Overview

SEHER (Strengthening Evidence base on scHool-based intErventions for pRomoting adolescent health) is a study conducted in a three-arm cluster randomized controlled trial (RCT) with an embedded pilot study in 75 secondary schools in Bihar, India, from 2013 to 2017. It aimed to assess the effectiveness and cost-effectiveness of two delivery models of a school-based intervention, SEHER, promoting reproductive and sexual health, gender equity, and mitigating gender-based violence. SEHER was delivered by lay counsellors (SEHER Mitra) and teachers (teacher-as-SEHER Mitra) compared to the government-led Adolescence Education Programme.

Results indicated that the lay counsellor-led intervention significantly improved school climate, bullying, violence, depression, and gender equity attitudes compared to the control and teacher-led arms. Teacher-led intervention showed no significant effects. Process data revealed higher coverage in the lay counsellor arm. Qualitative analysis suggested factors contributing to the teacher-led arm's ineffectiveness, including limited collaboration, time constraints, and hierarchical dynamics.

The additional cost of the lay counsellor intervention was $3213 per school per year, about 10% of the annual per student expenditure in Bihar. These findings underscore the effectiveness and feasibility of lay counsellor-led interventions in schools for improving student well-being and school climate at a relatively low cost.

Rationale

Adolescence, a transitional period between childhood and adulthood is the critical phase of life when risk behaviours for adverse health outcomes, both during adolescence and in later adult life, are established. Healthy attitudes and behaviours during these formative years are considered a priority for health promotion interventions across a range of health outcome domains. In this context, schools have been recommended as a key platform for health promotion interventions in children and young people. This is the basis of the World Health Organization’s ‘Health Promoting Schools’ framework, an approach to promoting health in schools that addresses the whole school environment. A systematic review of HPS effectiveness showed evidence of effects on body mass index, physical activity, dietary habits, cigarettes consumption, and being bullied.  However, most studies are from high income countries.

In India, there has been a substantial investment in a variety of school-based health promotion interventions however, they have mostly focused on single health outcomes (such as reproductive and sexual health) and on provision of information as the primary intervention.

Progress till date

SEHER developed a scalable, manualised intervention delivered by lay counsellors, significantly benefiting secondary school adolescents in Bihar. It improved school climate and health outcomes like depression, bullying, violence, and gender equity attitudes. The intervention, featured in UNICEF's 2021 report, impacted 56,000 students in 75 schools, with 150 trained deliverers and research support from an embedded PhD project. SEHER's response to the Covid-19 pandemic included tele-counselling. Partnerships have extended to Karnataka and Maharashtra, scaling to 100+ government schools and tribal Ashramshalas, and adapting the intervention in Karnataka through the SAMA study. SEHER produced three peer-reviewed papers.

Partner/s

• London School of Hygiene and Tropical Medicine, London, UK

• Department of Education, Government of Bihar, India

• Public Health Foundation of India (PHFI), India