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Global Health Action
ISSN: 1654-9716 (Print) 1654-9880 (Online) Journal homepage: http://www.tandfonline.com/loi/zgha20
The development and pilot testing of a
multicomponent health promotion intervention
(SEHER) for secondary schools in Bihar, India
Sachin Shinde, Bernadette Pereira, Prachi Khandeparkar, Amit Sharma,
George Patton, David A Ross, Helen A Weiss & Vikram Patel
To cite this article: Sachin Shinde, Bernadette Pereira, Prachi Khandeparkar, Amit Sharma,
George Patton, David A Ross, Helen A Weiss & Vikram Patel (2017) The development and pilot
testing of a multicomponent health promotion intervention (SEHER) for secondary schools in Bihar,
India, Global Health Action, 10:1, 1385284, DOI: 10.1080/16549716.2017.1385284
To link to this article: http://dx.doi.org/10.1080/16549716.2017.1385284
© 2017 The Author(s). Published by Informa
UK Limited, trading as Taylor & Francis
Group.
Published online: 08 Nov 2017.
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ORIGINAL ARTICLE
The development and pilot testing of a multicomponent health promotion
intervention (SEHER) for secondary schools in Bihar, India
Sachin Shinde
a,b
, Bernadette Pereira
a
, Prachi Khandeparkar
a
, Amit Sharma
a
, George Patton
c
, David A Ross
d
,
Helen A Weiss
b
and Vikram Patel
a,b,e
a
Sangath, Bardez, Goa, India;
b
London School of Hygiene and Tropical Medicine, UK;
c
Murdoch Children’s Research Institute, University
of Melbourne, Australia;
d
Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva,
Switzerland;
e
Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
ABSTRACT
Background: Schools can play an important role in health promotion by improving students’
health literacy, attitudes, health-related behaviours, social connection and self-efficacy. These
interventions can be particularly valuable in low- and middle-income countries with low health
literacy and high burden of disease. However, the existing literature provides poor guidance for
the implementation of school-based interventions in low-resource settings. This paper describes
the development and pilot testing of a multicomponent school-based health promotion inter-
vention for adolescents in 75 government-run secondary schools in Bihar, India.
Method: The intervention was developed in three stages: evidence review of the content and
delivery of effective school health interventions; formative research to contextualize the
proposed content and delivery, involving intervention development workshops with experts,
teachers and students and content analysis of intervention manuals; and pilot testing in situ
to optimize its feasibility and acceptability.
Results: The three-stage process defined the intervention elements, refining their content
and format of delivery. This intervention focused on promoting social skills among adoles-
cents, engaging adolescents in school decision making, providing factual information, and
enhancing their problem-solving skills. Specific intervention strategies were delivered at three
levels (whole school, student group, and individual counselling) by either a trained teacher or
a lay counsellor. The pilot study, in 50 schools, demonstrated generally good acceptability
and feasibility of the intervention, though the coverage of intervention activities was lower in
the teacher delivery schools due to competing teaching commitments, the participation of
male students was lower than that of females, and one school dropped out because of
concerns regarding the reproductive and sexual health content of the intervention.
Conclusion: This SEHER approach provides a framework for adolescent health promotion in
secondary schools in low-resource settings. We are now using a cluster-randomized trial to
evaluate its effectiveness and cost-effectiveness.
ARTICLE HISTORY
Received 9 May 2017
Accepted 10 July 2017
RESPONSIBLE EDITOR
Stig Wall, Umeå University,
Sweden
KEYWORDS
Adolescent; intervention
development; school health
promotion; India
Background
Adolescence is characterized by dramatic physical
and psychological changes and alterations in social
perceptions and expectations [1]. The emergence of
health risk behaviours during this period has impor-
tant consequences for physical and mental health, as
well as for emotional well-being both during this
phase of life and in later life [2]. Schools are an
important platform for the delivery of health promo-
tion interventions for adolescents, targeting risk and
protective factors operating in the school environ-
ment and providing specific health-focused interven-
tions [3,4]. Guided by the Ottawa Charter for Health
Promotion (1986), the World Health Organization
(WHO) introduced the concept of Health Promoting
Schools (HPS) in 1995 [5]. This model promotes a
comprehensive total life approach to school-based
health promotion and takes into account not only
the curriculum but also the school’s ethos and envir-
onment, as well as partnerships with community and
access to health services [6,7]. Although the HPS
provides a broad framework for action, there is little
evidence that schools are able to implement this
approach. In fact, few programmes have been found
that implement and evaluate the HPS approach in its
entirety, and most continue to use only a curriculum/
social skills approach [6,7]. For many, there remains a
continuing emphasis on health education rather than
co-curricular health promotion [7].
India is home to around 20% (250 million) of the
world’s 10- to 19-year-olds [8]. Enrolment in second-
ary schools has almost doubled, from 19 million
students in 2000–01 to 37 million in 2013–14. This
increasing enrolment offers an important opportunity
for promoting health in secondary schools. Since
2005, the primary health promotion intervention in
schools has been the Adolescence Education
CONTACT Vikram Patel vikram.patel@lshtm.ac.uk Sangath, H No 451 (168), Bhatkar Waddo, Succour, Porvorim, Bardez, Goa 403501, India
GLOBAL HEALTH ACTION, 2017
VOL. 10, 1385284
https://doi.org/10.1080/16549716.2017.1385284
© 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
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Programme (AEP) [9]. This programme is a teacher-
delivered implementation of a classroom-based life-
skills curriculum focused on reproductive and sexual
health (RSH), and also addressing a range of other
risk behaviours. Such programmes often fail to take
into account the needs of particular school commu-
nities, the institutional context, and fail to value and/
or measure changes in the system that may have
occurred or need to occur for the sustainability of
health promotion programmes [10].
This paper describes the development of the
SEHER intervention (SEHER meaning 'dawn' in
Hindi language; ‘Strengthening Evidence base on
scHool-based intErventions for pRomoting adoles-
cent health programme in the state of Bihar, India’),
in particular its conceptual framework and delivery,
and evaluates the feasibility and acceptability of this
intervention through a pilot study. The overall aim of
the SEHER study is to develop and evaluate a com-
prehensive health promotion intervention, extending
the ongoing AEP (called TARANG in Bihar;
TARANG means 'waves' in Hindi language) with
the ultimate goal of evaluating its effectiveness against
the TARANG in government-run secondary and
higher secondary schools.
Methods
The intervention development involved three stages
[11]: (1) reviewing the literature on the content and
delivery of school health interventions; (2) formative
research to contextualize the content and delivery;
and (3) pilot testing to optimize the feasibility and
acceptability of the intervention. The fieldwork was
carried out in the Nalanda district of Bihar, India
from July 2013 to March 2015. Table 1 shows a
breakdown of the outcomes from the activities con-
ducted at each stage.
Bihar is a state in north India with a total popula-
tion of over 103 million, with 22.5% of the population
aged 10–19 years. Bihar was ranked 21 out of 23
major Indian states in terms of human development
in 2014 [12]. Hindi is the official and most prevalent
language of Bihar. Nalanda district has a population
of over 2.8 million, and a literacy rate of 66% com-
pared with India’s overall literacy rate of 74% [8].
There are 136 secondary government-run schools in
the district and the Department of Education (DoE)
is the main education provider. In total, 67,542 stu-
dents (44% girls and 56% boys) were enrolled in these
schools in the academic year 2013–14.
SEHER was implemented by Sangath, an Indian
non-government organization with a long-standing
record of working with adolescents, in partnership
with the London School of Hygiene & Tropical
Medicine (LSHTM) and the Department of
Education, Bihar. All research procedures were
approved by the institutional review boards of
Sangath, the LSHTM and the Health Ministry
Screening Committee of the Indian Council for
Medical Research. Written informed consent was
obtained from all the adult participants. We sought
parental approval through opt-out consent for ado-
lescent participants; in addition, assent was obtained
from the adolescent participants.
Stage 1: Reviewing the national and global
literature
Thegoalofthisstagewastoidentifyevidenceon
effective school-based health promotion interven-
tions. Systematic reviews show that school-based
health promotion interventions, including HPS,
bring about positive health outcomes including
reduction in body mass index, increased physical
activity, decreased substance use, reduced reports
of being bullied, and reduced sexual risk behaviours,
indicating the value of these interventions [13,14].
Of these interventions, the most effective were mul-
ticomponent, involving changes to the school envir-
onment, of long duration and high intensity,
involving whole-school strategies and led by the
school itself, with a school health coordinator [15].
The provision of the health promotion coordinator
has been found to increase social connectedness,
reduce health risks, and increase physical activity
among students. However, most of the studies con-
tributing to this evidence are from higher-income
countries, mainly the USA, Europe, the UK, and
Australia.
A few studies which have examined the process of
planning and implementation of HPS initiatives have
provided useful findings concerning the main chal-
lenges and facilitators of HPS practice. The setting-up
of school-based HPS steering groups/committees pro-
vides a useful support structure for schools as they plan
and design health promoting policies, strategies, and
procedures [10,16–20].Thesecommitteesaimto
engage with various stakeholders and work towards
developing all components of a health-promoting
school ethos. Perhaps unsurprisingly, this kind of
shared responsibility among school staff and indeed
among all stakeholders (e.g. the creation of health com-
mittees) has been identified as crucial to the success of
this type of intervention [18]. At the same time, these
kinds of committee can be difficult and time-consum-
ing to develop, especially when time and resources are
limited. It is also often the case that one or two cham-
pions are required to drive the initiative forward [19].
For this reason, the appointment of a health promotion
coordinator to support schools in taking responsibility
for the planning and implementation of health-promot-
ing school work has been recommended [18,19]. While
external guidance is clearly important, school
2S. SHINDE ET AL.
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Table 1. Results from application of three-stage methods for development and testing of SEHER intervention.
Stage Objectives Outcomes
(1) Evidence synthesis Identify evidence on effective school-based health
promotion interventions
●School-based health promotion interventions have
produced small to moderate effect sizes on range of
adolescent health outcomes including: physical
activity; tobacco, alcohol and drug use; bullying;
sexual risk behaviours; and mental health
●Multi-component and whole-school interventions,
delivered within a supportive school environment,
show more potential for health promotion than only
classroom-based curricula
●Provision of a Health Promotion Coordinator has been
found to increase social connectedness, reduce health
risks, and increase physical activity among students
●A school-based steering committee is essential for
planning and designing health policies and activities
(2) Formative research
2A. Intervention development
workshops
a. Develop a conceptual framework of the
intervention
b. Identify the intermediary and long-term outcomes
c. Identify the specific components of the
interventions
d. Identify the selection, training, and supervision
requirements of the delivery agents
Content of the intervention
●Focus of the intervention on building ‘school climate’
as the primary intermediary outcome
●Identified following long-term outcomes: reduction in
substance use, sexual risk behaviours, bullying and
violence, and depressive symptoms
●Identified four priority areas or foci for action: (i)
promoting social skills among adolescents, (ii) enga-
ging the school community in the school-level decision
making processes, (iii) providing access to factual
knowledge to the school community, and (iv) enhan-
cing problem-solving skills among adolescents
●Intervention activities organized at three levels: whole-
school, group, and individual
●Avoid duplication of existing intervention elements,
and thus drop classroom-based life skills sessions
(already being delivered by the TARANG programme in
the study context)
●Added peer groups to intervention component to
strengthen school-belongingness among students
Selection, training and supervision of the delivery
agents
●Two human resources identified for the role of health
promotion coordinator: a new, low-cost human
resource (the lay counsellor) and an existing human
resource (a teacher)
●Selection criteria for lay counsellors: to be members of
the local community, ≥21 years of age, have com-
pleted at least high school education, and have no
professional health training
●Selection criteria for teachers: have a ≥5 years’
experience of teaching in secondary schools, have
≥12 years of service remaining, not teaching TARANG
curriculum, and willing to undergo a weeklong resi-
dential training
●Six-day training curriculum to train lay counsellors and
teachers; supplemented by monthly group meetings
for lay counsellors and teachers
●Separate training and monthly group meetings to
avoid contamination
●A combination of two planned and one unplanned
supervisory school visits per month to each interven-
tion school
2B. Content analysis of
intervention manuals of
adolescent health
promotion
Identify evidence-based practices to implement the
specific components laid out in the conceptual
framework, and draft the standard operating protocols
for each component
●Adapted and defined standard operating guidelines
for intervention components based on evidence-
based practices to local context
(Continued )
GLOBAL HEALTH ACTION 3
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ownership and ‘buy-in’from all staff is also essential for
a successful and sustainable initiative; again, this
appears to be inextricably linked to the development
of an effective health-promoting school ethos/culture
[17,20].
This global evidence was supplemented by a
review of case studies of four school health promo-
tion interventions in India [21]. Drawing on informa-
tion from professional networks and the academic
and grey literature, 20 organisations were identified
as supporting adolescent school health promotion
interventions. The selected interventions were char-
acterized by different types of human resource deliv-
ery models, different levels of engagement with the
school community, and variation in scale from a pilot
intervention in 10 schools to a state-wide programme
in over 2000 schools. However, these case studies
provide limited evidence of the impact of such inter-
ventions in influencing students’knowledge, atti-
tudes, and behaviours as they lacked a comparison
arm. Of the four case studies, Sangath’s School
HeAlth Promotion and Empowerment (SHAPE)
intervention [22] demonstrated that a lay school
counsellor could be an effective delivery agent, play-
ing the role of health promotion coordinator, for a
multi-component school-based health promotion
intervention in Goa, which is better resourced than
most Indian states. In India, school-based health
promotion interventions have generally been deliv-
ered by teachers, healthcare providers, or peers who
are already part of the school, as these are perceived
as the least resource-intensive options. However,
these interventions can compete with teaching duties
and other commitments, and the sustainability of
peer-delivered education interventions can be limited
as the population of student peer-educators is not
stable. We, therefore, decided to compare delivery
of the SEHER intervention by a new, low-cost
human resource (such as a lay counsellor) and an
existing human resource (such as a teacher). During
this stage, we also identified the intervention manuals
from low- to middle-income countries that could
potentially be adapted to design guidelines of inter-
vention components in Stage 2.
Stage 2: Formative research to adapt the
intervention to the local context of Bihar
The objective of this stage was to build on the evidence
gathered from the review to develop a conceptual frame-
work, identifying the intermediate and long-term out-
comes and the specific components of the interventions.
Two methods were adopted: intervention development
workshops with various stakeholders, and content ana-
lysis of intervention manuals for adolescent health
Table 1. (Continued).
Stage Objectives Outcomes
(3) Pilot testing
Evaluate the acceptability and feasibility of the
intervention, and identify the gaps and improvements
needed
Acceptability
●Intervention activities were well accepted in most
schools
●Perceived as meeting important needs of students
●Acceptance of both types of delivery agents
●One school dropped out as the school management
perceived the reproductive and sexual health-related
content inappropriate
Feasibility
●High coverage of whole-school activities in both arms;
higher intervention coverage in the lay counsellor arm
relative to the teacher delivery arm
●Key facilitators: participatory nature of intervention
activities, availability of platforms to raise students’
concerns, redressal of students’complaints or pro-
blems while maintaining confidentiality, engagement
and support of the headmaster, and involvement of
other teachers in intervention activities
●Key barriers: lack of engagement of teachers in inter-
vention activities, lack of male students’participation,
fall in students’attendance in last months of the
school year (after January), and non-availability of
teachers during ‘unplanned’supervisory visit due to
their competing teaching responsibilities
Strategies employed to address barriers
●Added teachers’monthly meeting as a component to
improve teachers’engagement in intervention
activities
●Added monthly intra-school competitions to increase
boys’participation
●Focus on completing all core intervention components
between June and January
●Monthly unplanned supervisory visit per month chan-
ged to a planned visit to lend more support to tea-
chers and lay counsellors
4S. SHINDE ET AL.
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promotion. Eight intervention development workshops
–three each with secondary school students (n=42),
and teachers (n= 24), and one each with experts
(n= 12), and project staff (n= 8) were conducted.
Small group works and guided discussions were used
to refine the content of the intervention and delivery-
related issues [18,23]. Simultaneously, we reviewed the
intervention manuals of 10 school-based adolescent
health interventions from low- to middle-income coun-
tries [24–33] identified through the literature review
during Stage 1. Data collated through these two activ-
ities was triangulated to develop a conceptual frame-
work for the SEHER intervention and implementation
strategy for each component.
Intervention development workshops
The SHAPE programme, developed and piloted by
Sangath in Goa, was chosen as the framework of the
intervention as it closely matched the SEHER pro-
gramme context (India), and provided evidence on
effective interventions (multi-component with whole-
school, group-level, and individual strategies) [22]as
well as protocolized manuals for their delivery. In
SHAPE, the whole-school level activities included
school mapping and needs assessment; health screen-
ing camps; an anonymous letterbox for students to
voice their questions and concerns (the ‘speak-out
box’); a School Health Promotion and Advisory
Board (comprising of headmaster, school counsellor,
teachers, school management staff, and student and
parent representatives) to oversee the design and
implementation of the intervention in each school;
and development and implementation of the school
health policies. The group-level activities included
classroom-based life skills training, while the indivi-
dual level activities included individual counselling
and referral services.
An important starting point was to describe cur-
rent best practice already being implemented by the
DoE. The TARANG programme comprises 16 hours
of classroom sessions on life skills, including the
process of growing up, establishing positive and
responsible relationships, gender and sexuality, pre-
vention of HIV/AIDS and other sexually transmitted
diseases, and prevention of substance use. It is deliv-
ered by a trained teacher in each school. To avoid
duplication, the classroom-based life-skills sessions
were removed from the intervention, as were the
health camps, which were already being organized
by the DoH. The ‘Theory of Change’to achieve our
ultimate desired health outcomes emphasized that
classroom sessions alone were not enough to bring
change and highlighted the importance of an
‘enabling school climate’as a key intermediary out-
come. Stakeholders identified varied constructs to
define school climate, including safety; quality of
interpersonal relationships among students, teachers,
and staff; the degree to which students, teachers, and
staff contribute to decision-making at the school;
feeling of school connectedness, such as responsive-
ness of school authorities to student concerns; school
infrastructure; discipline and order in the school;
quality of instructions; and dedication to student
learning and achievement. Based on this theory and
the recommendations from the intervention develop-
ment workshops, modifications were made to the
intervention. For example, we added content related
to bullying and gender-related violence, rights and
responsibilities, and on effective study skills, with
each month of the academic year being allocated to
a particular theme. As all stakeholders emphasized
the engagement of peers and families, peer-groups
were added to the intervention to strengthen school
belongingness amongst students by providing a plat-
form to discuss shared problems and propose
Figure 1. SEHER conceptual framework.
GLOBAL HEALTH ACTION 5
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solutions, and an annual workshop for parents (on
‘How to handle an adolescent’) was designed.
Figure 1 shows the resulting conceptual framework
for the SEHER intervention, which emphasizes the
importance of positive school climate. We defined
this as consisting of supportive relationships among
school community members, a sense of belonging to
school, a participative school environment, and stu-
dent commitment to academic values. The SEHER
intervention identifies four priority areas for action:
promoting social skills among adolescents; engaging
the school community –i.e. adolescents, teachers,
and parents –in school-level decision-making pro-
cesses; providing access to factual knowledge to the
school community; and enhancing problem-solving
skills among adolescents. The strategies (whole-
school, group, and individual) were largely modelled
around the SHAPE intervention and comprised the
following:
(1) The whole-school level activities included (i)
school mapping and needs assessment; (ii)
activities to raise health awareness; (iii) a
wall-magazine on health-related topics; (iv)
extracurricular competitions; (v) an anon-
ymous letterbox for students to voice their
questions and concerns (‘speak-out box’); (vi)
a School Health Promotion Committee to
oversee the design and implementation of the
intervention in each school; and (vii) the
development and implementation of school
health policies.
(2) The group-level activities included peer groups
of class IX students and workshops for stu-
dents and teachers.
(3) The individual level activities included individual
counselling and referral services for students.
Content analysis of intervention manuals
The content analysis of intervention manuals helped
to identify evidence-based practices to implement the
specific components in the conceptual framework,
and to draft Standard Operating Protocols (SOPs).
The analysis assessed, for each strategy, the adequacy
of the description of its implementation, feasibility
for delivery by the target human resources (see
below), and the extent of adaptations needed for its
use in the context. For example, the resource guide
for peer leaders of the Yuva Mitr, a community-based
programme to promote health and well-being of
young people evaluated in a randomized controlled
trial in Goa [24], provided the basis for developing
guidelines of peer-group formation and facilitation.
The final SOPs and resource materials were reviewed
and revised for appropriateness and cultural suitabil-
ity by an expert committee of the State Council
Educational Research and Training, DoE,
Government of Bihar, and three independent experts
on adolescent health promotion in April 2014 (see
Acknowledgements).
In addition to the scope and content of the interven-
tion, the selection, training, support, and supervision
requirements of the delivery agents were discussed with
the stakeholders. To maintain the comparability of the
two delivery formats –that is, the lay school counsellor
(SEHER Mitra [friend], or SM) and the teacher
(Teacher-SM, or TSM) –the stakeholders recom-
mended keeping the curriculum the same for both but
conducting the training separately to avoid contamina-
tion. The SM were required to be members of the local
community, at least 21years of age, having completed at
least high school education, and with no professional
health training. The TSM would be a teacher nominated
by the school principal. The classroom training curri-
culum needed to be a maximum of six days because
teachers could not provide more time due to competing
commitments in the school. The classroom training was
to be supplemented by a monthly group meeting for all
SMs and TSMs, respectively, which served multiple
roles including team-building, sustaining motivation,
and shared problem-solving. On-site supervision was
considered essential in order to assure the quality of the
intervention and supervisors were expected to have a
postgraduate degree and experience of working in the
development sector. A combination of two planned and
one unplanned supervisory visits per month to each
school was recommended to provide support in plan-
ning and implementing activities and reviewing the
intervention progress.
Stage 3: Pilot testing of the intervention
The cluster-randomized controlled trial to evaluate
the SEHER interventions selected 75 schools from a
sampling frame of 112 schools (https://clinicaltrials.
gov/ct2/show/NCT02484014), which were rando-
mized to three arms (SM, TSM, and control, i.e.
TARANG alone) using minimization to balance on
the type of school, school size and gender composi-
tion. The pilot testing of the intervention was con-
ducted prior to the trial (between April 2014 and
March 2015) in the 25 schools randomly allocated
to SM and TSM arms, respectively. We conducted the
pilot in the same schools as the main trial for two
reasons: (1) the secondary schools only included
grade IX onwards (our primary target group for the
evaluation of the effectiveness) and thus, the cohort
of students to be included in the main trial would not
have been exposed to the intervention during the
pilot; and (2) piloting the intervention in the schools
participating in the trial enabled us to embed the
intervention and refine its delivery to optimize its
feasibility and acceptability in each school. Twenty-
6S. SHINDE ET AL.
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nine SMs (25 in schools and four back-up SMs), 25
TSMs and eight supervisors were selected and com-
pleted their training. Each supervised both SM and
TSM schools, with an average of six schools per
supervisor. The 50 schools included in the pilot
study had a total of 16,973 students, in Grades IX to
X (8529 students in SM and 8444 in TSM schools).
We assessed the fidelity of intervention implementa-
tion (the coverage of each component, the extent to
which stakeholders engaged with it and the quality of
its delivery). Coverage indicators were collected through
monthly reporting forms and quality indicators were
assessed through ratings of specific components, such
as the wall-magazine and peer group meetings, by
respective supervisors and by observations made by the
intervention team during field visits. At the end of the
pilot, we conducted a qualitative evaluation in 12 schools
(six SM and six TSM schools, respectively). The schools
were purposely selected based on the high or low cover-
age of intervention activities. The overall aims of the
qualitative evaluation were to gather multiple perspec-
tives about the intervention components and its delivery,
and to identify the gaps and improvements needed. In
each school, we conducted in-depth interviews with the
principal (n= 12), TARANG teacher (n=12)andone
fellow teacher (n= 12); and focus group discussions
(FGDs) with students (n= 24, 12 each with boys and
girls). In addition, three rounds of FGDs were conducted
with the TSMs, SMs and supervisors during the inter-
vention implementation.
The interviews and FGDs covered a range of topics
including the stakeholders’perceptions of the need for
the intervention, adequacy of the content and design of
supportive materials (i.e. SOPs, posters, and supplies),
how school personnel and students were involved in the
intervention, what support or resources were helpful for
the intervention implementation, and facilitators for,
and barriers to implementation of the intervention.
Interviews and FGDs were conducted in Hindi and
recorded. Digital recordings were transcribed and
translated before coding using both a priori and emer-
gent codes by two researchers (S.S. and B.P.) using
NVivo version 10 (QSR International, Burlington,
MA, USA). Data collection and analysis progressed
iteratively, identifying and interpreting themes, leading
to modifications to the intervention. A thematic analy-
sis was used for data analysis, with codes and qualitative
results discussed by the team to achieve consensus. The
following analytical themes and subthemes were
employed for the synthesis and interpretation of the
quantitative and qualitative data:
●Acceptability: Is the need for the intervention
acknowledged by the stakeholders; stakeholders’
acceptability of the intervention content; and
stakeholders’participation in and attitudes
towards the intervention activities.
●Feasibility: What was the implementation of the
intervention activities compared with what was
planned; stakeholders’perceptions of the bar-
riers to, and facilitators of, the introduction
and delivery of the intervention activities; sys-
tems for implementation and supervision.
Results
Acceptability
The school principals, teachers, TSMs, and SMs were
almost unanimously of the view that the intervention
was meeting an important need, considering the fact
that students in government schools are socially and
economically disadvantaged and require health and
social skills training. Drawing attention to the low
status of women in the region, many stakeholders
also spoke of the potential of the intervention to
raise awareness of reproductive and sexual health
issues, gender equity, and gender-based violence to
change the outlook of youth.
What is special about this programme is that the
grade IX and X students are getting health education
through participatory methods. There is no teaching
as such, but the whole school is engaged in delivering
key messages like what is gender-based violence, what
are key reproductive and sexual health issues, what is
anxiety and stress, how to handle stress and so on.
(Principal of a SM school)
Of all the stakeholders interviewed, only one
school principal and three teachers expressed linger-
ing doubts about the desirability of providing infor-
mation on sex and pregnancy to adolescents. They
feared that this might have negative consequences,
such as heightening attraction to the opposite sex,
which, in turn, could result in a growing number of
romantic and/or sexual relationships.
One thing I don’t like about this programme is
that the kind of information given to these children
on adolescence . . . these children are not mature
enough to understand these things; they may act on
the information, which is not good. (Teacher of a
TSM school)
The school principals, teachers, SMs, and TSMs
acknowledged that through the meetings with the
staff and SHPC members, the schools identified
issues of concern and reviewed the practices and
priorities of their schools. For many schools, the
discussions during these meetings provided the
impetus for shared planning and action. For example,
in two schools, the SHPC meeting discussed the need
for separate toilets for boys and girls and networked
with the District Education Office for financial sup-
port. As a result, these schools received funds to build
toilets.
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The school staff also acknowledged that a lot of
changes took place in the school due to the pro-
gramme. For example, teachers mentioned that a reg-
ular whole-school assembly was being organized, and
the chits submitted by the students in the speak-out
box motivated the teachers to follow a daily school
schedule. Teachers mentioned that through activities
like whole-school assembly sessions, wall-magazine
development and competitions, the interactions
between students and teachers improved significantly.
Apart from providing information to the students,
SEHER has been useful in bringing positive changes in
our school. Earlier, there was no student assembly
organized in our school;however, since joining, the
SEHER-Mitra is facilitating the daily assembly.
Students are participating in the various activities dur-
ing the assembly like newspaper reading, cleanliness
drive, skit presentation, and so on. Similarly, the daily
schedule was not being followed in our school, but a
large number of students have demanded a regular
schedule of classes in the school through chits, which
has pressurized the headmaster and teachers to follow
a schedule. (Female teacher from SM school)
Although the SMs and TSMs were generally enthu-
siastic about the intervention, two of each, all from
lower-performing schools, mentioned that support
from fellowteachers was not always forthcoming,either
because they did not consider the subject important or
because they did not approve of the content of the
intervention. Several teachers complained that not
enough information was shared about the intervention.
Students were unanimous across both intervention
arms in their enjoyment of the activities, and equally
unequivocal that the activities and topics were inter-
esting and informative. Specifically, students praised
the activities like debates and panel discussions, story-
telling, and roleplays conducted during the whole-
school assembly; the development and display of a
monthly wall-magazine on various topics; and
organization of monthly competitions. Students also
appreciated the provision of the speak-out box, as they
could submit their concerns and complaints. However,
several students in the TSM arm said that they were
apprehensive about sharing their complaints through
the speak-out box because they were not sure how the
TSM would react. The boys from both arms suggested
including activities that would increase their participa-
tion in, and engagement with, the intervention such as
having more competitions and physical activities.
Overall, the students participating in the FGDs
described the SEHER intervention as ‘very useful’
and ‘helpful for our future careers’.
Students like us, living in villages, face multiple
problems. Many students drop out due to the poor
financial status of the family. Girls are forced to
marry before they complete their education or are
asked to sit at home to finance the education of the
male child, and so on. Many girls do not come to
school during ‘those’days [referring to menstruation]
because there is no separate toilet for girls in the
school. Our science teachers do not talk about these
topics in the classroom and ask us to read about it on
our own. Now we can directly go to the TSM or drop
a chit in the box and ask our questions, and seek
guidance. I myself have sought his advice for my
difficulties and it has helped me. (Female FGD parti-
cipant from TSM school)
In general, the students’perception of the SM was
favourable and they perceived the SM as someone who
was readily available in the school, was ‘friendly’and was
more approachable than other teachers, and because s/he
could help them in solving their issues while maintaining
the confidentiality. The TSMs were also perceived
favourably, although some students mentioned that
they were not always available and/or approachable due
to their other engagements in or out of the school. Some
students were not confident that the TSM would respect
confidentiality and share their issues with other teachers.
Table 2. Coverage of SEHER activities in pilot study (September 2014 to February 2015).
School level target
TSM arm
(n= 25) Coverage
SM arm
(n= 25) Coverage
Awareness generation
Number of assemblies addressed 4/month 246 41% 450 75%
Number of staff meetings 1/month 102 68% 144 96%
Wall-magazine
Number of issues 1/month 135 90% 144 96%
Speak-out box
Number of chits received –321 –527 –
Number of chits addressed –230 –353 –
Number of chits not addressed –91 –174 –
School Health Promotion Committee
Number of meetings 1/year 25 100% 25 100%
Workshops
Number of workshops with students 1/year 25 100% 25 100%
Number of workshops with teachers 1/year 25 100% 25 100%
Individual counselling
Number of cases (total number of students) –152 (8444) –203 (8529) –
% of students who accessed counselling –1.80 –2.38 –
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In addition, the TSMs often felt overloaded due to other
competing assignments such as teaching of regular sylla-
bus, administrative tasks, election duties, answer sheet
evaluations, etc. Their motivation was based only on
their enthusiasm; they did not get any additional pay or
benefits for this work.
Feasibility
Intervention coverage
At the beginning of the academic year, the interven-
tion team set detailed targets for intervention activ-
ities. Coverage of the monthly intervention
components was generally high in both arms
(Table 2) with the exception of awareness-generation
activities during the school assembly. This was not
organized daily in many schools until the SM/TSM
were able to persuade the headmaster to start this
practice. The acceptability of the intervention during
the latter six months (September 2014 to February
2015), was reflected by the high number of submis-
sions to the speak-out box and the number of stu-
dents who have availed counselling services. The
coverage of some intervention activities was higher
in SM than TSM schools. For example, the SM
schools conducted more whole-school assembly
activities (75% versus 41%) and staff meetings (96%
versus 68%) than TSM schools. Similarly, the SM
schools received more chits through the speak-out
box (527 versus 321) and more students accessed
counselling services in these schools than the TSM
schools (2.38% versus 1.80% of the total student
population). These quantitative indicators were con-
sistent with qualitative data and helped in identifying
facilitators of, and challenges to, intervention
delivery.
Facilitators to intervention delivery
Students described the participatory nature of the
activities, availability of platforms such as the speak-
out box and the peer groups to raise their concerns,
recognition of contributors to the wall-magazine or
daily assembly, redressal of students’complaints or
problems while maintaining the confidentiality as the
facilitators to the engagement with intervention com-
ponents. Other key factors in the high-performing
schools were the engagement and support of the
headmaster, ownership and participation of other
teachers, and ongoing training and continuous pro-
fessional support through supervisory and, once each
month, day-long meetings for the SMs and TSMs. In
the TSM schools, the monthly ‘unplanned’supervi-
sory visit was not serving its purpose as the TSMs
were often unavailable due to their competing teach-
ing responsibilities. Consequently, the monthly
unplanned supervisory visit per month was changed
to a planned visit to lend more support to the TSMs
in completing their targeted activities. The SMs and
TSMs mentioned that the monthly group meetings
increased their confidence in implementing SEHER
activities, provided a platform to discuss school-level
challenges and generate solutions, and served to
motivate them. The supervisors mentioned that
intense monitoring and supervision of the interven-
tion was one of the factors that helped in quickly
identifying bottlenecks in the delivery and addressing
these.
Barriers to whole-school level activities
Common barriers to the delivery of the whole-school
level activities included lack of engagement of tea-
chers in SEHER activities, lack of boys’participation,
negligible participation of parents in school govern-
ance and day-to-day proceedings, and a fall in stu-
dents’attendance after mid-December/early January
once government incentives for attendance were dis-
bursed. The lack of teacher engagement was
addressed through a regular monthly meeting with
the school staff to review the previous month’s activ-
ities and plan for the upcoming month. In addition,
all the teachers, instead of a few representatives, were
invited to be a part of the School Health Promotion
Committee. This increased the engagement of the
headmaster and teachers, and moved the ownership
of the intervention to the teacher community. Male
student involvement was improved through expand-
ing the scope of the peer-group and wall-magazine
activities through school-wide monthly competitions
(e.g. on elocution and drawing), and increasing the
number of peer groups from one for the entire grade
to one for each division of the grade (on average,
there were two to four classes of grade IX in each
school). The challenge of the fall in attendance led to
increased focus on completing all core intervention
components between June and January. One barrier
that the intervention was unable to address was the
low participation of parents, reflected in the very low
attendance in the annual workshop on ‘handling
adolescents’, despite multiple efforts including letters,
phone calls, and personal visits; this resulted in drop-
ping the annual workshop with parents from the
intervention.
The barriers to the delivery of whole-school activ-
ities were different in the SM or TSM schools. One of
the TSM schools opted out after completing the pilot
study as the school management committee perceived
the reproductive sexual health content of the inter-
vention unacceptable for the secondary students. In
three SM schools, headmasters and senior teachers
felt that the SMs were not equipped to facilitate such
an intervention as they were younger than the tea-
chers in the school, did not have appropriate educa-
tional qualifications or experience to work in the
school setting, and were perceived as external to the
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school. This feeling was stronger in those schools
where the SMs shared with the headmasters that
students complained about the disciplinary practices
of some teachers. This challenge was addressed by
including an annual workshop for the teachers on
‘discipline practices’and through engagement with
all teachers in the intervention, as described earlier.
This resulted in reducing the performance anxiety of
the SMs and improving other teachers’participation
and support in the intervention activities.
Barriers to group-level activities
The barriers observed in organizing peer group activ-
ities included the responsible peer group member not
fulfilling their duties, unclear understanding of the
group’s objectives and role, hesitance to participate in
mixed-gender group activities, and irregular atten-
dance at the group meetings. These barriers were
addressed through highlighting the importance and
role of such groups to the members in the monthly
meetings. The participation of group members
increased gradually due to enhanced diversity and
frequency of the intervention activities –such as
celebration of important days related to health, orga-
nization of monthly competitions, and a school-level
cleanliness drive.
Barriers to individual-level activities
In most schools, girls were unwilling to consult male
SM/TSMs for counselling services. As it was not
feasible to provide SM/TSMs of both genders in
each school, female students were encouraged to con-
tact a female teacher in the school to discuss the
sensitive issues if they did not wish to consult the
male SM/TSM. Through the awareness-generation
meetings during the daily assembly, the SM/TSMs
assured students of confidentiality and wherever pos-
sible made a private space available for a confidential
counselling session. A key barrier observed in TSM
schools was the TSM’s inability to switch swiftly
between the role of a teacher and counsellor; some
students felt uncomfortable or uncertain about seek-
ing counselling from the TSM on matters that may be
perceived as sensitive or concerning the school
environment.
Discussion
The evidence base for the design and sustainable
delivery of school health promotion interventions
from low- and middle-income countries is limited.
This paper describes the development and piloting of
the SEHER intervention in the state of Bihar, one of
the most socio-economically disadvantaged states of
India. Our goal was to design a health promotion
intervention that extended the ongoing classroom
based life skills programme (called TARANG in
Bihar) with the ultimate objective of evaluating its
effectiveness against the TARANG in government-
run secondary schools. Our methodology was aligned
with the approach recommended by the MRC frame-
work for the design and evaluation of complex inter-
ventions [11] and involved three stages of evidence
synthesis, formative research, and a pilot study.
The existing literature, the vast majority of which
is from high-income countries, shows that whole-
school and multicomponent interventions have
more potential for health promotion than purely
classroom-based curricula and that the provision of
a health promotion coordinator increases social con-
nectedness, reduces health risks, and increases physi-
cal activity among students [16,18,19,34]. Our study
builds on this evidence in several ways: first, the
SEHER intervention emphasizes the mediating role
of school climate in improving health and health-
related outcomes among adolescents; second, we
demonstrate that a range of participatory delivery
methods –including daily school assembly-based
activities, within-school competitions, wall-magazine,
speak-out box, and school health promotion commit-
tee –enhances the acceptability of the intervention;
third, the role of the health promotion coordinator
can be played by either existing teachers or lay coun-
sellors (low-cost additional human resource); fourth,
better coverage and acceptability of some interven-
tion activities (e.g. weekly assembly activities and
counselling) are observed in the lay counsellor arm
than the teacher arm, but as the latter involves less
cost, a comparison of these delivery arms on out-
comes and costs is required to inform policymakers
of the relative advantages and limitations of each
delivery model; and finally, the participatory nature
of intervention activities, availability of platforms to
raise students’concerns, redressal of students’com-
plaints while maintaining confidentiality, engagement
and support of the headmaster, and involvement of
other teachers in intervention activities are key
requirements for acceptability and feasibility.
A key outcome of this process was a recognition of
the complex pathways through which such multicom-
ponent interventions exert their ultimate effects on
health outcomes and the crucial role of intermediary
outcomes, notably school climate, in this pathway
(Figure 1). Thus, the stages of the intervention devel-
opment moved the theory of the intervention from
directly influencing the student health outcomes to
engaging the school community in building the
school climate, which then plays a mediating role in
facilitating positive health outcomes. Identification of
these pathways also influenced the choice of primary
outcomes within the relatively short period available
for a definitive randomized controlled trial. The
intervention framework extended the narrow view
of school health as primarily focused on classroom
10 S. SHINDE ET AL.
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curriculum or health education to the broad, multiple
strategies of policy, improving the school’s physical
and psychosocial environment and providing a range
of services –all with participation of headmaster,
teachers, and students, and coordinated by a health
promotion coordinator in the form of a teacher or lay
counsellor. These findings are consistent with the
evidence which shows that the participation of tea-
chers, family, community members, and students in
the design and implementation of the programme,
and the use of participatory, active learning techni-
ques where young people have the opportunity to
practice or demonstrate specific skills, are key drivers
of the acceptability and feasibility of a school health
promotion intervention [7]. Similarly, individuals
who strongly support and advocate for a programme
have often been cited by the education and health
agencies as among the primary reasons they have
been able to implement innovative programmes
[35–38]; in our study, the leadership of school prin-
cipals was a key factor in the successful implementa-
tion of the intervention and facilitating the
engagement of the wider school community.
Conclusions
The relationship between school enrolment, participa-
tion, and improved health outcomes is well established
[7]. With rapid extensions to education in many devel-
oping countries, including in South Asia [39], second-
ary schools have the potential to be an important
platform for health promotion and prevention.
However, most evidence about the effectiveness of mul-
ticomponent HPS interventions for behaviour changes
is from developed countries or settings in middle-
income countries where schools are relatively better
resourced, with relatively high levels of literacy and
social inclusion [8,13–15,30]. The SEHER intervention
builds on this evidence and was designed for the most
poorly resourced educational sector in a population
with very low human development indices. Following
a systematic methodology, we have attained our goal of
developing an intervention that is acceptable to various
stakeholders, feasible to deliver, is designed to be scal-
able, and has a clear Theory of Change in which influ-
encing school climate lies at the heart of achieving
desirable long-term behavioural and health outcomes.
The SEHER intervention development process also lar-
gely confirmed the acceptability and feasibility of the
components of the intervention as originally developed
and piloted in the relatively more advantaged state of
Goa to the Bihar context, indicating their generalizabil-
ity to the widely varying socio-cultural settings of
schools in India. The resulting intervention, delivered
either by a teacher or a lay school counsellor, is now
being evaluated in a cluster randomized controlled trial
(NCT02484014). If either delivery arm is found
effective and cost-effective, it has the potential to be a
model for promoting health and well-being in other
low-resource school settings.
Acknowledgments
We are grateful to the Department of Education,
Government of Bihar, and the students, teachers and staff
of the 75 secondary and higher secondary schools who
participated in the study in Bihar. We also thank Anju
Sinha from Gramin Evam Nagar Vikas Parishad, Sudipta
Mukhopadhyay, and Deepti Priya Mehrotra, independent
researchers in adolescent health, for reviewing the standard
operating procedures of the intervention components. We
are grateful to Luiza Lobo and Rashmi Mishra, who
assisted in the intervention development procedures. VP
is supported by a Wellcome Trust Senior Principal
Research Fellowship in Clinical Science. GP is supported
by a National Health & Medical Research Council Senior
Principal Research Fellowship.
Author contributions
VP is the principal investigator of the SEHER project, SS is
the research manager and led the intervention development
with PK. SS, BP, PK, and AS conducted all intervention
development activities and data analysis. GP, DR and HW
are co-investigators and advisors to the project. The first
draft of the paper was written by SS. All authors read,
contributed to and approved the final manuscript.
Disclosure statement
No potential conflict of interest was reported by the
authors.
Ethics and consent
The study received ethical clearance from the Institutional
Review Boards at the London School of Hygiene and
Tropical Medicine, UK and Sangath Centre, India.
Written informed consent was obtained from all study
participants.
Funding information
We declare that we have no conflicts of interest. The
SEHER project is jointly funded by the John D. and
Catherine T. MacArthur Foundation, USA, and United
Nations Population Fund, India.
Paper context
In this paper, we report on the development and piloting of
a multicomponent school-based health promotion inter-
vention in secondary schools in Bihar, India. Evidence
from systematic reviews, formative research, and a pilot
test in 50 schools led to the design of the SEHER interven-
tion, which focused on promoting school climate to build
social skills among adolescents, engage adolescents in
school decision making, provide factual information on
health and its determinants, and enhance problem-solving
skills. Specific intervention strategies were delivered at
GLOBAL HEALTH ACTION 11
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three levels (whole school, student group, and individual
counselling) and coordinated by either a trained teacher or
a lay counsellor. The intervention showed generally good
acceptability and feasibility of the intervention. We are
evaluating the effectiveness and cost-effectiveness of these
two delivery models in a cluster-randomised trial in Bihar.
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