-
tion of blood samples in the school setting and urine samples from the home setting.
Before the final data collection, pilot testing will be undertaken to assess the adequacy of
study tools and test the feasibility of implementing study protocol in school settings. A senior
faculty member working in health promotion will do quality control of the data collection pro-
cess. In addition, a Doctoral Committee comprising of seven faculty members of the institute,
working independent from the sponsor and competing interests, has been explicitly consti-
tuted for data monitoring and progress evaluation of this project. The first author (SK) will be
the implementer and evaluator of the intervention.

Statistical analysis
The quantitative data analysis will be performed using the Statistical Package for Social Sci-
ences (SPSS) version 21 based on intention-to-treat analysis. The complexity of cluster sam-
pling design will be taken into consideration during the analysis. Descriptive statistical analysis
will include the sample mean (along with standard deviation) and proportions according to
the variable types.
ANOVA and Chi-square test will be used to compare the statistical significance of continu-
ous and categorical variables. Within-group changes in quantitative variables from baseline to
end-line at six months will be analysed using a paired t-test. Unpaired t-tests will be applied
for assessing between-group comparisons. Multivariable regression analysis will be used to
explore potential differences between groups (e.g., socio-economic status, age, and gender).
The linear mixed-effects models will be used to estimate Difference-in-Differences (DiD) to
assess the net effect of the intervention on primary and secondary outcome measures among
adolescents. The net changes in primary and secondary outcome measures among parents and
teachers will be considered as exploratory analysis [43]. Intention to treat analysis will be con-
sidered for the correlation between measures and loss of follow-up [51].

Ethical considerations
Ethical permission has been obtained from the Post-Graduate Institute of Medical Education
and Research, Chandigarh (INT/IEC/2018/000082; Date: 22/ 01/2019). Permission has already
been granted for the selection of schools by the Department of Education, Chandigarh. Writ-
ten assent of adolescents and consent for teachers and parents will be obtained after informing
them about the study purpose, data to be collected, estimated time for data collection, the con-
fidentiality of the data, and risks involved, before their enrolment in the study. As this is a
behavioural intervention study, it involves no potential harm to the study participants. The
reports for fasting plasma glucose, lipid profile, urinary sodium excretion, potassium and chlo-
ride levels will be given to the participants. Participants with blood pressure above 140/90
mmHg and abnormal blood or urine test reports in both the study arms (intervention and
control) will be referred to the local health centre’s doctors. Any modifications in the protocol
will be conveyed to the institute ethics Committee after approval from the Doctoral Commit-
tee. These changes will be regularly updated on the Clinical Trial Registry-India. No later than
three years after collecting the 1-year end-line assessment, we will deliver a wholly deidentified
data set to an appropriate data archive for sharing purposes.

Discussion
Behavioural risk factors for chronic diseases, such as unhealthy dietary habits, low physical
activity levels, and tobacco and alcohol consumption, develop during early adolescence [2]. It
is essential to ’catch them young’ to prevent the development of these risk factors into various

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PLOS ONE Health promotion intervention to prevent risk factors of chronic diseases

intermediate conditions, including obesity, high blood pressure, elevated blood lipids and glu-
cose levels, which can lead to various chronic diseases in adulthood [52]. If health promotion
interventions are carried out in school settings, the effects could diffuse to many people and
prove beneficial at a population level [53].
The use of health promotion interventions involving various interactive educational activi-
ties can effectively change individuals’ behaviour [54]. However, there are several limitations
with previous studies. Most of the previous studies have targeted individuals at high risk of dis-
ease, as they are more motivated than the general population [55]. Secondly, the control group
did not receive any intervention in some trials, raising questions on the study’s validity [56].
Thirdly, most studies did not have a theoretical framework to support the health promotion
intervention [15, 16, 57]. Lastly, those studies conducted at the school setting level had explic-
itly focused only on school-going children. They did not look into the effect of the intervention
on the behaviours of teachers or their parents [9, 12, 58]. The findings of our study will reveal
the impact of health promotion interventions implemented in a school setting, not only on
school children but also on their teachers and parents.

Methodological considerations
The ability to measure any change requires the use of robust assessment methods. The
24-hour dietary recall methods have emerged as a reliable and helpful tool for dietary intake
measurement compared to other tools, such as the Food Frequency Questionnaire (FFQ) [45].
We will use 24-hour dietary recall on two non-consecutive days as it has been shown to give a
precise picture of individual dietary habits when taken on two or more times on non-consecu-
tive days. The use of the 24-hour dietary recall tool became necessary in Indian settings as it
imposes less burden on the participants when compared to other nutritional assessment tools.
One of the limitations of using 24-dietary recall is underestimating the salt (sodium) intake
[59]. Additionally, the salt intake will also be estimated through urinary sodium excretion
from 24-hour urine samples collected for all the participants at the baseline survey, which is
considered as the gold standard for evaluating salt intake [60–62]. In addition, urinary sodium
excretion will also be assessed for all the participants through spot urine samples collected at
the baseline and the end-line survey.

Strengths and limitations

Before the final data collection, pilot testing will be undertaken to test the protocol’s feasibility
and assess research instruments adequacy. Pilot testing will also aid in identifying problems
that could arise later in data collection [63]. Cluster RCT design has been chosen over an indi-
vidual RCT to minimise the threat of any intervention contamination. The use of the randomi-
sation process throughout the sampling procedure helps in minimisation of any potential
selection bias. Another strength of the study is using previously validated and pretested tools
in the Indian scenario, standard apparatus, and methodological guidelines of data collection
for the anthropometric, physiological, and biochemical measures. Difference in difference
(DID) method will help assess the intervention’s true effect by not underestimating or overesti-
mating the effect due to factors other than the intervention. Formative research, community
consultation, and PRECEDE-PROCEED model for planning, implementation, and evaluation
would help design a pragmatic intervention with potential for scale-up if found effective. One
of the potential limitations of the study is the non-inclusion of private sector schools. The sig-
nificant implication of excluding private schools is that it may lead to a lack of representation
of participants across various socio-economic groups, limiting generalizability.

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PLOS ONE Health promotion intervention to prevent risk factors of chronic diseases

Conclusion
Chronic diseases are on the rise. Hence, researchers, policymakers, and program implementers
need to focus on evidence-based strategies for preventing the emergence of risk factors. Health
promotion interventions implemented in the school setting simultaneously targeting adoles-
cents, teachers, and parents could be more cost-effective. The PRECEDE-PROCEED model
for planning, implementation, and evaluation of the intervention in a cluster Randomized
Controlled Trial design with DID analysis could objectively assess the impact of scaling up pri-
mordial prevention to stem the tide of chronic diseases.

Supporting information
S1 Checklist. SPIRIT checklist.
(DOC)
S1 File. Institute’s ethics committee approved protocol.
(DOCX)

Acknowledgments
We wish to extend our special thanks to Dr. Jacqui Webster, PhD, RPHNutri, Head, Public
Health Advocacy and Policy Impact, Food Policy, Centre Director WHO Collaborating Centre
Salt Reduction, Professor, Faculty of Medicine, UNSW, Sydney, The George Institute for
Global Health, Australia for her technical inputs in improving the methodology and for
reviewing the manuscript. We also thank the Director of School Education, Chandigarh
Administration, for granting the permission to carry out this PhD project in public schools of
Chandigarh Union Territory.

Author Contributions
Conceptualization: Sandeep Kaur.
Methodology: Sandeep Kaur.
Project administration: Manmeet Kaur, Rajesh Kumar.
Supervision: Manmeet Kaur, Rajesh Kumar.
Validation: Manmeet Kaur, Rajesh Kumar.
Writing – original draft: Sandeep Kaur.
Writing – review & editing: Sandeep Kaur, Manmeet Kaur, Rajesh Kumar.

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