Preplanned Studies: Construction of Evaluation Indicators for the Public Health System in Primary and Secondary Schools — Beijing, China, 2024–2025

Introduction: To construct a set of evaluation indicators suitable for the public health system in primary and secondary schools in Beijing, this study aimed to provide a basis for objectively assessing the current status of system development and identifying future directions for improvement.

Methods: An indicator pool was established based on literature reviews and expert consultation. The indicator system was then refined and finalized through two rounds of the Delphi method, and the weights of the indicators were determined using the analytic hierarchy process.

Results: The expert participation rate reached 100%, and the average expert authority coefficient was 0.87. The indicator coordination coefficient W was statistically significant (P<0.001). Ultimately, an evaluation system comprising 5 first-level indicators, 15 second-level indicators, and 39 third-level indicators was developed.

Conclusion: The indicator system constructed in this study shows good expert consistency and credibility. It can effectively pinpoint key components of system development, providing a scientific foundation for optimizing resource allocation and supporting ongoing improvement.

School public health is a key part of the public health system, responsible for promoting healthy habits and improving adolescent health literacy, and has now been elevated to a national strategic level. In 2023, the General Offices of the CPC Central Committee and the State Council issued the “Opinions on Building a High-Quality and Balanced Basic Public Education Service System,” clearly emphasizing the need to strengthen school health systems and signaling a new stage in the development of school public health capacity. Various international frameworks for evaluating school health have been developed, such as the WHO’s Health-Promoting Schools framework, the United States’ Comprehensive School Health Program, and Germany’s Health-Literate Schools model. These frameworks primarily focus on student health literacy and do not comprehensively assess the full scope of school health work. In China, school health services cover multiple areas (1–2), but evaluation research remains fragmented (3–5), as there is no comprehensive system that integrates multiple components and considers both internal and external factors. To address this gap, this study applied the Delphi method combined with the Analytic Hierarchy Process (AHP) to construct an evaluation indicator system for the public health infrastructure in primary and secondary schools, aiming to assess current conditions and support the physical and mental development of adolescents.

This study began in October 2024 and completed two rounds of the Delphi method within six months. Twenty experts of primary and secondary school public health system were selected, based on representativeness and professional expertise. The group included: 1) Policymakers and administrators holding (deputy) section-level or (deputy) senior titles, ensuring alignment between indicators and policy frameworks as well as practical feasibility; 2) Technical professionals with (deputy) senior titles, contributing clinical and disease prevention expertise to inform indicator development; 3) Researchers with (deputy) senior titles, providing scientific and theoretical support; and 4) Frontline practitioners with more than 10 years of school health experience, ensuring that the indicators reflect real-world operational needs (Table 1).

A Delphi expert evaluation system using a five-point Likert scale was employed to assess each indicator in terms of importance, operability, and sensitivity. Statistical analysis was performed using SPSS (version 26.0), which generated arithmetic means, full-score frequencies, coefficients of variation, and Kendall’s W concordance coefficients for each indicator. Indicators that ranked in the bottom 10% across any two or more dimensions were marked for elimination after expert deliberation (6). Finally, an AHP judgment matrix was constructed to calculate the weights of indicators at all levels.

Drawing on the Guiding Opinions on Strengthening the Construction of Public Health System in Schools in Beijing, issued by the Beijing Municipal Education Commission and the Beijing Municipal Health Commission, a review of the literature on school health services, student healthcare, and health education — combined with expert input — resulted in the development of an initial indicator pool of 67 items (Table 2).

This study conducted two rounds of expert consultations. The questionnaire response rate was 100%, indicating strong expert engagement. The average Cr value for first-level indicators was 0.87, reflecting good reliability. All first-level indicators scored above 4.0 points for importance, operability, and sensitivity. Their coefficients of variation were below 0.25, and full-score frequencies exceeded 20%. Kendall’s W concordance coefficient reached statistical significance (P<0.001), with an upward trend (importance: 0.167→0.239; operability: 0.207→0.230; sensitivity: 0.199→0.317), indicating increasing expert consensus and high reliability on results.

After two screening rounds, the evaluation index system for the public health system in primary and secondary schools in Beijing included five first-level indicators, 15 second-level indicators, and 39 third-level indicators (Table 2). The first-level indicators comprised the public health governance system; public health emergency management and infectious disease prevention and control capabilities; capacity for prevention and control of common diseases; health education system; and guarantee of public health resources.

Indicator weights were calculated using the AHP. An analysis model was built with four layers: the target layer (I), the criterion layers (II and III), and the solution layer (IV). Based on the mean importance scores from the second round of expert evaluations, a judgment matrix was constructed using Saaty’s scale and tested for consistency (CR<0.10). The weights of indicators at each level were calculated based on the mean importance scores from pairwise comparisons. Composite weights were obtained through multiplicative hierarchical aggregation. The results are shown in Table 3.

The Chinese school health system currently faces systemic challenges, including weak institutional mechanisms, limited capacity to prevent and control common and infectious diseases, insufficient health-behavior promotion, and uneven resource allocation, which hinders the transition from “passive response” to “active prevention and control” (7–8). To address the lack of a comprehensive evaluation framework, this study integrated the Delphi method and AHP to develop an evaluation index system for public health in primary and secondary schools. The active coefficients of both expert rounds were 100%, the expert authority coefficient (Cr=0.87) exceeded 0.70, and Kendall’s W values were statistically significant (P<0.001), indicating strong consensus, high reliability, and solid scientific and practical validity.

The five first-level indicators were weighted as follows: B (0.417), A (0.265), C (0.177), E (0.094), and D (0.048). This distribution aligns with national priorities for school health. In 2021, the Ministry of Education and four other departments issued the “Opinions on Comprehensively Strengthening and Improving School Health and Health Education in the New Era,” emphasizing stronger emergency response capabilities in schools based on lessons from COVID-19. The high weight of indicator B reflects schools’ role as key sites for infectious disease transmission in China (9), where density and mobility increase risk. As emerging infectious diseases remain a global threat, school-based prevention is essential. Persistent challenges such as fragmented management, weak professional support, and poor coordination underscores the need for improved top-level design (8). Indicator A addresses these issues: A1 establishes a principal-led leadership group integrating teaching, logistics, and health functions, while A3 introduces a vice-principal for health and promotes home-school-community collaboration. This strengthens emergency management and governance, therefore forming the core of school health protection.

Among the 15 second-level indicators, the five highest-weighted — B1 (0.225), A1 (0.208), B2 (0.124), C1 (0.109), and B3 (0.068) — account for 73.4% of the total. The prominence of B1 aligns with Ou Qixiang et al.’s emphasis on emergency response capacity (3). Although indicator C carries a lower overall weight, C1 ranks fourth overall, highlighting the importance of accurate monitoring for disease prevention. C1 and C32 depend on A1 for institutional support, use B2 for symptom-data sharing, and rely on A3 to facilitate home-school collaboration. Indicator E’s weight (0.094), concentrated in E1 (0.048) and E2 (0.031), reflects its supporting role. This suggests that current challenges stem less from hardware shortages than from the need to improve resource allocation — achievable through indicators A (e.g., A1) and B (e.g., B2). Indicator D has the lowest weight because its effects are long-term rather than immediately operational. Health education, represented by D11 (0.025), must be embedded in practical activities such as disease prevention (e.g., C24) and emergency management (e.g., B12). Its evaluation (e.g., D21) serves as an “add-on,” combining qualitative and quantitative approaches while avoiding overly rigid metrics. The 2021 National Opinions also call for reorganizing health education to establish a high-quality system. The indicator weights in this study guide schools to promote healthy behavior through multisystem linkage (e.g., C3 and A31). Lower-weighted indicators operate effectively only when supported by higher-weighted governance and emergency-management systems, highlighting that strengthening these foundations is essential for maximizing disease prevention, ensuring resource availability, and improving health education.

The findings in this report are subject to at least two limitations. First, due to differences in organizational structures, management models, and health needs across educational levels, it is difficult to develop a unified public health evaluation system applicable to all settings. The current index system is designed for primary and secondary schools and cannot be directly applied to universities or kindergartens. Second, the system has not yet undergone empirical testing. Future research will use mixed methods to conduct empirical assessments of school public health systems and validate the scientific validity, feasibility, and applicability of the indicators.

Approved by the Research Ethics Committee of the Capital Medical University (Z2023SY093), and all participants provided written informed consent.

All individuals who contributed to data collection and participated in this research.