PATEL SHINDE RAJARAMAN

School Health Promoti on: Case Studies from India off ers evidence-based insights and recommenda ons to those engaged in addressing the social determinants of health at the school level. The book provides an overview of school health SSCCHHOOLOOL promo on and adolescent health in India, and presents case studies of four programmes: SHAPE, UDAAN, Drishti and Prayatna. Together, these programmes cover seven states of India, and are characterised by diff erent types of human resource delivery, levels of engagement with the school and students, and systems HHEEAALTLTH for monitoring and supervision. The case studies provide valuable lessons for strengthening exis ng programmes and developing new approaches. The target audience includes educa on and health policy-makers, administrators, PPROMOTIOROMOTION researchers and prac oners in government, academic ins tu ons, funding agencies, non-governmental organisa ons and civil society.

BYWORD BOOKSTM ` 595

SCHOOL HEALTH PROMOTION CASE STUDIES FROM INDIA ii SCHOOL HEALTH PROMOTION CASE STUDIES FROM INDIA

EDITED BY

DIVYA RAJARAMAN SACHIN SHINDE VIKRAM PATEL © Divya Rajaraman, Sachin Shinde and Vikram Patel 2015

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers.

First published 2015

ISBN 978-81-8193-123-8 (print version) ISBN 978-81-8193-090-3 (e-book version)

Cover design: Netra Shyam Typesetting: Shailesh Mishra

Published by Byword Books Private Limited GF-15, Virat Bhavan Mukherjee Nagar Commercial Complex Delhi 110009, India; Phone: 011-47038040 email: [email protected] website: www.bywordbooks.in

Printed at Replika Press Private Limited, Kundli 131028, India Contents

Preface...... ix Editors and contributors...... xiii Abbreviations...... xix

1. School-based adolescent health promotion: The evidence and context.....1 Divya Rajaraman, Sachin Shinde, Vikram Patel ...... 1 ...... 2 • Introduction ...... 4 • School-based adolescent health promotion: The global context ...... 7 • Adolescents and school health promotion: The Indian context ...... 11 • Selection of school health promotion programmes for case studies ...... 13 • The case study methodology 2. The • Structure SHAPE ofprogramme this book ...... 14 Divya Rajaraman, Prachi Khandeparkar, Achira Chatterjee, Vikram Patel ...... 14 ...... 16 • The Setting: Goa ...... 23 • The School HeAlth Promotion and Empowerment (SHAPE) programme ...... 28 • The SHAPE Case Study Evaluation ...... 31 • Acceptability ...... 35 • Feasibility ...... 40 • Evidence of impact 3. The • Summary UDAAN programme...... 44 Divya Rajaraman, Bhargav Bhat, Vinita Nathani, Aparajita Gogoi ...... 44 ...... 46 • The Setting: Jharkhand ...... 54 • The UDAAN programme ...... 58 • The UDAAN Case Study Evaluation • Acceptability vi contents

...... 61 ...... 69 • Feasibility ...... 73 • Evidence of impact 4. The • Summary Drishti programme...... 76 Sachin Shinde, Divya Rajaraman, Mahtab Alam Siddiqui, Dilreen Kaur ...... 76 ...... 78 • The Setting: Rajasthan ...... 82 • The Drishti programme ...... 87 • The Drishti Case Study Evaluation ...... 90 • Acceptability ...... 96 • Feasibility ...... 102 • Evidence of impact 5. The • Summary Prayatna programme...... 105 Sachin Shinde, Divya Rajaraman, Jaya, Gracy Andrew ...... 105 ...... 107 • The Setting: Multiple states in India ...... 114 • The Prayatna school-based counselling programme ...... 117 • The Prayatna Case Study Evaluation ...... 121 • Acceptability ...... 129 • Feasibility ...... 130 • Evidence of impact 6. Conclusion • Summary ...... 132 Divya Rajaraman, Sudipta Mukhyopadhyay, Sachin Shinde, Vikram Patel ...... 132 ...... 136 • Key features of the school health promotion case study programmes ...... 138 • Impact of the school health promotion case study programmes ...... 145 • Key considerations for school health promotion interventions Appendix • Summary A. Partner questionnaire on school health promotion programmes...... 148 B. Summary of responses to school health promotion programme questionnaires...... 150

References...... 156 List of tables

Table 1.1. Key characteristics of programmes selected for school health promotion case studies...... 9

Table 2.1. Socio-demographic and health indicators of Goa...... 15 2.2. The SHAPE intervention...... 19 2.3. SHAPE classroom programme: Topics covered in different grades...... 24 2.4. Documents reviewed for SHAPE evaluation...... 25 2.5. Coverage of the SHAPE intervention activities in all schools, 2009–11...... 33 2.6. Characteristics of counselling cases...... 39

Table 3.1. Socio-demographic, economic and health indicators of Jharkhand...... 45 3.2. The UDAAN syllabus...... 52 3.3. Documents reviewed for the UDAAN case study...... 55 3.4. Respondents interviewed for UDAAN end-line qualitative evaluation...... 58 3.5. Indicators of KAP across UDAAN evaluations...... 70

Table 4.1. Socio-demographic and health indicators of Rajasthan...... 77 4.2. The Drishti syllabus...... 81 4.3. Documents reviewed for the Drishti case study...... 83 4.4. Interviews conducted for end-line qualitative evaluation...... 86 4.5. Schools and students included in the KAP assessments...... 97 4.6. Changes in perceptions about gender roles and stereotypes and substance abuse before and after the intervention...... 99 viii list of tables

Table 5.1. Health indicators of Prayatna states and India...... 107 5.2. Educational indicators of five states and India...... 108 5.3. Prayatna programme: Training curriculum...... 113 5.4. Prayatna reports included in case study document review...... 115 5.5. Respondents interviewed for end-line qualitative evaluation...... 117 5.6. Participation in the Prayatna programme trainings...... 122 5.7. Average scores obtained by staff nurses at pre- and post-orientation training...... 123 5.8. Mean scores obtained by staff nurses during assessment of counselling skills at second round of refresher training...... 126

Table 6.1. Comparison of key characteristics of four school health promotion programmes...... 133 6.2. Comparison of four school health promotion programmes in India: Evidence of impact...... 137

Preface

Approximately a third of the Indian population is between the ages of 10 and 24 years. Young people face a range of health concerns and risks that may affect their long-term health and well-being, but have limited routine contact with health facilities. Given the well-documented mutually reinforcing positive relationship between education and health, and the rising rate of school enrolment in India, there is great potential for schools to serve as a platform for promoting adolescent health. In its National Health Policy of 2002, the Government of India recognised that schools can play an important role in improving the health of young people through the provision of health information and services. Governmental and non-governmental agencies are supporting a range of school-based programmes to improve health. These include the school Mid-day Meal Programme, state-sponsored School Health Programmes and the Adolescence Education Programme (AEP), the focus of which is on reproductive and sexual health education and building life skills. To make the best use of the resources available and scale up the school health promotion strategies that offer the greatest value to society, it is critical to build the evidence base in terms of what works, in which contexts and under what conditions. A comparison of the programmes currently under implementation can shed light on the most successful components of different models, and provide valuable lessons for those attempting to strengthen existing programmes and develop new approaches. School Health Promotion: Case Studies from India offers evidence-based insights and recommendations to those engaged in addressing the social determinants of health at the school level. The target audience includes education and health policy- makers, administrators, researchers and practitioners in government, x preface academic institutions, funding agencies, non-governmental organisations and civil society. The book starts with an overview of school health promotion and adolescent health in India, followed by an account of the methodology used for the case studies and brief descriptions of the four programmes discussed: SHAPE, UDAAN, Drishti and Prayatna. These programmes cover mixed geographical areas, spanning seven states. They are characterised by different types of human resource delivery (a lay fulltime school health counsellor, trained school teachers and trained school nurses); different levels of engagement with the school and students (intense multi-level programmes, classroom-based programmes and individual counselling services); and different levels of supervision. The resource implications are different in each case and there are variations in scale (from a pilot programme covering 10 schools to a state-wide programme covering over 2000 schools). Two programmes cover the basic AEP syllabus, while the other two include a component of individual counselling services for students. Some programmes are delivered in regular day schools and others in residential schools. All the programmes are delivered in government or government-aided schools, and receive technical assistance from a non-governmental partner. Each case study is presented as a separate chapter, starting with a review of the history, current implementation and content of the programme. The sources of information for the evaluation are summarised, and the findings are discussed in relation to acceptability, feasibility and evidence of impact of the programme. Each of the chapters on the case studies ends with a summary of the key findings. The final chapter compares the four programmes in terms of their content, mode of delivery, acceptability, feasibility and evidence of impact. It highlights major issues brought to the fore by the case studies and offers recommendations for future programming and further generation of evidence. We would like to acknowledge the support from the MacArthur Foundation to undertake this initiative to build evidence on adolescent school health promotion. We would also like to thank the CEDPA, Ritinjali and UNFPA for developing the case studies in partnership with us. At Sangath, we thank Prachi Khandeparkar, who coordinated this project with great good humour, and Sandra Travasso and Suraj Parab for their contributions in data collection and analysis. We are grateful to Sudipta preface xi

Mukhyopadhyay for providing valuable insights and inputs on the first draft of the book. We also thank the many programme stakeholders for sharing their experiences and perspectives with us, and the government officers and school management who facilitated the evaluations. Finally, we express our admiration for the dedication of all the people involved in developing and delivering school health promotion programmes in India.

and October 2014 Divya Rajaraman, Sachin Shinde Vikram Patel

Editors and contributors

EDITORS

Dr Divya Rajaraman

Divya Rajaraman has been working in health research, programme development, and implementation since 2001. She has worked for academic institutions and UNICEF (in partnership with governments and NGOs), on a range of projects in India and sub-Saharan Africa. Her work has included evaluating health and hygiene promotion interventions, assessing health service delivery and access to services, and programming for HIV treatment and care. Divya has a master’s degree in Development Studies and a doctoral degree in Social Policy from Oxford University. She is currently an assistant professor in the Department of Nutrition, Food Studies and Public Health at New York University.

Sachin Shinde

Sachin Shinde holds a Master of Public Administration in Health Economics and Policy Analysis from the New York University in New York City, USA, and Master of Arts in Organizational Psychology from the University of Pune, India. He works as the Research Director for SEHER Project which is aimed at developing evidence base on school-based health promotion programmes among adolescents in Bihar, India. Sachin is trained in both quantitative and qualitative research methods and has about 12 years of research experience in planning, execution, monitoring and management of various projects xiv editors and contributors related to health and development. His primary research interests include social determinants of health, and developing and evaluating complex interventions aimed at preventing and promoting health among adolescents. He has extensive experience working with state and national governments, national and international NGOs, grassroots organizations, and a wide range of stakeholders on programme development, implementation and evaluation.

Dr Vikram Patel

Dr Vikram Patel is a Professor of International Mental Health and Wellcome Trust Senior Research Fellow in Clinical Science at the London School of Hygiene and Tropical Medicine (UK). He is the Joint Director of the School’s Centre for Global Mental Health (www.centreforglobalmentalhealth.org). He is also the Co-Director of the Centre for Chronic Conditions and Injuries at the Public Health Foundation of India. He is a co-founder of Sangath and member of its Managing Committee. He serves on the Ministry of Health (Government of India) Mental Health Policy Group and National Rural Health Mission ASHA Mentoring Group. He also serves on the WHO’s Expert Advisory Group for Mental Health and the Technical Steering Committee of the Department of Child and Adolescent Health. He was elected as a Fellow of the Academy of Medical Sciences of the UK and won the Chalmers Medal from the Royal Society for Tropical Medicine and Hygiene in 2009. His book Where There Is No Psychiatrist (Gaskell, 2003) has become a widely used manual for community mental health in developing countries. He is a Commissioner for the Lancet Commission on Adolescent Health.

CONTRIBUTORS

Gracy Andrew

As CorStone's Country Manager in India, Gracy Andrew oversees local programme implementation, quality control and certification, and impact assessments. She is a clinical psychologist by profession. She has also been trained at the London School of Hygiene and Tropical Medicine in Sexual and Reproductive Health Research. Before joining CorStone, she served as an Executive Director of Sangath Goa. At Sangath, she established the editors and contributors xv organization's branch in the south of Goa and was involved in several studies related to adolescent health, including the Prayatna programme, one of the case studies of this book. She is a co-author of several publications such as the Adolescent Health Needs Study, Teacher’s Toolkit, Barefoot Counselling Manual and many scientific papers.

Bhargav Bhat

Bhargav Bhat, associated with Sangath for the past 10 years in different capacities, works currently as a Data Manager. He has recently completed an MSc in Public Health from the London School of Hygiene and Tropical Medicine, UK. He also has a master’s degree in Economics and a postgraduate diploma in Human Resource Management from Goa University.

Achira Chatterjee

Achira Chatterjee has a background in Clinical Psychology and has worked across mental health projects in India and Australia. Her area of interest is school health and she is currently the Head of the Department of Psychology and counsellor for a school in Bengaluru, Karnataka.

Dr Aparajita Gogoi

Dr Aparajita Gogoi is the Executive Director of CEDPA (the Center for Development and Population Activities), India and National Coordinator, the White Ribbon Alliance for Safe Motherhood, India. In CEDPA India she works to improve the lives of girls, women and young people by empowering them with skills to build better lives. Aparajita is a political scientist; she has over 20 years of extensive experience in programme management, with expertise in designing and implementing programmes, advocacy campaigns, and defining approaches and strategies for policy issues in population, especially safe motherhood and young people’s health and rights. She holds a PhD (International Politics), Jawaharlal Nehru University, New Delhi and a postgraduate diploma in Journalism. She has been accorded recognition for her work in various forums—on 8 March 2011, Guardian, UK, marked International Women’s Day by selecting 100 of world’s most inspiring xvi editors and contributors women, and Aparajita was named as one of these 100 women. In 2010, at the “Women: Inspiration and Enterprise” Symposium hosted in New York City by Sarah Brown, Donna Karen and Arian Huffington, Aparajita was given the WIE Humanitarian Award for her good work on behalf of humanity that help make our world a better place.

Dr Jaya

Dr Jaya is a National Programme Officer, Adolescent Reproductive and Sexual Health at United Nations Population Fund’s, Delhi office (2008 onwards). She earned a master’s (2000–01) and doctorate in public health (2001– 05) at Johns Hopkins Bloomberg School of Public Health. Jaya trained as a physician (1986–91) at Delhi University and has a postgraduate diploma in community health administration (1994–96), also from Delhi University. She is interested in studying transitions to adulthood from both a physiological and sociological perspective to enable young people to respond to real-life situations effectively. Over the next few years, Jaya would like to contribute towards generating and consolidating the evidence from existing pilots and programmes to strengthen the agenda of youth-friendly research, programmes and policies in India.

Dilreen Kaur

Dilreen Kaur is the Director of Ritinjali since March 2014. She has worked as an Editor with Oxford University Press (OUP) for several years where she was responsible for developing the Humanities and Social Sciences list. Her work focused on gender, sexuality, education and culture. In 2000 she joined Learn Today, the learning division of the India Today Group where she played a key role in setting up a unit for publishing and printing affordable texts for classrooms. She has designed effective professional development programmes for practitioners in government and private schools across the country. Simultaneously she has been involved with the non-profit sector designing curriculum, training school heads and teachers on life skills, gender and sexuality issues, compassionate communication, and best practices in education. She has been involved in developing school improvement programmes aimed at rejuvenating and improving the quality editors and contributors xvii of learning and teaching in government schools in Rajasthan, Delhi, Punjab and Bhutan. With the coming of the Right to Education Act (2010), she is actively involved in designing and developing projects to address issues of enrolment and retention in schools in the National Capital Region. She is also keenly engaged with developing monitoring and evaluation frameworks to assess the existing teacher education institutes across the country, through her involvement with the NCTE.

Prachi Khandeparkar

Prachi Khandeparkar is a Clinical Psychologist by profession and currently leads the adolescent health programme at Sangath. She has been working with Sangath in various capacities for the past 15 years. Her work primarily involves developing and evaluating interventions for children, youth and families. Currently, she is managing the SEHER trial in Bihar. She has conducted numerous workshops and trainings for parents, teachers and professionals. She was a member of the Goa State Commission for Children and the Juvenile Justice Board (JJB), under the Juvenile Justice (care and protection) amended Act 2006. She is also a member of the sexual harassment at workplace committee for various institutions and organizations in Goa. She is also a member of the counselling cell for the Goa Education Development Corporation (GEDC).

Sudipta Mukhopadhyay

Sudipta Mukhopadhyay is an experienced development professional with 18 years of experience working on rights, gender, sexuality, advocacy and health service delivery in the South Asia region. She has worked extensively on youth and women’s development issues in South Asia.

Vinita Nathani

Vinita Nathani is the Senior Advisor (Youth) at CEDPA, India. She holds a master’s degree in Social Work from the Department of Social work, University of Delhi and is responsible for visioning, planning and managing the youth portfolio at CEDPA. She has over 28 years of experience in the xviii editors and contributors development sector with a major focus on youth development, sexual and reproductive health and rights, gender issues, sexuality, community participation and civil society engagement. She has a proven track record of leading a non-profit oriented development organisation (PRERANA) for over 12 years. She has experience of working at district, state and national levels in close collaboration with government counterparts, local NGOs and CBOs, CSO networks, service delivery agencies and a wide range of stakeholders for programme management, research within programme implementation, policy advocacy, capacity building and institutional partnerships.

Mahtab Alam Siddiqui

A postgraduate in Sociology from Patna University, Patna and Master in Business Administration (MBA) in Human Resource Management, Mahtab Alam Siddiqui is working with Ritinjali since 2005 as a State Coordinator for Drishti in Rajasthan. Mahtab Alam Siddiqui’s expertise lies in micro finance, life skills, gender sensitization and monitoring and evaluation. Mahtab has experience of working in the development sector for more than 11 years. Before joining Ritinjali, Mahtab was working as a Monitoring Officer in Agricultural Finance Corporation (AFC), New Delhi and has monitored more than 50 NGOs under different projects like Swa-Shakti (Rural Women Development and Empowerment Project) funded by IFAD, Government of India’s Rashtriya Mahila Kosh Project, and different projects run by the Ministry of Rural Development, Government of India. Abbreviations

ABE Archdiocesan Board of Education AEP Adolescence Education Programme AIDS acquired immunodeficiency syndrome ARSH adolescent reproductive and sexual health BLP Better Life Options Programme BMI body mass index CBSE Central Board of Secondary Education CEDPA Centre for Development and Population Activities DEO district education officer EIT economic information technology FGD focus group discussion GCHS Goa College of Home Sciences GDP gross domestic product HEPI Higher Education Policy Institute, UK HIV human immunodeficiency virus HRD human resource development JNV Jawahar Navodaya Vidyalaya JSACS Jharkhand State AIDS Control Society KAP knowledge, attitude and practice KGBV Kasturba Gandhi Balika Vidyalaya MIS monitoring information system NACO National AIDS Control Organisation NGO non-governmental organisation NRHM National Rural Health Mission NVS Navodaya Vidyalaya Samiti xx abbreviations

SACS State AIDS Control Society SAEP School AIDS Education Programme SCERT State Council of Educational Research and Training SHAPE School HeAlth Promotion and Empowerment SHARP School Health Annual Report Programme SHC school health counsellor SHPAB School Health Promotion Advisory Board STI sexually transmissible infection UNESCO United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Population Fund UNICEF United Nations Children's Fund VIMHANS Vidyasagar Institute of Mental Health, Neuro & Allied Sciences 1

School-based adolescent health promotion:Divya Rajaraman, SachinThe Shinde,evidence Vikram Pateland context

Introduction Adolescence, the transition period between childhood and adulthood, is marked by intense physical, psychological and social changes. The UNICEF 2012 report on the global status of adolescent well-being highlights a number of risks to adolescent health and well-being [1]. For example, approximately 11% of pregnancies occur among girls who are 15–19 years old, an age group in which the risk of birth complications and maternal mortality is high; about 2.2 million adolescents (60% of whom are female) are infected with human immunodeficiency virus (HIV); and adolescent girls who are in relationships commonly experience sexual and domestic violence. Recent data indicate that there has been a rise in the number of adolescents dying of HIV, despite the reductions in HIV mortality among children and young adults [2]. The provision of effective education and healthcare, appropriate social policy, and mechanisms for family and community support are essential for adolescents to make a transition to a healthy, happy and productive adult life. India is home to about 243 million adolescents, a fifth of the world’s adolescent population [1]. As in other parts of the world, adolescents in India face a range of sexual and reproductive health risks, such as sexually transmissible infections (STIs), early marriage, adolescent pregnancy and sexual abuse [3]. In recognition of the need to improve adolescent health, the Indian government launched a national strategy (Rashtriya Kishor Swastha Karyakram) in January 2014 with the aim of strengthening the 2 d. rajaraman, s. shinde, v. patel provision of information and services to fulfil the specific health needs of adolescents [4]. The strategy, which targets the age groups of 10–14 years and 15–19 years, envisions that all adolescents should be able to realise their full potential by making informed and responsible decisions related to their health and well-being. The realisation of these goals will require concerted multi-sectoral efforts, involving several ministries, as well as development partners, civil society and communities. While there is a growing evidence base for community-based strategies to improve the health of young people in India [5], there is a lack of information on feasible and effective school-based models for promoting adolescent health. The introduction of sex education in schools through programmes for HIV prevention in the 1990s led to the launch of the Adolescence Education Programme (AEP) by the Ministry of Human Resource Development, Government of India. This has formed a basis for school health promotion programmes in many parts of the country. However, the different models of delivery and experiences with the implementation of these schemes through schools have not been described adequately and the existing descriptions do not suffice to inform discussions on the future direction of health promotion for young people. This book presents case studies of four school-based health promotion programmes in India, with a view to identifying the lessons learnt and gathering insights that may prove useful for future initiatives in this sphere. The four programmes featured in this book are the UDAAN programme in Jharkhand, the Drishti programme in Rajasthan, the SHAPE programme in Goa, and the Prayatna programme, which was delivered in Bihar, Maharashtra, Madhya Pradesh, Orissa and Rajasthan. This chapter provides an overview of school-based adolescent health promotion, both globally and in India. The overview is followed by a description of the methodology used for selecting the programmes and conducting the case studies.

School-based adolescent health promotion: The global context A strong focus on adolescent health promotion is critical to achieving the global health goals of eliminating HIV/AIDS, improving maternal, infant, sexual and reproductive, and mental health, and preventing injuries and non-communicable diseases [6]. The reproductive health of adolescents school-based adolescent health promotion 3 will be critical for achieving the Millennium Development Goals [7]. However, adolescents are often excluded from health interventions, which are targeted either towards younger children or adults. Given the rising rates of enrolment in secondary school across the world, and the fact that school-going adolescents spend about a third of their waking hours in school or engaged in school-related activities [8], schools provide a highly effective platform to reach young people. There is a well-established bi-directional relationship between education and health. Extensive research evidence indicates that more education results in better physical and mental health, and healthier behaviours [9–12]. At the same time, healthy students learn better. Good health improves school attendance and enrolment in schools. It also improves cognition and development, and ultimately, educational attainment [13,14]. The earliest school health programmes date back to the early 20th century, when feeding programmes were introduced in industrialised countries as a form of social protection. In 2000, the World Education Forum in Dakar emphasised the importance of school health and nutrition programming in attaining the goals of “Education for All” [13]. This strengthened the commitment to introduce programmes for school health, and the percentage of countries implementing such programmes rose from 8% to 44% in sub-Saharan Africa and from 45% to 73% in South and South-east Asia between 2000 and 2007 [15]. Today, school health programmes across the world are providing health information, promoting healthy behaviours, building healthy environments and delivering health services [13,14,16–22]. There is already substantial evidence of the effectiveness of feeding and supplementation programmes, which have improved the students’ nutritional status and cognition, and have led to an increase in school enrolment and attendance [23]. Deworming programmes can easily be implemented by non-healthcare professionals, and have proved to be highly effective in reducing absenteeism, decreasing anaemia and improving learning [13,14]. Huge efforts are also being made to improve water, sanitation and hygiene at schools. There is growing evidence of the positive impact of this on the students’ health and education: there has been a reduction in the incidence of diarrhoea, worm infestation and respiratory infections, and an improvement in school attendance, especially among adolescent females who require sanitation facilities during their periods [24]. A major component of school health promotion 4 d. rajaraman, s. shinde, v. patel programming is the provision of the information and skills that students need to live healthier, safer and happier lives [25–28]. Education on health and life skills and mental health programmes can have a direct impact on educational outcomes. Research has shown that better mental health is positively associated with academic performance [29,30]. In addition, sound training in life skills can reduce risk behaviours related to health and delay the students’ sexual debut [31], and decrease the likelihood of their dropping out from school. The need to integrate health promotion activities into the education sector has been expressed in international conventions, endorsed by international organisations, and translated into national policies and programmes. Reviews of school health programmes in different settings [16,17,27,32,33] have identified factors related to design and implementation that can increase the programme’s effectiveness. These are:

• An approach that encompasses the whole school • The involvement of different stakeholders • Theory-based design and practically tested programmes for the programme implementers • Effective training and continuing opportunities for capacity-building programme activities • Adequate time, space and funding for organising and delivering

• TailoringHowever, the while programme general to principles the needs ofare the relevant school andacross community. different settings, there is wide variation in the content and delivery strategies of school-based health education programmes across the world [17]. At the same time, interventions that have proven effective in one setting may not yield the same results in another context [34]. At the national and sub-national levels, school health programmes need to be feasible and acceptable, and must meet the specific needs of the communities they serve.

Adolescents and school health promotion: The Indian context According to the National Family Health Survey’s data from 2005–06, about 30% of women give birth before the age of 20 years. Such a low school-based adolescent health promotion 5 maternal age can increase the risk of neonatal death and low birth-weight by 50%, while also raising the likelihood of maternal complications and death [35]. There is a high level of undernutrition among male and female adolescents in India [36]. Iron deficiency is also highly prevalent and, according to recent assessments, 65%–90% of adolescent girls are anaemic [37,38]. The level of comprehensive knowledge of HIV/AIDS is low, at 35% among adolescent males and 19% among adolescent females [1]. This naturally increases the potential risk of contracting HIV and other STIs. Apart from concerns related to physical health, adolescents face challenges in the social and academic spheres, as well as in the area of mental health. This can lead to depression and suicidal behaviour [39,40]. Suicide is the second leading cause of death among both young men and young women of the age of 15–29 years in India, accounting for 13%–14% of the mortality in these groups [41]. Jejeebhoy and Santhya have comprehensively reviewed the laws, policies and programmes supporting the adolescent’s rights and needs in the spheres of sexuality and reproductive health [3]. A number of national policies have recognised the need to provide adolescents with information on health and health services. These include the National Health Policy (2002), the National AIDS Prevention and Control Policy (2002), and the National Youth Policy (2003 and 2010). The National Curriculum Framework (2005) mentions the importance of integrating adolescence education into the school curriculum, while the National Plan of Action for Children (2005) acknowledges the need to provide services for the betterment of the physical and mental health of adolescents. In line with these policies and schemes, a range of programmes and services have been proposed and initiated by government agencies, often in partnership with international and domestic non-governmental organisations (NGOs), to improve adolescents’ access to health- related information and services in schools. Most recently, the Indian government launched a national strategy for adolescent health in January 2014. The strategy focuses on six key areas: sexual and reproductive health; life skills; nutrition; injuries and violence (including gender- based violence); non-communicable diseases; and mental health and substance misuse [42]. In 2011, the Ministry of Health and Family Welfare initiated the Rajiv Gandhi Scheme for Empowerment of Adolescent Girls, which was built on two prior initiatives – the Nutrition Programme for Adolescent 6 d. rajaraman, s. shinde, v. patel

Girls and the Kishori Shakti Yojana. The scheme aims to improve the nutritional and health status of adolescent girls by promoting awareness of health, hygiene, nutrition, the reproductive and sexual health of adolescents, and family and child care, through a range of methods, mostly community-based. The AEP is a school-based initiative for imparting education on health and life skills that was launched jointly by the National AIDS Control Organisation (NACO) and the Department of Education, Ministry of Human Resource Development in 2005, in partnership with UNICEF, UNESCO and UNFPA. The curriculum has been developed for 9th and 10th grade students and covers a range of topics, including the transition to adolescence, prevention of HIV/AIDS, sexual and reproductive health, mental health and substance abuse, and life skills. At the heart of the interventions is the implementation of a life- skills curriculum, which aims to broaden the scope of the programme beyond education on reproductive and sexual health to reducing risk behaviours and building resilience among the youth. The programme is delivered primarily by trained teachers in classroom sessions. While the number of people reached by the programme is high, with 85,000 secondary schools being covered in 2012–13 [43], there have been serious obstacles. Social conservatism and a political backlash against educating adolescents on sexual and reproductive health resulted in a temporary ban on the programme in some states and substantial variation in its implementation. The AEP has been brought up to date to address the issues of making a healthy transition to adulthood (being comfortable with changes during adolescence), understanding and challenging the stereotypes and discrimination related to gender and sexuality, the prevention of HIV/AIDS, and substance abuse. However, the content, delivery model, quality and coverage of the AEP remain variable across the states, and there is a need for greater understanding of the experiences of implementation and the evidence of the programme’s impact. The School Health Programme, launched by the Ministry of Health and Family Welfare in 2008 under the National Rural Health Mission (NRHM), is another important initiative that aims to “address the health needs of children, both physical and mental, and in addition, it provides for nutrition interventions, yoga facilities and counselling” [44]. The school health programmes in Tamil Nadu, Kerala, Gujarat and West Bengal provided the basis for the development of national guidelines and school-based adolescent health promotion 7 for costing. It is envisaged that these will be adapted at the state level and implemented by district health offices, in partnership with schools. Teachers are expected to play a role in screening students for basic health problems, treating them for common ailments that are not serious, referring them to health services where necessary, administering health interventions such as deworming and micronutrient supplementation, counselling them, and educating them on issues related to health, hygiene and nutrition. While the objectives of the programme are sound, its scope is extremely wide. For this reason, its implementation has focused primarily on services for identifying and treating physical health problems, at the cost of activities for the promotion of health. In the case of both the AEP and School Health Programme, monitoring and evaluation are weak, raising questions about the coverage and impact of the programmes. Given the critical need to expand the reach and strengthen the quality of adolescent health promotion in India, and the important role that schools play in this regard, it is essential to identify the lessons learnt, best practices, areas that require strengthening, and the further evidence that is needed in relation to school health programmes.1

Selection of school health promotion programmes for case studies Sangath is a non-governmental non-profit organization, based in Goa, India, whose primary programme focus area are child development, adolescent and youth health, and mental health. A key element of the organisation’s approach is to strengthen the existing services offered by the state and private sector by developing and evaluating affordable and integrated interventions, with the goal of scaling these up. In 2008, Sangath received funding from the John D. and Catherine T. MacArthur Foundation to build an evidence base for school-based promotion of adolescent health in India. With this end in view, Sangath developed, implemented and evaluated the SHAPE school health promotion intervention in secondary schools in Goa. The Sangath research team simultaneously undertook a review of

1 It is well-recognised that further work is needed to strengthen the promotion of health among out-of-school adolescents; however, that discussion is outside the scope of this book. 8 d. rajaraman, s. shinde, v. patel the implementation of school health promotion interventions in India in 2010, with the goal of identifying other interventions for in-depth case studies. The eligibility criteria for an intervention to be selected as a case study were: (i) the inclusion of a health promotion component; (ii) targeting of low-income students; (iii) potential to be scaled up; (iv) operation of the intervention during the proposed evaluation period (2011–12); and willingness of the implementing organisations to share programme documentation, facilitate an end-line qualitative evaluation, and provide inputs on the design of the case study and the interpretation of the findings. Drawing on information from professional networks and the academic and grey literature, 20 organisations were identified supporting adolescent health promotion interventions that might have a school- based component. A questionnaire was sent to these organisations to gather information on the coverage, target population and content of their interventions, as well as the age groups to which they are applicable (Appendix A). Four organisations did not respond to the initial or two subsequent attempts to make contact. Nine happened not to be supporting such interventions at the time, and one was uncertain whether its intervention would be fully operational during the proposed period of evaluation. One programme focused on community rather than school-based health promotion. One organisation felt that it would not be able to facilitate an evaluation in the proposed time period. Finally, four programmes were selected to conduct case studies. Appendix B presents a summary of the organisations contacted, the main characteristics of their programmes and the reasons for their exclusion (if not selected). The key features of the four case study programmes are summarised in Table 1.1. The geographical coverage of these programmes is mixed, spanning seven states. They are characterised by different types of human resource delivery (a lay full-time school health counsellor, trained school nodal teachers and trained school nurses), different levels of engagement with the school and students (intense multi-level programmes to the provision of only individual counselling services), different levels of supervision, different resource implications, and variation in scale, ranging from a pilot programme covering 10 schools to a state-wide programme covering over 2000 secondary schools. Two programmes cover the basic AEP syllabus, while the other two have a component of individual counselling services for students. Some of the programmes are school-based adolescent health promotion 9 ) continued ( Intervention Intervention states Rajasthan Madhya Bihar, Pradesh, Maharashtra, Orissa, Rajasthan Department of of Department Education, Rajasthan Education, Samiti, Ministry of and Resources Human Development Key partners Key – – Ritinjali Vidyalaya – Navodaya – Sangath – UNFPA Description is being programme Skills Education Life The Drishti secondary schools 1500 government in over delivered and Kota (Jhalawar, districts of Rajasthan three across staff and provides teaching trained by It is delivered Baran). and sexual education on reproductive classroom-based students in the 8th and skills to in life health and training 9th grades. that offers programme is a youth-friendly Prayatna and group in individual counselling services, delivered The school staff nurses. trained counselling sessions by an from and support supervision telephonic receive nurses the students of 158 Jawahar serves The programme NGO. rural talented schools for Samiti residential Vidyalaya students. Key characteristics of programmes selected for school health promotion case studies school health promotion for selected of programmes characteristics Key Programme and and Programme of launch year Drishti 2006 Prayatna 2009 Table 1.1. Table 10 d. rajaraman, s. shinde, v. patel Intervention Intervention states Goa Jharkhand Corporation Jharkhand Education, Society Control Key partners Key of Goa – Archdiocese – Sangath – Dempo/Sesa Mining – MacArthur Foundation – Department of AIDS State – Jharkhand – CEDPA Description (SHAPE) and Empowerment Promotion The School HeAlth Schools Promoting is based on the WHO Health programme of physical, the promotion for activities Model. It organises and emotional and mental health at the school, classroom in 12 government- 5th–12th graders to levels individual and coordinated are schools. Most activities supported is who school health counsellor, lay a trained by delivered the principal, by a local NGO and supported supervised by partners. staff and external teaching education on reproductive provides programme The UDAAN health in all secondary and senior and sexual to trained are The teachers the state. schools throughout clubs to UDAAN and form syllabus a classroom-based teach student and community activities. promote ) continued ( Programme and and Programme of launch year School Health and Promotion Empowerment (SHAPE) 2008 2007 UDAAN Table 1.1. Table school-based adolescent health promotion 11 delivered in regular day schools and others in residential schools. All the programmes are delivered in government or government-aided schools, and receive technical assistance from a non-governmental partner.

The case study methodology The case study methodology was originally developed in management schools as a means of studying a single business in depth. The approach involves synthesising and triangulating multiple sources of information and evidence to build a complete understanding of a specific case [45]. The case study approach is particularly useful for exploratory, descriptive and comparative research, as it allows for the collection and analysis of context-specific data, provides the flexibility to include cases that may be very different from each other, and does not require common outcomes for the comparison of cases. The programmes selected for review differed in terms of their content, structure, delivery mechanism, coverage and projected outcomes, and the data available also varied. Adopting a case study approach allowed us to collect data from a variety of sources, which enabled us to describe the programmes within the contexts in which they operate and to compare them along the following broad parameters: (i) acceptability of the programme; (ii) feasibility of its implementation; and (iii) evidence of its impact. The Sangath research team developed case study protocols for each of the programmes, with review and inputs from partner organisations. The case study protocols were approved by the Sangath institutional ethical review board and the partner organisations. For the SHAPE programme case study, the evaluation methodology was built into the development of the intervention and its delivery. For the other case studies, a review of the documents and end-line qualitative evaluation were undertaken. The purpose of the document review was to gather secondary information on the programmes, identify important issues for further exploration in the qualitative evaluation, and gather information to triangulate the findings of the end-line qualitative evaluation. The sources of data for the review of documents were annual reports, training reports and past evaluations. The purpose of the end-line qualitative evaluation was to gather oral histories of the programme and fill the gaps identified in the evidence obtained during the review of documents. In addition, the 12 d. rajaraman, s. shinde, v. patel end-line evaluation aimed to formulate recommendations to strengthen the implementation and sustainability of the programmes. As part of the end-line evaluation, individual and group interviews were conducted by members of the Sangath research team, with government officers, programme coordinators, principals, teachers, students and parents. The interview and focus group guides for the end-line evaluation were developed by the Sangath research team and reviewed by the partners to ensure that they were complete and appropriate. The interview guides covered the following areas:

• History of the programme • Socio-economic background and needs of the students • Acceptability of the programme to different stakeholders • Adequacy of the content and material • Feasibility and effectiveness of the training model • Facilitators for and barriers to implementation • Impact • Sustainability.The interview guide and consent forms were translated into the relevant vernacular languages (Hindi and Konkani). The partner organisations provided inputs on the selection of respondents for the interviews and helped with the logistics of conducting the interviews. The researchers from Sangath conducted the interviews in English, Hindi or Konkani, depending on the preference of the respondent. All interviews which were not in English were translated. The interviews were transcribed and reviewed by the interviewer for accuracy. The qualitative end-line data were analysed using a framework approach [46]. A qualitative data analysis software package, NVivo, was used for coding data. The following analytical themes were employed for the synthesis and interpretation of the qualitative and quantitative information from the case studies:

Acceptability

• Acknowledged need for the programme by stakeholders • Stakeholders’ willingness to participate in the programme • Stakeholders’ support for the programme and the syllabus school-based adolescent health promotion 13

Feasibility

facilitators, and to equip them with sufficient skills to deliver the • Ability to recruit and train the required number of trainers and programme

programme, and sustainability of the system • Establishment of a system for delivering and administering the

• Coverage and delivery of the programme • Monitoring and supervision of the programme • Barriers and facilitators to programme implementation Effectiveness/evidence of impact

attitudes and behaviour of students and other school and community • Quantitative and qualitative evidence of changes in knowledge, members as a result of the school health promotion programme

In addition, we elicited suggestions on how the programme can be improved, as well as recommendations on means of strengthening and/ or scaling up the programme in the future. The Sangath research team conducted the primary analysis of the data for the case studies. The partner organisations provided critical inputs during the process of interpreting the findings and writing the case studies.

Structure of this book The next four chapters describe the SHAPE, UDAAN, Drishti and Prayatna programmes, in the order in which the case studies were conducted. Each case study includes a description of the setting, history and current context of the programme. The sources of data are summarised, followed by the findings and a summary of the key points and recommendations on how the programme may be strengthened. The final chapter compares the four programmes in terms of content, delivery model, acceptability, feasibility and impact, with a focus on interpreting the findings in the context of scaling up adolescent school health promotion in India in an effective and sustainable manner. 2

Divya Rajaraman, Prachi Khandeparkar, Achira Chatterjee, VikramThe SHAPE Patel programme

The Setting: Goa Goa is a coastal state in west India. In comparison to other Indian states, it is small in geographical and population size. The state is divided into two districts (North Goa and South Goa), and 12 sub-districts/talukas. The primary industry in Goa is tourism, followed by mining. These industries are a major source of employment, and also attract a large number of migrant workers, both from within and outside the state. A significant proportion of the population is also involved in agricultural work. Konkani and Marathi are the vernacular languages, while English is also spoken commonly. A minority of the population still speaks Portuguese, a remnant of the four-and-a-half centuries of Portuguese colonial rule in Goa. The Census of India 2001, which contains the most recent published data on the religious composition of the population, indicates that about 66% of Goans are Hindu, 27% Christian (primarily Goan Catholic), and the remaining 7% mostly Muslim. Goa’s per capita gross domestic product (GDP) in 2009–10 was the highest of all the Indian states and 2.5 times the national average, according to the statistics of the National Planning Commission. The population is primarily urban, with 62% of Goans residing in urban areas, the corresponding figure for the rest of India being 31%. Overall, Goa has better living conditions, and health and education indicators than the rest of India (Table 2.1). All government schools in Goa fall under the authority of the Goa the shape programme 15

Table 2.1. Socio-demographic and health indicators of Goa

Area1 3702 square km

Population1 1.46 million

% urban population1 62.2%

Annual per capita income 2009–102 Rs 132,719

Households with electricity4 96.4%

Households with safe drinking water4 74.9%

Households with latrines4 73.6%

Crude birth rate3 13.3 per 1000

Child sex ratio1 942

Women of age of 20–24 years married by age 11.7% of 18 (%)4

Men of age of 25–29 years married by age 7.2% of 21 (%)4

Infant mortality rate3 11 per 1000 live-births

Children immunised4 79%

Underweight in children under 3 years4 29%

Mothers with at least three antenatal care visits 95% at last birth4

Institutional deliveries4 92.6%

Literacy1 88.7%

Male literacy1 92.7%

Female literacy1 82.2%

1 Office of the Registrar General and Census Commissioner. Census of India 2011 tables: http://censusindia.gov.in 2 Planning Commission of India. Directorate of Economics Statistics for respective state and all-India. http://planningcommission.gov.in/data/datatable/1612/table_158.pdf 3 Registrar General, India. Sample Registration System Bulletin, December 2011 4 International Institute of Population Sciences and Ministry of Health and Family Welfare. 2005–06 National Family Health Survey. Goa Fact Sheet 16 d. rajaraman, p. khandeparkar, a. chatterjee, v. patel

Directorate for Education. In the light of the need to provide affordable education to the population and its own capacity constraints, the government also extends aid to a large number of schools to make services available at no or a low cost. These include minority schools which fall under the religious Archdiocesan Board of Education (ABE). Despite the fact that Goa has better socio-economic indicators than the rest of the country, it faces a range of health issues. These include the high proportion of elderly people, poor quality of health services, a large migrant population whose needs with respect to health and education are poorly met, a declining sex ratio among young children, and high levels of anxiety, depression and alcoholism [47].

The School HeAlth Promotion and Empowerment (SHAPE) programme History The SHAPE programme (2009–14) was developed by Sangath and funded by the John D. and Catherine T. MacArthur Foundation. The overall goal was to implement, evaluate and scale up a school-based health promotion intervention in Goa and to use the evidence to strengthen programmes across India. To achieve these goals, the following three strategies were identified:

scaling it up to more schools in Goa • Developing an intervention package, piloting it for two years and based health promotion interventions being implemented in India • Evaluating the SHAPE intervention package and other school- to strengthen the evidence on the effectiveness of school health interventions

health promotion interventions in India. • Building the capacity of other organisations to scale up school-based Sangath is a non-governmental, non-profit organisation, which was established in 1996 with the aim of improving the health of a person across his/her life-span. Sangath’s primary areas of focus are child development, health of the adolescent and youth, and mental health. Prior to the launch of the SHAPE programme, Sangath had established a resource centre for adolescent health interventions and had built up the shape programme 17 a large body of research on the health of adolescents and the youth. An earlier project, Yuva Mitr, had launched and evaluated an integrated community-based intervention for promoting the health of the youth in rural and urban communities. As part of the project, a range of school- based teaching materials and modules on adolescent health had been developed; these formed the basis for a school-based health promotion intervention. In 2008, the Dempo/Sesa Mining Corporation’s Corporate Social Responsibility arm provided Sangath with funds to implement a school- based health promotion intervention in five schools in rural areas in Goa for the academic year 2008–09. This project was called “Manthan”. The experiences of the team responsible for the implementation of the project in this first year, along with a year-end evaluation of the programme, were used to refine the intervention package. In 2009–10, the revised intervention was launched in four new schools under the SHAPE programme, which was funded by the MacArthur Foundation. The Manthan and SHAPE interventions were implemented in government- aided schools that served students from low-income families. In 2010– 11, one more school was added. In 2011–12, the intervention was discontinued in the four SHAPE schools (due to the end of project funding for those specific schools), but was introduced in two other schools. In 2012–13, five more schools were added, making for a total of 13, In 2013–14, the intervention was discontinued due to funding constraints. However, the individual counselling component of the intervention is now being incorporated in the school health counselling programmes of the Goa Education Development Corporation/Goa Directorate of Education. Through these programmes, all government and government- aided schools have access to a counsellor. A total of 80 counsellors and 12 supervisors were to be appointed for approximately 324 schools in the state. Sangath, together with other NGOs, is involved in the training and supervision of counsellors, and is a member of the counselling cell of the Goa Education Development Corporation, which oversees the scheme. The SHAPE intervention targeted male and female students studying in the 5th–12th grades (9–17 years old), and was aligned with WHO’s health-promoting schools approach, which was endorsed by a Government of India committee on education in 2007. Some of the distinguishing features of a health-promoting school are that it:

• involves all the significant stakeholders concerned 18 d. rajaraman, p. khandeparkar, a. chatterjee, v. patel

• strives to provide a safe and healthy environment • promotes skills-based education on health • promotes access to health services • promotes the adoption of health-promoting policies and practices • ultimately strives to improve the health of the community.

Health-promoting schools go beyond the conventional model of simply providing information on health; they aim to create a setting in which the school environment, policies, institutional culture and linkages with external partners all contribute to improving the health and educational outcomes of students. The goals of the SHAPE intervention were to promote health and reduce health-related impairments and disabilities among the school- going youth. The approach to health was holistic, in that it aimed to address all the major health concerns of the target population, and was tailored to the needs of the individual and his/her school environment. The multi-component intervention was implemented at three levels: whole-school (universal), group and individual. Table 2.2 presents the details of the components of the intervention. At the whole-school level, the intervention team conducted an initial situational analysis and assessment of needs to identify the priorities. It raised awareness and spread knowledge of adolescent health and issues pertaining to the well-being of adolescents. Annual health screening camps were initiated. Finally, the team implemented policies and practices to promote the health of all school members. At the group level, targeted workshops were conducted for teachers, parents and students on issues of relevance, such as practices for disciplining students, nutrition and guidance on career choices. For students, trained school health counsellors (SHCs) provided skills-based education on health through a classroom programme. At the individual level, the intervention provided counselling and/or referrals for students experiencing emotional and behavioural problems, social difficulties or learning difficulties, as well as those suffering from nutritional problems. Counselling was also provided to the school staff on request.

Delivery team The school health promotion intervention was developed and supervised by a team of professionals at Sangath. The team included the shape programme 19

Table 2.2. The SHAPE intervention

Universal (school-wide) level

School mapping Mapping was carried out to assess the infrastructure, and needs health environment and the health resources available. assessment A structured questionnaire was administered to the school management, teachers, students and parents to identify priorities related to health and well-being. This information was used to tailor the intervention for each school’s needs.

Generation of The SHCs introduced themselves and generated awareness awareness of the programme in their schools by addressing the assembly, classes and parents–teachers’ association meetings.

School Health When the programme was first initiated in a school, the Promotion school formed an SHPAB, consisting of representatives Advisory Board of the management, parents, teachers and students, and (SHPAB) the SHC. The SHPAB was responsible for monitoring the programme in the school, making recommendations on its implementation and overcoming barriers. It met on a quarterly basis.

Development and Three policies were identified for adoption: discouraging implementation of bullying, promoting inclusive education and discouraging health-promoting substance use. policies

Speak-out box A letter box was hung on a wall in an easily accessible area to enable school members to make anonymous submissions on any health, social or school-related concern. The SHC reviewed the submissions on a weekly basis and followed these up, as appropriate.

Health camps The SHCs were trained to measure the students’ weight and height, and to conduct visual screening to identify possible refractory errors and colour blindness. The students’ body mass index was estimated and those identified as possibly having nutritional or visual problems were given appropriate advice/referral.

(continued) 20 d. rajaraman, p. khandeparkar, a. chatterjee, v. patel

Table 2.2. (continued)

Class level

Workshops Workshops were conducted for teachers on teaching language, team-building, understanding learning difficulties and positive disciplining practices. They were also sensitised to the needs of the youth. Workshops were conducted for parents on parenting practices, nutrition and understanding learning difficulties. Workshops were conducted to provide guidance on career for students in the 8th–10th grades. The workshops were organised and facilitated by the SHCs, and led by external partners, consultants and/or the senior programme staff of Sangath.

Education on life The classroom programme on life skills was developed skills using international and national resources. The programme was delivered over one period (35–40 minutes) per class per week. The sessions were designed to be interactive and activity-based. They covered physiological and sexual and reproductive health; psycho-social issues/mental health; and effective learning techniques.

Individual level

Individual Face-to-face counselling was offered to students who counselling referred themselves or were referred by a teacher or principal. In the first year, a clinical psychologist conducted the counselling sessions in the presence of the SHC. In the second year, the SHC provided counselling to the students, with supervision and support from the NGO staff.

clinical psychologists, social workers and public health specialists. As monitoring and evaluation were integral to the design of the intervention, the research team at Sangath worked in partnership with the team delivering the intervention so as to to identify the data needs; ensure the shape programme 21 timely, reliable and ethical collection of data; and analyse and interpret the data to strengthen the intervention and regularly report the progress to stakeholders. The keystone of the intervention was the SHC, who was recruited from the local community and trained for a period of two months by Sangath. The SHCs were nominated by the schools in which the intervention was being implemented. They were all female and the minimum qualification required was having passed senior secondary school (12th grade). Some of the SHCs were former students of the school in which they were now working. The SHCs were hired by Sangath. A range of methods was used in the training, which was conducted prior to the start of the academic year. These included short lectures, group discussions, role-play, documentaries and games. The SHCs were oriented to the programme and to the issue of health promotion. Another component of the training was the building of skills, such as in the areas of communication, networking, facilitation, classroom management, and working with stakeholders. The SHCs were familiarised with the materials to be taught in the classroom component of the intervention, and were trained in counselling, case management and referral of serious cases. They were also trained in reporting procedures. During the course of the intervention, a number of formal training materials were developed and refined. These included a school counsellor’s training manual, a video on basic counselling, and an intervention manual for classroom sessions. The SHC’s role was to coordinate and implement the activities related to the intervention in her school. This involved coordinating with the stakeholders and convening meetings; conducting nutritional and visual assessments of all students; reviewing and taking appropriate action with respect to the speak-out box submissions; delivering the classroom- based programme on life skills; providing individual counselling to students; and record-keeping. The individual counselling was conducted jointly by a clinical supervisor and the SHC in the first year of the intervention to provide on-the-job training. In the second year, the SHCs were encouraged to counsel students on their own and refer only difficult cases to the clinical supervisor. In the first year, the SHCs were supervised by a clinical supervisor (trained clinical psychologist) during weekly group meetings at Sangath and bi-monthly visits to the school. In the second year, there was a 22 d. rajaraman, p. khandeparkar, a. chatterjee, v. patel reduction in the frequency of the supervision, which now took place during bi-monthly group meetings at the Sangath office and monthly supportive supervision visits at the school. Group supervision was conducted once a week at the Sangath office. In a group format, and in the presence of one or more clinically trained supervisors, the SHCs would summarise the progress of the intervention in their schools; discuss the speak-out box submissions; discuss any interesting or difficult individual counselling case; share any concerns or challenges faced in the delivery of the intervention; and provide feedback on the life skills modules. They would also receive materials for the life skills modules for the following week, and submit activity registers to be reviewed and recorded. The onsite supportive supervision consisted of a weekly visit by a clinically trained supervisor from Sangath to the school. The supervisor would review the progress of the delivery of the intervention with the SHC and discuss any concerns; meet members of the school management and teachers, if necessary; conduct and/or supervise individual counselling; observe the implementation of the life skills module; review the speak- out box submissions with the SHC; and provide feedback to the SHC. While the SHCs, supported by the Sangath programme team, were the nodal persons for facilitating and delivering the intervention, a School Health Promotion Advisory Board (SHPAB) was established in each school as a formal structure for involving the stakeholders in the planning, delivery and monitoring of the programme. The SHPAB was composed of the school principal, the SHC, one teacher, two parents, and a male and female student. It was to meet once in three months, and its purpose was to tailor the programme to the school’s needs, provide inputs on all activities, monitor progress, and keep the stakeholders informed about the programme and targets. A number of partnerships were established with other stakeholders for the delivery of the intervention:

and two Catholic societies for the latter to run the SHAPE programme • Formal memorandums of understanding were signed between Sangath in their government-aided schools.

the SHCs on nutritional interventions and a consultant organised • The principal of the Goa College of Home Sciences (GCHS) trained workshops on “Healthy eating practices” in all the schools. The GCHS students assisted in conducting body mass index (BMI) nutritional the shape programme 23

assessments, as well as workshops for parents and students on healthy eating practices.

Department of Ophthalmology and Blind Surveillance Unit of Goa • SHAPE collaborated with the Department of Preventive Medicine, Medical College to train the SHCs to understand ocular morbidity among children and adolescents, and to conduct visual screening for the school staff and students. Students identified to have visual problems were referred to the Department of Ophthalmology of Goa Medical College or the nearest government primary health centre with specialist services in ophthalmology.

Content The classroom-based component on life skills included modules in three domains: effective learning, psycho-social health and physical health. The training and teaching materials were developed by the SHAPE team for the intervention, and built on existing resources, including the AEP manuals and the materials developed by Sangath earlier. An effort was made to define age-appropriate activities and learning outcomes for each grade, as shown in Table 2.3. Some topics, such as substance use, stress, reproductive and sexual health, and sexually transmitted infections, were not taught to the lower grades.

The SHAPE Case Study Evaluation A monitoring and evaluation framework was built into the design and delivery of the SHAPE intervention. The SHCs’ weekly and monthly registers, as well as the Sangath clinical supervisors’ monitoring visits, were the source of the quantitative process and quality indicators. Mid- line and end-line qualitative interviews were conducted with a range of stakeholders. Such interviews were conducted in all nine schools in the first year of the intervention, and in a sub-set of four schools in the second year. The findings were reported in the 2009–10 and 2010– 11 Monitoring and Evaluation Reports, as well as a publication in a peer-reviewed journal [48]. Additional information for the case study was drawn from the SHAPE annual project narrative report of 2012– 13. These sources of data, methods and sample are summarised in Table 2.4. 24 d. rajaraman, p. khandeparkar, a. chatterjee, v. patel

Table 2.3. SHAPE classroom programme: Topics covered in different grades

Modules 5th–6th 7th–8th 9th–10th/ 11th–12th

Effective learning techniques

How do I learn X X X

Effective concentration/active listening X X X

Goal-setting and motivation to continue X X X studies

Memorising techniques X X X

Timetabling/time circling X X X

Examination anxiety X X

Psychosocial domain

Building self-esteem X X X

Understanding relationships X X X

Dealing with emotions X X X

Communication skills and assertive X X X communication

Understanding values X X X

Substance use X X

Coping with stress X X

Conflict resolution X X

Personal safety and safety in the X X X community

Physiological

Healthy eating practices X X X

General hygiene X X X

Understanding my body X X X

STI/HIV X

Reproductive and sexual health X X the shape programme 25 (continued) Sample sample Quantitative 9 SHAPE schools. from Data collected sample Qualitative the 9 from interviewed 72 stakeholders 9 principals, 18 randomly schools: 9 SHCs, male selected 9 randomly teachers, selected selected 9 randomly students (5th–9th grade), 9 randomly students (5th–9th grade), female accessed individual male students who selected female selected counselling, 9 randomly counselling. accessed individual students who sample Semi-quantitative principals, teachers, Needs assessment to and students. Details of the sample parents not provided.

Study design/data source design/data Study methods Quantitative Indicators of programme outputs: number of activities of activities outputs: number of programme Indicators and activities, different by participants reached delivered, through identified and rectified other problems health or in their weekly SHCs by (recorded activities the intervention registers). activity and monthly of ratings quality: supervisors’ of programme Indicators visits. monitoring skills during onsite SHCs’ methods Qualitative with principals, teachers, interviews Semi-structured students, SHCs. methods Semi-quantitative on needs assessment. School mapping and questionnaire

Document title Document and Monitoring SHAPE Report, Evaluation 2009–10 Documents reviewed for SHAPE evaluation SHAPE for Documents reviewed Author(s) Sangath Year 2010 Table 2.4. Table 26 d. rajaraman, p. khandeparkar, a. chatterjee, v. patel 2 Intervention coordinators, coordinators, 2 Intervention Sample sample Quantitative 10 SHAPE schools. from Data collected sample Qualitative with stakeholders 37 people interviewed, 4 schools, from recruited uniformly as being best and worst selected purposively of the on the basis of a review performing year. previous Implementation: 4 principals, 3 clinical supervisors, 4 SHCs, male students (5th– 4 SHPAB teachers, SHPAB students (5th–9th female 4 SHPAB 9th grade), selected 4 randomly parents, 4 SHPAB grade), accessed individual male students who female selected counselling, 4 randomly counselling. accessed individual students who

Study design/data source design/data Study methods Quantitative of activities outputs: number of programme Indicators and activities, different by participants reached delivered, the through identified and rectified health or other problems and in their weekly SHCs by (recorded activities intervention registers). activity monthly of SHCs’ ratings quality: supervisors’ of programme Indicators visits. monitoring skills during onsite methods Qualitative with principals, teachers, interviews Semi-structured staff. programme parents, students, SHCs,

) Document title Document and Monitoring SHAPE Report, Evaluation 2010–11 continued ( Author(s) Sangath Year 2011 Table 2.4. Table the shape programme 27 Sample above As described Not available Study design/data source design/data Study 2009–11 data for and qualitative of quantitative Synthesis management report project SHAPE

) Document title Document The acceptability, and impact of feasibility health counsellor- a lay health- delivered schools promoting in India: a programme evaluation case study annual project SHAPE report, narrative 2012–13 continued ( Author(s) Rajaraman et al. Sangath Year 2012 2013 Table 2.4. Table 28 d. rajaraman, p. khandeparkar, a. chatterjee, v. patel

Acceptability The mapping and needs assessment conducted in each school at the beginning of the intervention provided information on the stakeholders’ views on the needs that should be met by the programme. The questionnaire for the assessment of needs was administered to principals, teachers, parents and students. The findings for the entire group showed that three academic priorities, i.e. offering guidance on career, focusing on children experiencing difficulties with their studies, and addressing those who are not interested in studying, ranked as the top areas requiring attention. Bullying was identified as an important issue in many schools, particularly by the students and parents. Family problems, health-related issues such as malnutrition and infestation with lice, and topics related to life skills, including emotional difficulties, also featured in the top ten concerns identified by the schools. There was little variation between the schools in terms of the priorities identified. However, the mapping exercise identified some important infrastructural gaps that varied by school, such as lack of drinking water and inadequate toilet and washing facilities. The acceptability of the SHAPE intervention was assessed qualitatively through the mid-term and end-line interviews with the stakeholders, and quantitatively through the proxy of uptake of services offered. A review of the stakeholders’ perceptions and the experiences of the programme provided qualitative evidence on the acceptability of the activities undertaken under the intervention and of the SHC as an agent of delivery. The level of support expressed by the principals, teachers and students for most of the activities was high. The school principals and SHCs summarised a range of factors that contributed to the acceptability of the intervention. These included consultation with the principal on the syllabus and proposed activities; age-appropriate modules; interactive sessions; and the fact that the topics taught were relevant to the students. The school management, teachers and students all saw the nutritional screening and vision assessment camps as an important way to identify and address common health problems among populations which have limited access to paid healthcare. In the words of one student:

Some students cannot afford to go to doctors for these types of health check-ups. They are doing so in our school, and that too, free of cost. That is what I like the most. (9th grade female student, 2009–10) the shape programme 29

The speak-out box was considered an important outlet for students by all groups of stakeholders. According to the students, the factors that contributed to its acceptability were that they could access it anonymously, it ensured confidentiality, and their concerns were addressed by the SHC. Two of the students described what they liked about the speak-out box thus:

I like the speak-out box because students can get their problems solved without others coming to know. (9th grade male student, 2009–10)

What we cannot share with our friends we can write and share with [the school health counsellor], who will keep it a secret. I like that. (11th grade female student, 2009–10)

The growing acceptability of the speak-out box among the students was reflected in an increase in the number of submissions, which rose from 220 in 2009–10 to 770 in 2010–11. In the second year of the implementation of the intervention, the majority of the submissions related to psychosocial issues (49.8%), followed by complaints and concerns relating to the school’s infrastructure, management and administration (36.9%). During the interviews, all members of the school management and most staff members indicated that they were in favour of the speak-out box. However, a few teachers had reservations. While one teacher expressed the apprehension that students might make false reports about the teachers they did not like, another felt that the lay SHC was not equipped to deal with the problems raised in the submissions. This apprehension may have been related to complaints by the students in those schools about the teachers’ disciplinary practices, and the SHC shared the feedback with the principal for review and action. All groups of stakeholders had a positive attitude to the classroom life skills programme. They noted that it was useful and relevant for adolescents. Many students said they enjoyed the interactive and activity-based nature of this component of the intervention. However, the sessions on reproductive and sexual health were dispensed with in four out of ten schools because the school management felt that the topic was not appropriate. The absence of a male counsellor was considered a limitation by a principal and a teacher, who observed that not all male students felt comfortable discussing their problems and their sexual and reproductive health concerns with a female counsellor. To address 30 d. rajaraman, p. khandeparkar, a. chatterjee, v. patel potential gender concerns in the delivery of the sessions on sexual and reproductive health, the sessions were delivered in a workshop format rather than as classroom-based sessions in the second year of the intervention, as this allowed a male resource person to be trained/ recruited to conduct the sessions with male students. In the first year of the programme, most SHCs and principals mentioned certain problems related to the component of individual counselling. These included stigmatisation of the service by students and the teachers’ disappointment with the results, which was related to their unrealistic expectations of the process and its outcomes. In the second year, the teachers were sensitised by the SHCs on the purpose of counselling and the type of results that could be expected. This appeared to make some difference, since the end-line interviews with the SHCs and teachers indicated that the latter had been making more appropriate referrals for counselling, in addition to the fact that they were more satisfied with the outcomes. The SHCs also noted that the students had become more positive about attending the counselling sessions and opening up about their problems. The principals, SHCs and the programme coordinators attributed the increased uptake of the counselling service to a greater awareness of the benefits of counselling, as well as growing confidence that the information shared would be kept confidential. The following two comments illustrate how counselling came to be accepted:

In the beginning, yes . . . counselling was seen as stigmatising, when teachers kept referring cases. But slowly, when the children started understanding that this counsellor is part of the school and they can go to her with any problem, there was less stigma and the students started coming on their own. (Female clinical supervisor, 2010–11)

Earlier, we used to feel that the [counsellor] might tell others whatever we tell her, so we were scared to speak. But because of counselling, our doubts were cleared and we got help in dealing with our problems. [Now] we know that [the counsellor] doesn’t share this information with anyone else. (9th grade female student, 2010–11)

The perceived improvement in the acceptability of counselling was also borne out by the increasing number and proportion of students who sought individual counselling on their own and returned for follow-up sessions in the second year. While the total number of students who the shape programme 31 accessed individual counselling was stable across the two years (just over 6% of the student population), the increase in acceptability was reflected in the higher number of counselling sessions (from 251 in 2009–10 to 323 in 2010–11), and the greater proportion of self-referred cases (from 8.2% in the first year to 24.2% in the second year). The students’ and principals’ perceptions of the SHC as an agent of delivery were mostly favourable. Many students said they were able to open up and engage with the SHC because she was more approachable than their other teachers. One student said:

Initially, we were not telling our problems to our teachers since they would get angry, but now we are telling our [SHC]. (6th grade male student, 2009–10)

However, the teachers’ opinions of the SHC were not as favourable. During the first year of the programme, teachers in three of the nine schools believed that the SHC was not mature enough to deliver all the programme activities. Several teachers also complained that not enough information was shared about the programme. This was addressed in the second year, when the SHCs started submitting monthly reports to the teachers. According to the SHCs, they began to receive greater support from the teachers after this measure was taken. The decrease in the negative feedback from the teachers in the second year seemed to corroborate this.

Feasibility Training Sangath was able to recruit and train lay SHCs to deliver the SHAPE programme in the 10 intervention schools over the two years of the intervention. Since not all SHCs from the first year were retained in the second year, a round of training for the new SHCs, as well as refresher training for old SHCs, were held before the second year of implementation started. The training curriculum and materials were revised on the basis of the experience of the first year and the mid-term evaluation of the programme’s implementation. The coordinators of the intervention had mixed feelings regarding the appropriateness of the practices for the selection of SHCs. While one coordinator believed that the nomination of SHCs by the schools 32 d. rajaraman, p. khandeparkar, a. chatterjee, v. patel was useful as it increased their acceptability, another opined that this practice made it difficult to recruit the most qualified candidate. The formal feedback from those who received training was not reviewed. Interviews with the SHCs and programme staff suggested that they were generally satisfied with the content and materials. In addition, there was a perceived need among both groups for further training on counselling and facilitation skills.

Coverage of intervention activities The coverage of the intervention-related activities was high to begin with and increased during the second year, as can be seen in Table 2.5. The SHAPE intervention team set detailed targets with respect to the activities in the beginning of the year. The proportion of the target activities delivered was high during the first year and increased in the second year, despite the reduction in the supervision of the SHCs. Over the two years, policies relating to bullying and violence were developed and disseminated in nine of the ten schools. The practical implications of the Goa government’s circular on tobacco-free schools were discussed at a workshop attended by members of the management of eight schools, and seven schools had a written copy of the government’s circular on inclusive education. SHPABs were constituted in all schools and met on a quarterly basis, as scheduled. All schools conducted the visual assessment and health camps as per the targets, and speak-out boxes were installed in all schools. The completion of the life skills programme increased from 86.6% to 92.2%. The number of students who accessed counselling increased marginally from 122 to 128, but the proportion of students availing themselves of the service remained steady, between 6.2% and 6.3%. Interviews with the SHCs and programme coordinators revealed that during the first year, no regular class period and/or classroom was allocated to almost half the SHCs for conducting the life skills sessions. Consequently, they had to take classes either after school, or when another teacher was absent or had completed his/her syllabus. This situation improved in the second year, when all but one school principal had allotted a slot to the life skills programme in the timetable. However, some schools still had trouble finding a suitable space for counselling. One of the clinical supervisors explained the situation as follows: the shape programme 33 91 100 100 100 91.6 95.2 92.2 (continued) (84.4–99.3) Coverage (%) Coverage 30 10 10 394 651 315 1360 Actual 2010–11 30 10 10 433 711 331 1475 Target 1 100 100 100 76.2 89.9 92.6 86.6 (84.6–98.9) Coverage (%) Coverage 9 9 27 326 661 324 1311 Actual 2009–10 9 9 27 428 735 350 1513 Target Coverage of the SHAPE intervention activities in all schools, 2009–11 activities intervention of the SHAPE Coverage Number of SHPAB meetings Number of SHPAB assessment Visual mass index Body techniques learning Effective (Total) School range Table 2.5. Table School Health Promotion Advisory Board meetings Board Advisory School Health Promotion Sangath by Health camps organised sessions classroom in of life skills education Delivery Physiological Psychosocial TOTAL 34 d. rajaraman, p. khandeparkar, a. chatterjee, v. patel 55 6.3 128 323 (30–92.8) (2.3–11.1) 2010–11 6.2 251 122 18.5 (1.8–13.1) (1.8–41.2) 2009–10 ) 2 continued ( Coverage is defined as a percentage of the target achieved. The targets were set a priori by the intervention coordinators. the intervention set a priori by were The targets achieved. of the target is defined as a percentage Coverage of the SHC. in the presence psychologist) a clinical supervisor (trained led by Other sessions were Table 2.5. Table accessed counselling % students who accessed (% students who School range counselling) cases Number of follow-up SHC % sessions led by SHC) (% sessions led by School range 1 2 Individual counselling Individual Number of cases the shape programme 35

Infrastructure is the problem of the school because they don’t have a proper place to hold their own classes, so we cannot demand a class or place for ourselves. (Female clinical supervisor, 2010–11)

The programme coordinators were of the view that a supportive and enthusiastic school management team would be the most important facilitator for the programme. They felt that this could reduce the burden on the SHC, who was loaded with the responsibilities of organisation and creating motivation, and improve the participation of all school members in programme-related activities. In the words of one of the coordinators of the intervention:

Actually, some schools gave us a class and some schools did not. Some schools talked about conducting our activities after class. A few schools gave us the library period or [physical education] period. You know, I think a lot of this was determined by the principals. So I can’t say that across the board everybody gave us a class . . . a lot depended on the principals and how important they thought the programme was. (Female intervention coordinator, 2010–11)

The intense monitoring and supervision of the intervention was one of the factors that made it possible to quickly identify bottlenecks in the programme and address these. The problems were remedied by providing feedback to the SHCs and making modifications in the intervention. This was of critical importance in the achievement of the high level of coverage of all the components of the programme by the second year, and in the resolution of a number of problems identified during the first year.

Evidence of impact by the number of students who were found to have health problems in the Quantitatively, the preliminary impact of the programme was indicated nutritional screening and visual assessment camps and the number who be gauged by the evidence from the mid-term and end-line interviews of received treatment or were followed up. Qualitatively, the impact could the stakeholders about the effects of the intervention-related activities on the students’ health and well-being. 36 d. rajaraman, p. khandeparkar, a. chatterjee, v. patel

Health camps In 2009–10 and 2010–11, camps for nutritional and visual assessment were conducted in all schools, with the majority of eligible students being screened. In the first year, some principals complained about the fact that the health camps had not resulted in adequate follow-up, even in cases in which problems had been identified. An improved referral system was, therefore, built into the activity in the second year. Of the 1987 students who underwent visual screening in 2009–10, it was found that 443 probably had a refractory error and 100 were probably colour blind. These students were referred for confirmation of the diagnosis and treatment. Of the 512 students who were referred, 223 (43.6%) visited a healthcare provider. One of the school teachers spoke about the benefits of the visual assessment camp:

After the check-up, [the SHC] did the follow-up and the children were given spectacles, which I had not expected. It was a really good initiative to give them spectacles because most of the students in our school are poor and may not have been able to afford spectacles. (Female teacher, 2010–11)

Of the 1917 students who underwent a nutritional assessment in 2010–11, 653 (34.1%) were found to be underweight and 134 (7%) were overweight or obese. These students were given dietary guidelines to share with their parents. In some cases, this led the adolescents to change their behaviour and the parents to modify their child’s diet. The following statement by a mother bears this out:

[My son] was underweight. [The SHC] gave us a chart which says what to eat and in what quantity, and my son is following this. At first, I used to have to force him to eat, but now, after this counsellor gave him a book about what to eat . . . he forces me to cook all the things mentioned in this book for him. (Female parent, 2010–11)

Speak-out box The submissions to the anonymous speak-out box were reviewed by the SHC on a weekly basis. The SHC took up the issues raised in the submissions with the school management, where appropriate and possible. The SHCs and principals related several instances in which the the shape programme 37 school management took action in response to the students’ complaints about the health environment. For example, fans and drinking water filters were installed, furniture was fixed, and an attempt was made to regularly clean the common facilities in some schools. The SHCs and principals also followed up on two cases of the use of extreme disciplining practices by teachers, resulting in modifications in the teachers’ behaviour. Many cases of bullying by students were reported through the speak-out box. These were addressed through anti-bullying workshops/sessions held both for the management and students in all the schools. In addition, individual follow-up, during which names were reported, was conducted life skills were frequently raised through the speak-out box, and were with the students. Questions about reproductive and sexual health and addressed by the SHC in the classroom-based sessions on life skills.

Classroom-based life skills programme Teachers, students and parents were unanimous that the sessions on life skills had had several positive effects. In this context, one teacher discussed the effect of this component on substance use among the students:

Earlier, some students used to [chew tobacco], which is no longer the case. They also used to gamble, but this year, we have not seen any students doing such things. . . . They are aware of the consequences. (Female teacher, 2010–11)

Some parents also noted behavioural improvements in their children. For example, one parent said:

[The intervention has had] a great effect on the children. Earlier, they would not offer their seats on the bus to other people. Now they get up and offer their seats, especially to elders. Earlier, my daughter would not listen and used to backchat, but now there is a lot of improvement in her. She behaves well. Ever since [the SHC] spoke to her, she has stopped answering back. (Female parent, 2010–11)

Students from across the schools and grades said that they were utilising the knowledge and skills learnt in the classroom in their daily lives. This included adopting healthy eating habits (e.g. reducing the consumption of aerated beverages), being respectful to elders and 38 d. rajaraman, p. khandeparkar, a. chatterjee, v. patel civil with one’s peers (e.g. not bullying), avoiding abusive language, changing one’s attitudes to education, becoming more aware of one’s personal safety and safety in the community, managing anger better, improving one’s personal hygiene, and trying to gain an understanding of the physiological changes associated with adolescence. In addition, many students said that they had benefited from the sessions on study skills. They were following the tips on concentration and memorisation, and said they appreciated the need to make a study timetable. In some cases, this had led to tangible improvements in their academic outcomes. According to one student:

[The SHC] used to tell us what should be done in the exams and all, so I followed that and I passed in many papers. First I had failed in two papers which I used to find difficult, but now I passed. (6th grade male student, 2009–10)

Finally, all the groups of stakeholders recounted examples of the impact of individual counselling on the students. The characteristics of the counselling cases are shown in Table 2.6. In the first year, the SHCs complained that there were many inappropriate referrals by teachers who were not able to discipline their students, pointing out that counselling could not be a substitute for better disciplining practices in the classroom. This was less of a concern in the second year, as the teachers’ and students’ awareness of the goals of counselling increased and there was a higher proportion of self-referred cases. The SHCs, students and teachers spoke of instances in which the SHCs, sometimes supported by the clinical psychologists, were able to help students to cope with and/or solve their problems. These included cases of harassment and abuse, domestic violence, academic difficulties, defiant behaviour, bullying and problems concerning relationships. The following are a few descriptions of the beneficial effects of counselling:

I spoke about my secret to (the SHC), which I had never done before, not even at home. She helped me to solve it and now I am fine. Now everyone is good to me; they all smile at me or speak to me. I liked it. (7th grade female student, 2010–11)

I was repeating the 9th grade. [The SHC] taught me study skills and gave me a timetable in writing. I followed that timetable and passed. Now I am in the 10th grade. (10th grade male student, 2009–10) the shape programme 39

Table 2.6. Characteristics of counselling cases

2009–10 2010–11 N % N % Class Grade 5 19 15.6 14 10.9 Grade 6 19 15.6 12 9.4 Grade 7 10 8.2 26 20.3 Grade 8 25 20.5 23 18 Grade 9 29 23.8 38 29.7 Grade 10 20 16.4 15 11.7

Sex Male 93 76.2 71 55.5 Female 29 23.8 57 44.5

Referred by Self 10 8.2 31 24.2 Teacher/principal 96 78.7 77 60.2 Speak Out Box 5 4.1 6 4.7

Other (parent, friend, SHC) 11 9 14 10.9

Type of problem Total number of problems identified 255 100 227 100 Educational/learning difficulties 100 39.2 60 26.4 Mental health 106 41.6 82 36.1 Reproductive and sexual health 3 1.2 5 2.2 Nutrition 1 0.4 3 1.3 Substance use 3 1.2 1 0.4 Bullying 4 1.6 23 10.1 Problems at home 21 8.2 31 13.7 Physical health 12 4.7 17 7.5 Other 5 2 5 2.2 40 d. rajaraman, p. khandeparkar, a. chatterjee, v. patel

[One] child was involved with a boy. She was her parents’ only child and used to be very disturbed in the class. The counsellor helped her and this child has really come out of the problem. She has determined that she will take care of herself and her studies at this moment, and not allow herself to be disturbed by all this. (Female principal, 2010–11)

My younger son was very short-tempered. They spoke to him. That anger he had learned from me because I used to get angry very quickly and he is just like me. Now my son is under control. They explained to him how to control his anger. (Female parent, 2010–11)

There used to be complaints about my son from all teachers in all classes. Now after counselling, there are no complaints about him from the teachers. (Male parent, 2010–11)

The coordinator of the intervention felt that the supportive supervision and joint consultations on cases had resulted in significant improvements in the SHCs’ counselling skills. In addition, this had helped all the counsellors to deal with cases relating to academic concerns (study skills, examination anxiety, detection of learning disorders and counselling on career options). Further, the coordinator of the intervention felt that this system had enabled the SHCs to deal with psycho-social issues such as bullying and disability, as well as physiological concerns such as nutrition. A few SHCs continued to seek help with cases related to reproductive and sexual health, relationships and suicidal ideation. The clinical supervisors and SHCs identified a few factors which could limit the effectiveness of the individual counselling. These included the fact that no specific time had been set aside for counselling in some schools, the stigmatising attitudes of some teachers, and the limitations in the SHCs’ capacity to deal with serious cases. The supervisors stressed the importance of ongoing supervision/training for the SHCs to ensure the continued development of their skills. This would also help in clearly defining the pathways for the referral of students who needed support from certified professionals.

Summary The SHAPE intervention aimed to introduce a locally appropriate school- based initiative for adolescents, within the WHO framework for health- promoting schools. The intervention comprised multiple components, the shape programme 41 which were delivered at the whole-school, group and individual levels. The primary agent of delivery was a lay SHC with a minimum qualification of having completed secondary school. This counsellor received strong support from a programme team of clinical psychologists. The intervention was targeted at students in the 5th–12th grades, and was piloted and refined in 10 schools in Goa between 2009 and 2011. The achievements of the SHAPE programme include the following:

of coverage, which increased from the first to the second year despite • All the activities undertaken under the intervention had a high level a reduction in the supervision of the SHCs. This was associated with preliminary evidence of the intervention’s positive impact on the students’ vision, nutritional practices, behaviour and well-being. In addition, the intervention resulted in improvements in the schools’ physical infrastructure, as well as policy and learning environment.

allowed for the rapid identification of problems and course corrective • The strong monitoring and evaluation system built into the intervention actions. For example, several changes were made in the second year in response to feedback from the mid-term evaluation. These included modifications in the content of the classroom module and the mode of delivery; regularly providing teachers with information on the activities; ensuring that a classroom and teaching period were allocated for the sessions on life skills; and arranging for a quiet and comfortable space for individual counselling. The monitoring and evaluation also included a robust system for the supervision of SHCs. The system provided for real-time feedback on performance and allowed for specialised attention to strengthen the SHCs with weak delivery skills.

agent of delivery for a multi-component school health promotion • The programme demonstrated that the lay SHC could be an effective programme. In India, the delivery of such programmes has generally been entrusted to teachers, healthcare providers, or peers who are already part of the school. One of the reasons for this is that it is perceived as a low-cost option. However, these programmes can compete with the other commitments of the teachers or healthcare providers, reducing the amount of time that the latter can devote to them. As for peer education programmes, the population of student peer educators is constantly shifting and this may limit the sustainability, and consequently, the effectiveness, of these delivery 42 d. rajaraman, p. khandeparkar, a. chatterjee, v. patel

models. The scalability of programmes delivered by dedicated teachers or health professionals is likely to be restricted by the limited number of such professionals in the country and their salary costs.

developed. These are to be published for wider use. The materials • Various training and implementation resource materials have been include a training manual for SHCs and a video on counselling, an intervention manual for classroom sessions, and a published casebook for school counsellors [49].

While the SHAPE programme showed some impressive results, there were also some constraints and limitations in the delivery. A few schools were not willing to allow instruction in sexual and reproductive health, underscoring the continuing lack of acceptability of the AEP across India. In the absence of a government mandate to educate schoolchildren on this subject, the acceptability of such instruction will continue to depend on the discretion of the school management. The absence of trained male resource persons also limited the benefits of the intervention for male students, who were not comfortable discussing their concerns regarding sexual and reproductive health with a female SHC. Finally, the delivery of the life skills programme suffered also because in some schools, no dedicated period was set aside for the subject. This was linked to the fact that the programme is not a part of the school curriculum. The evaluation indicated variability in the SHCs’ skills and performance, as well as in the level of support they received from the staff members. It was also recognised that there are limitations in a lay SHC’s ability to deliver appropriate counselling and provide facilitation in all the cases referred to her. For the SHCs to be capable of delivering individual counselling in an effective manner, continued training and development of skills would be required, besides strong supportive supervision. In addition, clear guidelines needed to be issued to the SHCs, as well as the management and staff of the schools, on the kinds of cases that can be referred and the type of results that can be expected. Given the limitations of lay counsellors in addressing serious cases, it would be essential to establish a strong referral network and formulate an appropriate policy on referrals to ensure the availability of appropriate resources in cases of serious health, emotional or social problems. This should ideally involve the local health systems to ensure sustainability. Perhaps most importantly, the major challenge will be to provide evidence that the approach is effective and affordable on a larger the shape programme 43 scale. The pilot phase of the project covered a small number of schools, and strong relationships were built between the NGO and school managements to facilitate the delivery of the programme. A large number of activities were undertaken, there was a high level of iterative review and modification of the programme, and the supervision of the SHCs, carried out by a highly qualified team, was fairly intensive. All these factors contributed to the success of the programme. However, the funding for this intensive programme was project-specific. The extent to which the quality and coverage of the services can be sustained in a scaled up programme remains to be seen. Another question is whether the governments would be willing to finance human resources dedicated to implementing health promotion activities in schools. Sangath is currently engaged in adapting the components of the SHAPE intervention to two other settings. One is the Goa Directorate of Education’s school health counselling programme, which Sangath is assisting by providing training and supervision to counsellors in government and government-aided schools. A second initiative is the forthcoming randomised controlled trial of the effectiveness of delivery models involving different human resources in the context of school- based health promotion in Bihar from 2014 . The trial will compare a teacher-delivered versus a lay SHC-delivered programme, based on the SHAPE model. These will be compared to a control arm, consisting of schools that implement the standard AEP. The experiences in the implementation of these schemes and the results of their evaluation will provide important evidence on the costs, requirements and effectiveness of different models of delivery of school-based health promotion programmes. 3

Divya Rajaraman, Bhargav Bhat, Vinita Nathani, AparajitaThe UDAAN Gogoi programme

The Setting: Jharkhand Jharkhand is a recently formed state in the eastern part of the country and has a population of almost 33 million. It was earlier a part of southern Bihar and through much of the 20th century, local politics was strongly influenced by a separatist movement led by the adivasi (tribal) populations. Jharkhand, which became a state in 2000, is divided into five administrative regions (Santhal Parganas, Palamu, Kolhan, North Chhotanagpur and South Chhotanagpur), and 24 administrative districts. The state’s capital is Ranchi. Much of Jharkhand is hilly and densely forested, and the land is rich in minerals. Mining is one of the state’s major industries. Coal, iron ore, mica, copper, clay and kyanite, bauxite and asbestos are the chief minerals. In addition, Jharkhand’s rich forest reserves fuel several industries, including lac, sal, timber and bamboo. Because of the young age and limited resources of the state, the government of Jharkhand faces serious challenges in administration and management. Moreover, regular political agitations and unrest take a heavy economic toll [50]. Tribals form a high proportion of the population (26.3%), compared to the national average of 8% [51]. Of the remaining population, 12% belong to Scheduled Castes (traditionally disadvantaged population groups). Table 3.1 presents the socio- demographic and health indicators of Jharkhand. The sex ratio is low, at 947 females to 1000 males. Although the mean age of marriage for males is 22.9 years, a striking 32.3% marry before the age of 21 years, the legal the udaan programme 45

Table 3.1. Socio-demographic, economic and health indicators of Jharkhand

Indicator Jharkhand

Area1 79,714 square km

Population1 32.96 million

Population density1 414 per square km

Residents in rural areas1 76%

Annual per capita income, 2009–104 Rs 22,780

Households with electricity2 40%

Households with piped drinking water2 11%

Households with access to a latrine2 22.6%

Women of age of 20–24 years married 61.2% by 18 years of age

Men of age of 25–29 years married 47.1% by 21 years of age

Crude birth rate3 25 per 1000

Child sex ratio1 943

Infant mortality rate3 38 per 1000 live-births

Children Immunised2 35%

Women with anaemia2 70%

Underweight children under 3 years of age2 59%

Antenatal care (at least three visits at last birth)2 37%

Institutional deliveries2 19%

Total literacy rate1 67.63%

Male literacy rate1 78.5%

Female literacy rate1 56.2%

1 Office of the Registrar General and Census Commissioner. Census of India 2011 tables: http://censusindia.gov.in 2 Ministry of Health and Family Welfare and International Institute for Population Sciences. National Family and Health Survey 2005–06. Jharkhand fact sheet. 3 Registrar General, India. Sample Registration System Bulletin December 2011 4 UNDP. Jharkhand Human Development Report 2011. 46 d. rajaraman, b. bhat, v. nathani, a. gogoi age of marriage for men. The mean age of marriage for females is 18.3 years; however, 35.9% marry before the legal age of marriage for women (18 years). The health indicators for the state are poor in comparison to the national average. There is a substantial difference between the levels of male and female literacy in Jharkhand, the figures for men and women being 78.4% and just 56.2%, respectively. The 2009–10 data of the District Information System for Education reveal that the state of the infrastructure in government schools is poor, and that the pupil:teacher ratio in upper secondary schools is low, at 47:1 [52]. Notwithstanding the current gaps, there is evidence of improving trends in these areas. This is a result of the current efforts to improve education under the Central Government’s Sarva Siksha Abhiyan (Education for All) initiative. An attempt is being made to increase the number of day schools in rural areas, and to set up project day schools and residential Kasturba Gandhi Balika Vidyalayas (KGBVs) for girls in remote areas. The state government reports that as a result of the efforts to promote female education, a substantial number of girls who had dropped out of school are returning. The school mid- day meal programme has been successfully rolled out across the primary schools, with the rate of implementation being 95% in 2009–10 [52]. It is envisaged that this will contribute to an increase in enrolment in schools and improve the nutritional status of children. Despite whatever progress has been made in improving infrastructure and providing essential services, such as health and education, there is a need to strengthen the initiatives in these areas, considering the persistent poverty and instability in the region, low literacy rates, low rates of retention in school and poor health indicators. CEDPA’s UDAAN – Towards a Better Future programme, which focuses on promoting information and knowledge related to reproductive and sexual health among school-going adolescents, operates within this context.

The UDAAN programme History The goal of the UDAAN programme was to scale up and integrate a sustainable and holistic education programme on life skills within the state education system, with a view to promoting positive and comprehensive development of adolescents, as well as creating a cadre the udaan programme 47 of healthy and empowered adolescents capable of making healthy decisions. It was hoped that this would discourage risk behaviours and bestow them with the information, skills and tools needed to adopt healthy behaviours. The UDAAN programme is one of the largest school-based health promotion programmes in India and has been scaled up over the years. It provides adolescents attending government schools in Jharkhand with education on sexual and reproductive health and training in life skills. It is supported by the David and Lucile Packard Foundation. The high level of political commitment in the state to scaling up education in sexual and reproductive health for school-going adolescents resulted in the formation of a partnership between the Jharkhand State AIDS Control Society (JSACS), Jharkhand Department of Human Resource Development (HRD), and the Centre for Development and Population Activities (CEDPA), India, with support from the David and Lucile Packard Foundation. The Government of Jharkhand requested the Packard Foundation to assist it in strengthening the School AIDS Education Programme in the state, and all the partners jointly finalised the modalities of the partnership. CEDPA was nominated as the nodal agency for providing technical assistance and support for the implementation of the programme. The Packard Foundation also helped with the formulation of a state youth policy, which was important for leveraging additional political support. The UDAAN programme replaced the Jharkhand School AIDS Education Programme (SAEP), which had been initiated by JSACS in 2003. The SAEP had been implemented for two years, covering students from the 9th–11th grades in 850 schools across the state (out of 1200 secondary schools and 450 intermediate colleges). At the core of this programme was the NACO–UNICEF–UNESCO training package, “Learning for Life”, the primary focus of which was HIV/AIDS. An end-line assessment of the programme had suggested that an age-appropriate curriculum should be developed for 9th and 11th grade students. In addition, it was felt that there was a need to cover a broader range of health issues, including subjects not related to HIV, and that the scope of the programme should be widened to give it a greater focus on general adolescent reproductive and sexual health. In 2006, a core committee was set up to review the SAEP programme. As a result, the curriculum was revised and expanded to include topics on life skills, marriage, parenthood and gender roles. CEDPA took the lead in providing technical 48 d. rajaraman, b. bhat, v. nathani, a. gogoi support for the development of the programme. CEDPA already had a few years’ experience in developing and implementing similar programmes for the empowerment of adolescent girls, and it is for this reason that JSACS requested it to provide technical assistance to strengthen the SAEP programme. An important upshot of this collaboration was the designing and development of age-appropriate content for students in the 9th and 11th grades. This would be relatively more interactive and activity-based, and aligned to the “Better Life Options for Adolescents” training pedagogy. The new curriculum was christened “UDAAN” (“flight” in Hindi). The overall goal of the programme is to improve knowledge of reproductive health among school-going adolescents by facilitating the introduction of education on sexual and reproductive health in schools. The teaching materials were translated and field-tested in three schools in Ranchi through teachers from government schools and managed by the Directorate of Secondary Education (part of the Department of Human Resource Development). The feedback received was incorporated into the final intervention package. JSACS formally handed over the programme to the Department of Human Resource Development in 2007, in its second phase. The UDAAN programme was delivered in three phases between 2006 and 2013:

master trainers from NGOs and private organisations and 757 • During Phase I (2006–07), UDAAN was under JSACS. Forty-eight nodal teachers were trained. The programme was implemented in 444 schools, covering approximately 30,000 students. The district education officers of 22 districts and all the principals involved were sensitised to the programme.

the government sector and 1115 nodal teachers from 623 schools • By the end of Phase II (2007–09), a total of 62 master trainers from had been trained. UDAAN was implemented in 1067 secondary government day schools. It covered about 200,000 students across the 24 districts of Jharkhand. During this phase, two approaches to the delivery of the programme were tested: the “camp” mode, in which the syllabus was taught intensively over one month, and the “regular academic year” mode, in which the syllabus was delivered over six months. At the end of Phase II, the second alternative was deemed to be preferable to the first because its implementation was more feasible. The district education officers of the 24 districts were the udaan programme 49

oriented on the programme. The National AIDS Control Organisation (NACO) disseminated The UDAAN curriculum to the State Councils of Educational Research and Training (SCERTs) and State AIDS Control Societies (SACSs) across the country, and CEDPA was recognised as an official resource organisation for adolescent education.

289 nodal teachers received training from KGBVs. The reach of the • During Phase III (2009–13), 25 additional master trainers and programme increased from 1067 to 1258 schools. These included all government secondary and higher secondary regular day schools, as well as project day schools for girls and KGBV residential schools for girls that fall under the Central Government’s Sarva Siksha Abhiyan programme to promote girls’ education.2

From the beginning of the programme to the end of Phase III, a total of 87 master trainers from the government sector and 2161 nodal teachers have received training.

The delivery team

From 2007 onwards, the SCERT in the Department of Human Resource Development has been the primary implementing agency for the UDAAN programme. JSACS has lent some financial support and assisted in monitoring, while CEDPA has provided technical support, funded by the David and Lucile Packard Foundation. The Department of Human Resource Development has designated human resources from among its existing staff to support the management of the programme and the monitoring of its implementation. At the district level, the key personnel involved in coordinating and delivering the programme from the Department of Education are the district education officer, the udaan mitra, who is a nominated liaison officer for the UDAAN programme, and the gender coordinator, who is the primary liaison officer for the KGBVs. During all three phases, the UDAAN teams in the district education office were responsible for the identification and nomination of nodal teachers

2 These schools were set up to retain those girls in school who would otherwise have dropped out due to the distance from their homes to regular schools, or because of the incidental costs associated with enrolment in day schools. Female dropouts are actively recruited back to the residential girls’ schools, which are run by a warden and female teachers who live on the campus. Since many students have previously dropped out of school, their average age is relatively high and some are even married. 50 d. rajaraman, b. bhat, v. nathani, a. gogoi who should be trained and given the responsibility of monitoring the implementation of the programme as a whole. CEDPA India is a non-governmental organisation (NGO) that works with communities, women leaders, civil society and the government to equip women and the youth to lead healthier lives. It has done pioneering work in the sphere of education in life skills for adolescents. CEDPA began its investment in the youth in India in 1987, when it launched the Better Life Options Programme (BLP) to help adolescent girls and young women make better choices concerning their health, economic status, participation in public life, education and employment. The programme is based on an empowerment model and combines elements of academics, education on family life, life skills and personality development, vocational training, and information on health and health services. Over the past two-and-a-half decades, CEDPA India has launched a number of ground-breaking initiatives and programmes as part of its commitment to continuous programmatic and institutional improvement. It has experimented with, piloted, refined and implemented – at a substantial scale – a full portfolio of programmes for adolescents, both in school and out of school. CEDPA has played an important role by liaising between JSACS and the Department of Education, and as an intermediary agency in order to support and facilitate dialogue between the Department of Education and the schools. It has also provided technical support for the development of the curriculum and materials, as well as the development of the training module and the delivery of training for master trainers. In addition, it has facilitated the training of nodal teachers. Finally, it has assisted with strategic planning and the monitoring and evaluation of the programme. The overall contributions of CEDPA to UDAAN are coordinated by a national UDAAN programme manager. At the regional level, two programme officers stationed in Jharkhand are responsible for liaising with the district education office teams from the districts. One of the aims of the provision of technical support is to monitor and evaluate the programme to ensure good quality and wide coverage. It is envisaged that assessing the effectiveness, success and shortcomings of the programme, as well as the challenges encountered, will help to strengthen its content and delivery. A broader goal of the monitoring and evaluation is to understand the situation and share the lessons learned the udaan programme 51 in the sphere of education on reproductive and sexual health and foster public–private partnerships for education, in order to contribute to the national and international evidence base in this area. The purpose of the monitoring and evaluation has been described in the following words:

. . . we have always tried our best to really gather evidence. Our objective is not really to show that the programme is changing the world, but more along the lines of identifying lessons which would ultimately tell us that when we do a programme at scale, these are the things that work and these are the things that don’t work. . . . There is no point in doing a programme if you don’t share the lessons. So evaluation is one of the most important and expensive parts of this whole programme. (CEDPA Programme Management team member)

In Phase III, a monitoring information system (MIS) was established to gather information on the implementation of the programme in every school and to record the reasons, if any, for the failure to complete the UDAAN sessions. Nodal teachers are requested to hand in quarterly reports to their principals, and these are forwarded to the district udaan mitra (day schools) or gender coordinator (residential girls’ schools). The reports are then forwarded to CEDPA India for collation and analysis. Since the reports are compiled on an annual basis, site visits are an important additional component of the monitoring strategy. When the district education office team, comprising the district education officer, udaan mitra and gender coordinator, visits the schools as a part of its routine inspections, it uses the opportunity to monitor the programme. The programme is also reviewed during monthly meetings between the district education officer and school principals in the districts where issues related to implementation have been identified or certain challenges are being faced. The programme staff of CEDPA also visits the schools, meets the nodal teachers and reviews the implementation of UDAAN. In addition to internal monitoring, evaluation has also been conducted periodically by either CEDPA or an external agency, usually at the end of the academic year or on the completion of a phase of the project. Such evaluation has focused on assessing the effectiveness of the programme and identifying barriers to its implementation. The findings have been taken into account while planning for the subsequent phase of the programme. 52 d. rajaraman, b. bhat, v. nathani, a. gogoi

Content The UDAAN programme has two components. The first is education in life skills, delivered to students in the 9th–11th grades through individual teaching modules specified in the UDAAN manual (Table 3.2). The primary focus of the programme is on the sexual and reproductive health of adolescents, although other issues, such as handling peer pressure, the consequences of early marriage, substance use and communal harmony,

Table 3.2. The UDAAN syllabus

Topics Covered

Module 9th grade 11th grade

Introduction Getting started Getting started

Life skills Understanding life skills What if…. Self-awareness and self-esteem Coping with emotions and Effective communication stress Management Assertiveness skills Improving interpersonal relationships; saying “no”

Goal-setting Setting a goal What do I want to do? Planning to reach my goal

Growing up Understanding changes Am I healthy? during adolescence Common diseases Sexual maturation during adolescence Myths, misconceptions and facts

Friendship Good friends Can boys and girls be friends? Dating

Values Let’s understand the values My own values of life

Peer pressure Relating with our peers

(continued) the udaan programme 53

Table 3.2. (continued)

Gender, sexual Gender roles and relationships Sexual abuse harassment/ What is sexual harassment? Domestic violence sex-related Sexual abuse violence What is rape?

Pregnancy in Early marriage and its Sexual decision-making adolescents/ consequences Having a baby by choice, adolescence to not by chance adulthood

Marriage and N/A Marriage parenthood Husband’s and wife’s roles and responsibilities Why son, why not daughter?

RTIs/STIs/HIV/ RTIs/STIs; basic facts about Basic facts about HIV/ AIDS HIV/AIDS AIDS Assessment of risk HIV transmission and Testing for HIV prevention Persons living with HIV/AIDS: Testing for HIV infection removing discrimination Friendship with HIV- positive persons

Substance abuse Adolescents and substance Adolescents and abuse substance abuse Overcoming substance abuse

Value of harmony Living in peace and harmony Living in peace and harmony

Moving ahead Towards a better future… Towards a better future

are also covered. It is recommended that the modules be delivered on a weekly basis over 6–9 months, in 27 sessions of 45 minutes each for 9th grade students and 24 sessions for 11th grade students. To facilitate classroom planning, an annual academic timetable has been developed for every school. The second component of the programme is the student-led “Udaan clubs” for life skills activities. The nodal teachers 54 d. rajaraman, b. bhat, v. nathani, a. gogoi also organise and facilitate students’ group activities, such as poster competitions, discussions on issues relevant to adolescents, interactive games and campaigns and events aimed at raising awareness in the community. The UDAAN programme encourages a participatory learning approach, on the premise that learning is best achieved by actively involving the students in class. The idea is that learners should identify their own problems, discuss the possible solutions, and plan and ultimately take effective action. The participatory teaching methods include case studies, brainstorming, field visits, panel discussion, storytelling, group discussion, debate, posters, role play, games and projects.

The UDAAN Case Study Evaluation Document review A total of 13 UDAAN reports from the period 2006–11 were included in the review of the documents of the case study. These comprised internal monitoring and programmatic reports, as well as external evaluation reports, as summarised in Table 3.3.

Qualitative end-line evaluation A sample of 26 respondents was selected to represent the perspectives and sum up the experiences of a range of stakeholders involved in the design, implementation and supervision of the programme. The four CEDPA staff members were purposively selected in the light of the key roles they played in delivering the programme. Other respondents were chosen randomly from three of the 24 districts of Jharkand. These were Chatra, Dumka and Gumla. The district education officer of each of the randomly selected districts was invited for an interview, and an udaan mitra and gender coordinator were purposively selected from one of the districts. As for the remaining respondents, master trainers, day schools and KGBVs were randomly selected from each district. However, in the district of Chatra, two schools that had been chosen were replaced on the advice of the udaan mitra, who cited their remoteness and security concerns as reasons not to include them. Students were not included as they were preparing for their examinations when the interviews were being conducted. The respondents are listed in Table 3.4. The interviews the udaan programme 55 (continued) Sample 1115 trainees schools 6498 students from112 group (2666 in the intervention and 3832 in the comparison group) groups, Number of focus groups, participants in focus interviews and semi-structured not reported 45 trainees

Study design/data source design/data Study methods and qualitative Quantitative test knowledge and post-training Pre- participants from feedback Written study Quasi-experimental (KAP) attitudes and practice Knowledge, test comparing post-intervention survey, UDAAN by of students covered results with those of students not covered study Qualitative discussions with students, group Focus with teachers, interviews semi-structured managers and programme principals methods and qualitative Quantitative test knowledge and post-training Pre- participants from feedback Written

Document title Document of Trainings District-level Nodal Teachers Study. Evaluation Phase I Project a towards UDAAN: future better Qualitative Phase I Project UDAAN: Study. Evaluation future a better towards of Trainers’ of a Training Report State Jharkhand for Workshop Trainers Master Documents reviewed for the UDAAN case study the UDAAN for Documents reviewed Author(s) India CEDPA India and CEDPA USA CEDPA India and CEDPA USA CEDPA India CEDPA Year Phase I 2008 2008 2008 Phase II 2009 Table 3.3. Table 56 d. rajaraman, b. bhat, v. nathani, a. gogoi

Sample 2234 students from schools and 40 intervention 40 comparison 1789 from schools groups, Number of focus groups, participants in focus interviews and semi-structured not reported 40 schools 2535 students from groups, Number of focus groups, participants in focus interviews and semi-structured not reported

Study design/data source design/data Study study Quasi-experimental post- comparing KAP survey, of students results test intervention with those of UDAAN by covered students not covered study Qualitative discussions with students, group Focus with nodal interviews semi-structured principals and trainers, master teachers, district education officers study Cross-sectional test no pre-intervention KAP survey, group control or study Qualitative discussions with students, group Focus with nodal interviews semi-structured principals and trainers, master teachers, district education officers

Document title Document Academic Phase II: Regular Mode KAP Evaluation Year Year Academic Phase II: Regular Evaluation Mode Qualitative Mode KAP Phase II: Camp Evaluation Mode Qualitative Phase II: Camp Evaluation

(continued)

Author(s) Economic Information (EIT), Technology and Kolkata India CEDPA EIT and CEDPA India EIT and CEDPA India EIT and CEDPA India Year 2009 2009 2009 2009 Table 3.3. Table the udaan programme 57

Sample training 260 teacher 13 training participants from batches 368 schools (out of 1067 schools implementing UDAAN) 30 day 1793 students from schools 31 KGBVs 787 students from groups, Number of focus groups, participants in focus interviews and semi-structured not reported 40 from trainers: 63 master schools and day regular KGBVs 23 from udaan mitras Study design/data source design/data Study methods and qualitative Quantitative test knowledge and post-training Pre- participants from feedback Written report indicator Process data on programme Compiled implementation Quasi-experimental and post- pre- comparing KAP survey group) (no control scores test intervention study Qualitative discussions with students, group Focus with nodal interviews semi-structured and teachers and scores knowledge trainers’ Master of performance assessment knowledge of post-training Comparison of master and performance scores test schools day government between trainers 2007–09 compiling data from and KGBVs, Document title Document Training of District-Level Report Kasturba from of Nodal Teachers (KGBVs) Vidyalayas Gandhi Balika on Monitoring Report System Information Intervention Phase III: Pre-Post Report KAP Evaluation Intervention Phase III: Pre-Post Report Evaluation Qualitative of Analysis A Comparative Performance: Trainers’ Master Regular from Trainers Master Schools and from Government KGBVs (continued)

Author(s) India CEDPA India CEDPA India CEDPA India CEDPA India CEDPA Year Phase III 2010 2010 2010 2010 2010 Table 3.3. Table 58 d. rajaraman, b. bhat, v. nathani, a. gogoi

Table 3.4. Respondents interviewed for UDAAN end-line qualitative evaluation

CEDPA programme staff 4

District education officers 3

Udaan mitra (Department of Education day school liaison officer) 1

District gender coordinator (Department of Education KGBV 1 liaison officer)

School principals in day schools (random selection) 3

Wardens in the KGBVs (random selection) 3

Master trainers, residential schools (random selection) 2

Master trainers, KGBVs (random selection) 2

Nodal teachers from day schools (random selection) 4

Nodal teachers from KGBVs (random selection) 3

Total 26

were conducted by a member of the Sangath research team between 17 January and 3 February 2011.

Acceptability The acceptability of the intervention was assessed through the qualitative end-line evaluation of the stakeholders’ perceptions regarding the need for the UDAAN programme, and the suitability of its content and delivery. Their views on the reported participation in and attitudes towards the programme were also taken into account. The district education office staff, CEDPA management, principals, master trainers and nodal teachers were almost unanimously of the view that the programme was meeting an important need, considering the fact that students in government schools are socially and economically disadvantaged, and require information and education on hygiene and the causes of disease. Drawing attention to the low status of women in the region, many stakeholders also spoke of the potential of the programme to raise the udaan programme 59 awareness of gender issues and the rights of women so as to change the outlook of young people. Several nodal teachers spoke about how they would have appreciated it if they had been given such information in their adolescence. One said:

The training that we are giving them was not given to us when we were adolescents at school. We did not know anything. We faced a lot of problems. Our bodies were changing and we faced a lot of problems. We were not able to share this with our guardians, as there was a lot of hesitation about these subjects at that time. We were not able to share this with our family and relatives, but these children are being educated on this and this is being done through me. What is special about this programme is that the 9th grade girls are getting this education at the time when they need it the most. (KGBV nodal teacher, Dumka)

Wardens and nodal teachers from the KGBV residential girls’ schools seemed to feel particularly strongly about the need for the UDAAN programme. The KGBV staff members were of the view that there was a crying need to educate their students on (i) hygiene, particularly in relation to menstruation, because they (the staff) had observed poor hygiene practices among the girls and had also found that many had reproductive tract infections; (ii) sexual health, because they felt that their students were likely to get involved in relationships with boys or men during the holidays; and (iii) basic life skills and decision-making, as they lived far from their families. Of all the stakeholders interviewed, only two nodal teachers expressed lingering doubts about the desirability of providing information 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. In the words of one teacher:

One bad thing about the programme is the information we give about adolescence. . . . Our children are not mature enough to understand these things and they may act on the information, which is not good. So we feel that we shouldn’t have this session [on adolescence] . . . they are not able to think. It is good to give the information, but they start doing these things when they learn about them . . . I think after the 10th grade, they are more mature, so in the 11th and 12th grades, it is okay to give this information. (Day school nodal teacher, Dumka) 60 d. rajaraman, b. bhat, v. nathani, a. gogoi

Although the nodal teachers were generally enthusiastic about the programme, some mentioned that support from fellow teachers was not always forthcoming, either because they did not consider the subject important or did not approve of the content of the programme. Further, a few nodal teachers reported that the students’ parents had expressed misgivings about the provision of education on sexual health in schools. This was not considered a major barrier by the UDAAN programme staff, since parents in India have a limited say in what their children learn in school, even with respect to other subjects. (Most schools do not have a parent–teacher association or any other forum for interaction between parents and teachers.) Nevertheless, the district education officers, CEDPA programme staff and principals all recognised the need to sensitise the community to the need for the UDAAN programme. One of the CEDPA programme staff members related how, in the early days of the implementation of UDAAN, a local newspaper had published an inflammatory article on the component on sex education, and related how CEDPA, along with state officials, had managed to deal with the situation by sensitising the media and community leaders. Those interviewed recalled no further incidents of this sort, indicating the growing acceptability of the programme. However, all groups of stakeholders expressed the concern that community norms and peer pressure might adversely affect the efforts to change the attitude and behaviour of the students. They suggested that this could perhaps be tackled by expanding the programme to cover the parents and communities. In this context, one school principal recounted that he had invited and encouraged parents to attend the UDAAN sessions. Another had encouraged the UDAAN teacher to deliver sessions to visiting students from other schools that were not implementing the programme. students had found the topics taught under the programme interesting. Qualitative evaluations commissioned by CEDPA indicated that the However, in the end-line evaluation, a few nodal teachers said that the students’ responses to the programme were mixed. The nodal teachers gave many examples of how students put the information to good use and changed their behaviours positively; however, a few mentioned a lack of interest in UDAAN on the part of some students. This was possibly due to the fact that no formal school examination was being held for the topics covered under the programme. Another factor could have been the udaan programme 61 poor school attendance, which would affect exposure to the UDAAN sessions as well. Several teachers suggested that to improve attendance and increase the students’ interest in the programme, the latter should be graded on their attendance in the UDAAN sessions, as well as on their performance, thereby increasing their accountability. According to one teacher:

Since it is not there in the curriculum, the children don’t show that much interest in it. When we go to class with the book and say that today we will learn this topic, then many of the children say, "Sir, this doesn’t come in the examination." (Project school nodal teacher, Dumka)

Feasibility

To assess the feasibility of the programme, a review was made of the UDAAN programme reports between 2008 and 2010 to obtain information on: the development and implementation of the teacher training programme; coverage of the programme in terms of the number of schools implementing it; proportion of lessons delivered in these schools; attendance of the sessions by students; and barriers to and facilitators for the implementation of the programme. The end- line qualitative evaluation aimed to assess feasibility by gathering the stakeholders’ perceptions on the barriers to and facilitators for the establishment of the programme and the systems for the implementation of the programme.

Training

The training workshops for the UDAAN master trainers and nodal teachers were organised by the Department of Human Resource Development in partnership with CEDPA. The majority (92%) of master trainers rated the CEDPA facilitators as highly effective and 82% of them agreed that the objectives of the workshops had been fully achieved. Those who trained to become nodal teachers also rated the training highly in terms of the trainers’ skills and content of the course.3 However, a large number of master trainers and nodal teachers felt that they would have preferred it if the training had been of a longer duration, as this would have helped

3 Numbers were not available from the evaluation reports 62 d. rajaraman, b. bhat, v. nathani, a. gogoi them to gain confidence in the subject and become more familiar with the style of participatory teaching. The training for master trainers, conducted by the CEDPA staff, was structured as a five-day residential workshop, consisting of 50 hours of teaching and practice sessions. The training covered a variety of topics from the UDAAN curriculum, participatory teaching techniques, and sessions of practice teaching. The criteria for the selection of master trainers, who were selected from schools and other educational institutions, were that they should be senior teachers, preferably with some experience in adolescent education, and below the age of 45 years. Between 2006 and 2009, 141 master trainers were trained in two batches, and in 2009, 36 received refresher training in two batches. Only 36% of the master trainers from day schools were women. The curriculum and format of the training for nodal teachers were modelled on those of the training for master trainers. The training was conducted by the master trainers, with some supervision and facilitation by the CEDPA programme staff. To standardise the selection of nodal teachers, CEDPA developed selection criteria that were approved by the UDAAN Core Committee. School principals were requested to nominate two candidates, preferably one male and one female, for the nodal teacher training. The majority of those selected were science/biology teachers, on the assumption that they would have some experience of teaching reproductive and sexual health and would also be comfortable doing so. Males formed a larger proportion of the teachers selected for training from day schools. In Phase I and Phase II, women constituted only 26% of those trained to become nodal teachers. However, in 2010, 289 female teachers from KGBVs were trained in 14 batches in the entire state. The performance of master trainers was evaluated by CEDPA through observation of the practice teaching sessions, pre- and post-training knowledge tests, and grading of performance during the training for nodal teachers. An analysis of the results of the tests showed a statistically significant increase in the level of knowledge of the master trainers – the proportion of correct answers rose from 49.4% before the training to 69.6% at the end of the training. In terms of performance, the KGBV master trainers fared particularly well, with 63% obtaining A grades, compared to 35% of the teachers from government day schools. Almost all master trainers were rated as excellent (A) or good (B), with only five of the 62 evaluated receiving a C. In the case of the nodal teachers, too, the udaan programme 63 there were substantial and significant increases in knowledge of issues related to adolescent health. The low baseline knowledge highlights the importance of providing health education and training in life skills to teachers, while the improvement in knowledge following the training workshops indicates the effectiveness of training in increasing teachers’ knowledge. Consistent with the findings of the quantitative assessment of the training, the end-line qualitative evaluation indicated that the CEDPA programme team, government officials, master trainers and nodal teachers felt that the trainers were competent, and that the training had succeeded in giving them a basic understanding of the participatory methodologies and subject matter of the UDAAN programme. Several participants spoke about how they had personally benefited from the training. One said:

If you don’t have knowledge of the subject, then how will you take the class? You must become the way you want the children to become. After teaching the UDAAN programme, there have been a lot of changes in me. I don’t know what changes there have been among the children, but individually I have changed a lot. (Master trainer, Dumka)

Some suggestions were made on how to improve the quality of teaching. The UDAAN programme team pointed out that the school principals did not always adhere to the criteria specified for the selection of nodal teachers. Consequently, some of the teachers being trained as nodal teachers were not very motivated, which could hinder and delay the effective implementation of the programme. As for the content of the training, the nodal teachers and principals recommended the addition of a few topics to the curriculum. These included the identification, prevention and treatment of several diseases; additional information on sanitation and hygiene; and women’s legal rights and empowerment. They also felt that there should be a greater focus on the consequences of making misguided choices in life. Confirming the views expressed in the written feedback from the participants in the training, the nodal teachers who were interviewed said that the duration of the training should have been longer to enable the participants to practise teaching all the sessions covered in the syllabus. This was especially important because some of the content and teaching methodology were new to them. In the words of one UDAAN teacher: 64 d. rajaraman, b. bhat, v. nathani, a. gogoi

We didn’t know anything much about life skills. In the training, the focus was more on the delivery of sessions on sexuality. After coming home, when I read about the sessions on life skills, I thought that these were very good and should be delivered to the children. (KGBV nodal teacher, Gumla)

All the district staff members, master trainers and nodal teachers felt strongly that the nodal teachers should undergo refresher training at least once a year. In their view, this would help them feel more confident about teaching the subject, serve to motivate them, and facilitate the introduction of any new materials added to the curriculum. The following quotes illustrate the perceived need for refresher training:

One can never give enough training because the method of training will change every time you give training. So training should be given from time to time for any programme. (Master trainer, Gumla)

There is no need to train them for many days, but there should be refresher training to renew their enthusiasm. At least once in six months, there should be training of three days or five days. It should aim to give them a sense of responsibility . . . so that they also feel that they have some role in this programme. They should not be facilitating sessions because the headmaster has instructed them to do so or the DEO has sent a directive, but they themselves should feel that it is their responsibility. (Day school principal, Chatra)

While the CEDPA team members recognised the potential utility of regular refresher training, they felt that it was not feasible, given the significant logistical and financial implications. A CEDPA staff member pointed out that refresher training of nodal teachers would be possible only if the Jharkhand government saw it as a priority, and earmarked or raised sufficient resources for the development and implementation of such training. Finally, all the nodal teachers and some of the master trainers and principals recommended the introduction of visual teaching aids, such as posters, charts, models and/or films. They felt that the use of visual aids would serve to improve the students’ understanding of the subject, keep them engaged and satisfy their curiosity. Further, it would ease the teachers’ discomfort. The following quotes illustrate these points: the udaan programme 65

There should be at least one lab for this purpose that is fully equipped for students. If the boys are sent there once, they can see everything for themselves and understand it. And if they still feel curious about something, they can ask the master trainers, who will be available. (Day school principal, Dumka)

I felt a little hesitant while teaching the sessions on the use of condoms in the context of HIV/AIDS. When talking to the students, I was unsure about how to explain how to use condoms because the girls don’t know much about all that right now. Even if they knew, I was not able to bring a condom to show them. . . . I was giving them some information and telling them, but if there had been a picture showing how it is to be worn, then they would have understood easily. (Day school nodal teacher, Dumka)

Coverage and implementation in schools In Phase I and Phase II (2007–09), the coverage of the programme was reported in terms of the number of schools in the state with trained UDAAN teachers. In the first year of the implementation of the programme, the camp mode approach was to be used to deliver the sessions. Twelve (9th grade) to 13 (11th grade) sessions of the UDAAN curriculum were to be delivered in at least 1000 schools in a short period of time. Although the camp mode approach brought about an improvement in the students’ levels of knowledge and awareness, as well as their attitudes, the improvements were below expectations. Consequently, the regular academic year mode approach was used the following year. Accordingly, the sessions were delivered over a full academic year. An evaluation was carried out to gather information on students’ exposure to UDAAN sessions in the schools where the programme was running, on the basis of the students’ self-reported attendance of UDAAN classes. While 86% of the 9th grade students and 61% of students of the 11th grade students said they had attended at least one UDAAN session, the percentages of students who had attended at least three sessions were only 41 and 13, respectively. This low exposure could be explained by poor school attendance and the relatively fewer number of students enrolled in the 11th grade. To better understand and address these reasons, an MIS was put in place in 2009–10 to monitor the completion of the programme in UDAAN schools. Another important issue to be considered in relation to the coverage 66 d. rajaraman, b. bhat, v. nathani, a. gogoi of the programme is the overall retention rate in secondary schools. While the UDAAN programme has made an impressive achievement by rolling out life skills sessions in secondary schools across Jharkhand, the low retention rate in these schools prevents the programme from reaching many adolescents.4

Facilitators In the qualitative end-line evaluation, the teachers named the following as facilitators for the implementation of UDAAN: a large number of the teachers trained; gender matching of the teachers and students; support from the principals/wardens; and mainstreaming of UDAAN by way of inclusion of the sessions in the school timetable. Another factor that was considered important in this respect was the fact that the government had given a mandate for the implementation of the programme. Implementation was much easier in KGBVs, as their residential nature made it possible to conduct UDAAN sessions in the evenings or on weekends. A master trainer and nodal teacher said:

These sessions are held from June to December, so we get sufficient time to complete them. And because this is a residential school, if I am unable to complete the sessions on time, then I hold sessions on Sundays to complete the syllabus. (KGBV master trainer and nodal teacher, Dumka)

Barriers In some schools, the syllabus was not completed. This was attributed primarily to the heavy workload of the nodal teachers:

Since I am a science teacher, I have been given the responsibility of UDAAN as well. I face problems because I have to teach my subject also and teach this also. And there is nothing in this that is bad. Rather, I enjoy teaching this, but the reason it is difficult at times is that I have to teach science in five grades, from the 6th to 10th grades. If there were designated teachers to teach UDAAN, then this programme would be more effective. (Day school nodal teacher, Gumla)

There is currently no incentive or public recognition given to those

4 In 2009–10, the net enrolment rate in upper primary school was 60.3%, and many of these students do not go on to/complete secondary school [52]. the udaan programme 67 implementing the UDAAN programme. Some staff members of the district education office and nodal teachers suggested that UDAAN teachers be incentivised or publicly recognised for their contributions. Apart from the additional workload that put the teachers under considerable pressure and the lack of recognition, several other problems were encountered by the programme. These included the fact that every school did not have two nodal teachers, often because of the transfer or retirement of teachers. Further, some nodal teachers were not comfortable teaching reproductive and sexual health. Another problem was the large size of the classes (up to 150 students), which made participatory teaching difficult. The teachers’ other responsibilities, such as electoral monitoring and census duty, took away from the time they could devote to the UDAAN activities. In addition, frequent strikes in the region often resulted in the closure of schools. The lack of female teachers for female students was problematic, particularly in remote schools, where male teachers felt uncomfortable explaining issues related to reproductive and sexual health to girls and/or the girls felt too shy to discuss these issues with a male teacher. Raising the problem of the inevitable retirement and transfer of teachers leading to a reduction in the number of staff members available for delivering the programme, one district education officer said that recruiting younger teachers for the training was an obvious way of ensuring that UDAAN teachers remain in the system. However, the selection of nodal teachers ultimately depended on the principals. Some nodal teachers recommended that school-wide training for nodal teacher would help to increase the resources for delivering the programme. Another suggestion made by all the stakeholders was that UDAAN should be made a part of the examinable curriculum to improve the coverage of the programme. It was felt that this would increase the motivation of the teachers and principals to implement the programme, and would ensure that the necessary resources for staff, training and course materials were sanctioned. The benefits of this option were described thus:

If it were a textbook subject . . . we would get very good buy-in from the teachers because then their entire teaching of the AEP would become a part of their teaching plan, as any other subject to be taught in that particular class. So the value of the AEP and the status of the AEP in 68 d. rajaraman, b. bhat, v. nathani, a. gogoi

the textbook curriculum would improve . . . (Member of the UDAAN management team)

Monitoring information system The quarterly MIS reporting format for each school seeks information on the number of UDAAN sessions delivered, the number of students (by grade and sex) who were covered by the programme, the number of UDAAN clubs and the activities undertaken, and the number of informational meetings held and monitoring visits made by the district education officer. In 2009–10, just over a third (34.5%) of all UDAAN schools provided an MIS report and only 2.4% provided all three quarterly reports. Of the schools that did submit a report, 51% reported that they had completed less than half of the 27 scheduled sessions. The majority of schools did not provide reasons for not completing the sessions. The few that did mentioned unscheduled holidays declared by the state government, weather constraints (heavy rain/summer/ cold), and the nodal teacher being absent or taking leave as the primary obstacles. The MIS reporting forms are fairly simple and almost all the principals were oriented on the MIS, either by the CEDPA staff or by the respective udaan mitras. The CEDPA staff and district education officers noted in the qualitative end-line evaluation that despite this, reports were not being submitted regularly. A few nodal teachers mentioned that they had never submitted a report, while others said they sent reports only if they received a reminder. One reason for the low level of reporting could be that though the UDAAN programme has been integrated into the academic schedule of the schools in Jharkhand, there is no formal internal evaluation of the programme at the school level. Apart from inconsistent reporting, which is among the significant challenges faced by any scaled up programme, another important barrier to regular MIS reporting was that those implementing the programme were not required to report on other school activities, which means that there is not a culture of reporting on implementation in the system. Site visits for the purpose of monitoring play an important and complementary role in evaluating the quality of the delivery of a programme. Such visits also presented an opportunity to provide supervision and feedback to the nodal teachers. The CEDPA team the udaan programme 69 and udaan mitras made regular visits to the schools to assess the implementation of the UDAAN sessions. Some of the problems identified during the on-site monitoring were the existence of vacancies in the district education offices (which were responsible for monitoring); frequent strikes, which forced the schools to close; and delays in the release of government funds, which made it difficult for the udaan mitras to travel as scheduled.

Evidence of impact Evidence of the programme’s impact was assessed through changes in the students’ knowledge, attitude and practice, i.e. the KAP indicators, as well as the qualitative examples of changes in knowledge and behaviour described in the qualitative end-line evaluation (Table 3.5].

Knowledge, attitude and practice assessments Between 2008 and 2010, four KAP assessments were conducted. The indicators used for the evaluations, as well as the findings, are summarised in Table 3.5. In Phase I and Phase II (regular academic year mode), the intervention was still being rolled out and hence, it was possible to compare the post-intervention test results with test results from schools that were not yet implementing the programme. In the evaluation of Phase II (camp mode), there was no control group or pre- intervention test, so no assessment was made of the effectiveness of the programme. In the Phase III KAP evaluation, there was no control group, and the pre-intervention test results were compared with the post- intervention results to assess change over time. The questions were based on the UDAAN syllabus, and were adapted from previously validated and standardised questionnaires or scales. The socio-demographic indicators of the respondents were also captured. Summary statistics (means, proportions and weighted means) were computed from the KAP surveys, and the key indicators were compared between the intervention and control arms. Sub- group analyses (including gender, class and school type) were carried out, where relevant. Significant differences were reported at the 95% confidence level, with p-values of less than 0.05 highlighted. The three evaluations that had comparison/baseline results showed 70 d. rajaraman, b. bhat, v. nathani, a. gogoi

Table 3.5. Indicators of KAP across UDAAN evaluations

PHASE I Phase II Camp Phase II RAY Phase III 2007 mode 2008 mode 2008 2009

Adolescence/reproductive – health issues √ √ √ Knowledge and attitudes – about menstruation √ √ √ Masturbation – – –

HIV/AIDS prevention – √

HIV/AIDS transmission √ – √ √

Common diseases √– – √ N/A√

Gender equity – √ –

Negative peer pressure N/A√ – √–

Positive peer pressure N/A – – √–

Substance abuse – – – N/A

Friendship – – N/A

Communication with – N/A√ N/A parents √ Self-efficacy N/A – – ×

Goal-setting – – – ×

Decision-making about N/A – × life partner √

comparison groups √: Statistically significant (p�0.05) Targeted positive difference from baseline or

×: Statistically–: No statistically significant significant (p�0.05) change/difference Negative change or no from baseline/comparison baseline or comparison group groups N/A: Outcome not assessed the udaan programme 71 consistent statistically significant increases in the students’ knowledge of the prevention and transmission of HIV/AIDS, and issues related to adolescence and reproductive health. They also showed an improvement in their knowledge of and attitudes to menstruation. In addition, there were some small, but statistically significant positive changes in the students’ knowledge and attitudes with respect to gender equity, friendship, peer pressure and common diseases. However, the improvements were not consistent across all the evaluations and in most cases, the magnitude of the difference was modest. Surprisingly, negative changes were seen with respect to a few indicators in the Phase III evaluation (self-efficacy, goal-setting, and decision-making about life partner). This finding, along with the low rate of completion of the syllabus, suggests that the UDAAN programme may take some time to bring about widespread changes in KAP, as it first has to deal successfully with the challenges faced in the early stage of implementing the scaled up programme.

Qualitative end-line evaluation

Several government officials and nodal teachers stated that students who had attended the sessions had at least gained an understanding of the changes in the body during adolescence, and of how to prevent sexually transmitted disease. Some nodal teachers noted that the students’ newly acquired knowledge of issues related to adolescence had made them less awkward and shy. One teacher believed that the knowledge had not only benefited the students, but extended to their families and communities as well:

. . . these girls are the most educated among the members of their family. . . . When they are given this education here, they go and tell people at home. If their brother is migrating for work, they say, “When you travel outside for work, don’t have [sexual] contact with anyone.” . . . They give advice in their own language: “Don’t do anything like that when you go out,” and, “We have learned that AIDS is this kind of illness which can spread through this.” Secondly, the information they get about hygiene is very useful because where they stay, drinking water is not easily available. They drink water from anywhere, like rivers. So through this, they learn that diseases spread due to infections. (Day school nodal teacher, Dumka) 72 d. rajaraman, b. bhat, v. nathani, a. gogoi

The UDAAN programme appeared to have had a greater impact on the students of the KGBV girls’ residential schools than on those of the day schools. The nodal teachers and wardens from the KGBVs pointed out that their close proximity with the students outside class hours made it easier for them to encourage the students to put what they had learnt into practice. They also felt that because of the residential nature of the schools, the students were more likely to adopt the norms of that environment over time. After the session on menstrual hygiene, the KGBV nodal teachers had observed changes in the practices followed by the students, and consequently in the frequency of reproductive tract infections. One of the KGBV nodal teachers even mentioned a reduction in the number of pregnancies among the students, and attributed this to the education on reproductive and sexual health. In addition, several teachers reported that following the UDAAN sessions, some of their female students had taken a stand against early marriage in their homes. One nodal teacher mentioned that the students had even been able to identify and report cases of sexual harassment. A CEDPA staff member, who had interacted with the master trainers, nodal teachers and students for a long period of time, described the various changes that the programme had brought about among the KGBV students. These included the ability to resist sexual harassment, to cope with and mediate conflict at home, and to resist early marriage, as well as an improvement in communication with the teachers. In his words:

In residential schools, we interacted with the teachers and the students. The teachers told us that the girls come to them and tell them the problems that they are facing, asking for advice. So the teacher works like a counsellor, giving them appropriate information. Many a time, it happens – for example, cases of sexual harassment are brought to the teachers and the students tell them what happened and how they resisted because of what they had learnt about sexual harassment. After implementing this programme, the children have started coming and discussing their problems with the teachers. For example, one girl came and told us, “My parents don’t talk properly and keep on fighting. So one day I said to my father, ‘You both have equal responsibility to run the house. Just because you work outside, it doesn’t mean you don’t have any work here.’” Similarly, if a girl’s marriage is being arranged early by her the udaan programme 73

family, since she knows the pros and cons, she is able to resist if someone pressurises her. (CEDPA programme staff member, Ranchi)

While the general feeling is that the UDAAN programme would lead to an increase in knowledge and eventually, attitudinal and behavioural change, the CEDPA management and nodal teachers pointed out that its ability to improve health outcomes is limited by lack of access to health services. There is a need to address the lack of convergence between different government departments in the area of the provision of easy access to adolescent-friendly health services in the area.

Summary

The UDAAN programme was scaled up in Jharkhand at a time when there was a considerable backlash against education on sexual and reproductive health for adolescents. Several states had suspended the AEP. The fact that it was possible to scale up the programme in these circumstances shows that it is culturally acceptable and feasible to provide such education even in a seemingly hostile environment. Indeed, the end-line evaluation conducted five years after the introduction of the programme indicated a perceived need for and strong endorsement of the programme among all stakeholders, with only a minority of school teachers (and potentially community members) still denying the value of such a programme. The stakeholders are better able to accept the UDAAN programme as it is driven by the government and delivered within the normal school curriculum by government staff. A major factor that has made it possible to scale up the programme rapidly is ownership by the state government, which manages and implements the programme. The UDAAN partnership has achieved the remarkable feat of developing an education programme on reproductive and sexual health for school-going adolescents, training teachers to deliver it, and rolling out the programme in an entire state. Even though it has been just five years, the coverage of the programme is immense: over 2000 teachers have been trained and 300,000 students in over 1400 schools have been covered by the annual programme activities. UDAAN has demonstrated the value of partnerships for the implementation of programmes. Due to the fact that the partners brought their own advantages and had clearly defined roles and responsibilities, much more 74 d. rajaraman, b. bhat, v. nathani, a. gogoi has been accomplished than would have been possible if any partner had been working alone. The rapid scale-up was possible because the delivery system of the government could be leveraged and the existing human resources utilised. However, it must be noted that the financial assistance and technical support provided by an external NGO were critical for developing and scaling up the programme. While the introduction and implementation of a state-wide school- based programme for health education are laudable achievements, there are several problems associated with scaling up a programme rapidly in a resource-constrained educational system. These include a shortage of trained teachers, high turnover of teachers, limited capacity of the existing staff to deliver the programme in addition to performing their own duties, and insufficient government structures to monitor and evaluate the delivery of classroom sessions. In addition, a high number of students do not attend classes or drop out of school. To overcome some of the challenges faced in monitoring, many stakeholders suggested that the UDAAN topics be made an examinable subject, either on their own or as a component of other subjects. Despite the challenges mentioned above, the case study also found quantitative and qualitative evidence of the positive impact of the programme. For example, there were substantial and statistically significant improvements in the knowledge and attitudes of the teachers trained to deliver the programme. The UDAAN teachers and school principals recounted many instances of positive change in the attitudes both of teachers and students. The most marked changes in behaviour were observed among the girls in the residential KGBVs, especially with respect to menstrual hygiene and in the matter of standing up to parental pressure for early marriage. Both these changes could have a significant impact on the outcomes for health and well-being. There is a strong rationale for continuing the UDAAN programme in the light of:

– its acceptability and feasibility and the scale that has been reached – the qualitative evidence of short-term attitudinal and behavioural change – the strong likelihood that the programme’s effectiveness and outcomes will improve if it is adequately supported – the fact that students and teachers have a right to information on health. the udaan programme 75

Finally, the ultimate success of the UDAAN programme will depend on the ability of the government system, with the support of the partners, to strengthen implementation. In the short term, this may necessitate greater stringency in the application of the selection criteria for nodal teachers, improved training and support for master trainers and nodal teachers, and public recognition of or financial incentivisation for nodal teachers. Additionally, the teachers and students may benefit from supplementary visual teaching materials. Also, given the high drop-out rates in the secondary schools, introducing younger students to the UDAAN curriculum and extending community activities should be considered essential strategies for increasing the programme’s coverage.

[Note: The UDAAN programme has been supported by the David and Lucile Packard Foundation. This chapter does not necessarily represent the views of the Foundation.] 4

Sachin Shinde, Divya Rajaraman, Mahtab Alam Siddiqui, DilreenThe Drishti Kaur programme

The Setting: Rajasthan Rajasthan is geographically the largest state in the Indian Union and is situated in the northwest of the country. The Thar Desert covers about 60% of the state. Rajasthan is home to 68.6 million people (6% of the country’s population). Thirty-nine per cent of the population is under 15 years of age, and only 5% is above 65. The state has a low population density compared to the national average (201 persons per sq. km versus 312). The key socio-demographic indicators are shown in Table 4.1. Rajasthan is divided into six zones, which cover 33 districts, 237 blocks and 41,353 villages. It is largely rural, with 80% of its population depending on agriculture for its livelihood. Less than one-third (29%) of Rajasthan’s households are located in urban areas. The availability of water is very low, with the state accounting for just 1% of India’s water resources. Drought is common, as is scarcity of food. About 34.4% of the state’s population lives below the poverty line (Planning Commission, 2009) and in 2006, the Union Ministry of Panchayati Raj identified the district of Jhalawar in Rajasthan as one of the most backward of the country’s 640 districts [53]. Women and girls are accorded a relatively low status across much of Rajasthan, as reflected in several socio-demographic indicators. The overall ratio of women to men is 926:1000, which is well below the national average of 940. The child sex ratio is among the lowest of all states, at 883 girls to 1000 boys, compared to the national average of the drishti programme 77

Table 4.1. Socio-demographic and health indicators of Rajasthan

Indicator Rajasthan Area1 342,239 km² Population1 68,548,437 % urban population1 24.9 Annual per capita income 2011–122 416,755 Households with electricity4 61.7% Households with safe drinking water4 81.8% Households with access to a latrine4 25.7% Crude birth rate3 26.7% Child sex ratio1 928 Women married by 18 years of age4 39.9% Men married by 21 years of age4 48.0% Infant mortality rate3 55% Children of 12–23 months of age fully immunised4 48.8%

Underweight in children under 3 years of age5 40% Mothers with at least three antenatal care visits at last birth4 27.7% Institutional deliveries4 45.5% Literacy1 66.1% Male literacy1 79.2% Female literacy1 47.8%

1 Office of the Registrar General and Census Commissioner. Census of India 2011 tables: http://censusindia.gov.in 2 Planning Commission of India. Directorate of Economics Statistics for respective state and all-India http://planningcommission.gov.in/data/datatable/1612/table_158.pdf 3 Registrar General, India. Sample Registration System Bulletin December 2011 4 District-Level Household Survey 2007–08. Rajasthan Fact Sheet. http://www.jsk.gov.in/ dlhs3/rajasthan.pdf 5 National Family Health Survey 3 (2005–06)

914. Child marriage is common, the median age at first marriage among people between 20 and 49 years of age being 15 years for women and 19 years for men. Rajasthan has the lowest female literacy rate of all the Indian states, with over half of its women unable to read or write. In 78 s. shinde, d. rajaraman, m.a. siddiqui, d. kaur contrast, the male literacy rate is 80.5%, which is close to the national average. In Rajasthan, more than 85% of children between the ages of 5 and 12 years go to school, but the retention of students between primary and secondary school is low, at 50%. The government is driving efforts to improve education, with the expansion of primary schools being a priority. This is reflected by the fact that more than half (51.3%) the elementary schools and 62.5% of all primary schools in the state have been established after 1994. However, the persistent poverty, low literacy rate, high number of school drop-outs, gender disparity and poor health indicators underscore the continued need to strengthen initiatives to improve education and health in the state. The Drishti programme, which aims at promoting life skills among school-going adolescents, operates in this context.

The Drishti programme History The Drishti programme was initiated by Ritinjali, an NGO that has been working in the fields of education and community development since its establishment in 1995. The NGO has worked with marginalised communities, including slum-dwellers, jail inmates, grief-stricken and poverty-stricken individuals and communities, and victims of war and natural disasters, in greater Delhi, Gujarat, Uttarakhand, Tripura and Meghalaya. Ritinjali runs intensive volunteer-based and professional programmes that aim to promote social development among individuals and communities. In 2005, it initiated the Drishti: Jeevan Kaushal programme (life skills programme for teacher educators), with support from the MacArthur Foundation and in collaboration with the Department of Education, Government of Rajasthan. The overall goal of the programme was to empower adolescents, parents, teachers and entire communities, and to enhance their overall quality of life by helping them to learn to make better choices. The specific objectives were:

in life skills in government schools in Rajasthan • Capacity-building of teachers and teacher trainers to impart education behaviour, practices and values in the sphere of adolescent • Enhancement of students’ knowledge to promote healthier attitudes, reproductive and sexual health (ARSH) the drishti programme 79

skills in the pre-service curriculum for teacher training at the state • Advocacy with the Rajasthan Department of Education to include life level.

This classroom-based programme for education in life skills and health-related issues was intended for 7th and 8th grade students, both male and female, studying in government schools. It was delivered by teachers who are trained in the curriculum and delivery methods. Drishti was based on the notion that effective education in life skills in school would produce a generation of adolescents who are capable of making informed and responsible decisions on their health and with respect to risk behaviours. It was envisaged that the teacher training would result in meaningful changes in the teachers’ attitudes and practices. The teachers will thus be able to set an example for the students and contribute to the elimination of gender stereotypes and bias among them. If delivered effectively, the programme will also enhance the knowledge, awareness, self-efficacy and autonomy of the students so that they can take informed decisions on sexual and reproductive health. The Drishti programme was delivered in three phases between 2005 and 2011:

Pilot phase (2005–06): A pilot programme was delivered over two years in two districts of Rajasthan. In 2005, 30 teachers from 14 • government schools in the district of Kota were trained. In 2006, 60 more teachers from 23 government schools in the districts of Kota and Jhalawar were trained. First phase of scale-up (2007–09): Between 2007 and 2009, Ritinjali extended the programme further in the districts of Jhalawar and Kota. • By the end of three years, 84 master trainers and 810 teachers from 783 schools had been trained. Second phase of scale-up (2009–11): During this phase, the programme was implemented in 1313 schools in three districts of Rajasthan; • Jhalawar, Kota and Baran. By the end of the phase, 2213 teachers from nearly 1300 schools had been trained.

The delivery team The Drishti programme was the product of a partnership between the Department of Education, Rajasthan and Ritinjali. The former is responsible for providing inputs on and sanctioning programme 80 s. shinde, d. rajaraman, m.a. siddiqui, d. kaur materials, and providing logistical support for training. It also approves the selection of the government personnel from the district education offices and schools to be involved in the delivery of the programme. Ritinjali is the primary implementing agency for the programme: it has played a leading role in the development of the curriculum and materials, strategic planning, development and delivery of training, and monitoring and evaluation of the programme. The training for master trainers and teachers is organised by Ritinjali, with support from the Department of Education. In each district, the district education officer is responsible for recruiting master trainers and teachers, and coordinating with the respective schools to confirm which participants have been selected for training. The Drishti staff follows up to ensure that the teachers attend the training. To meet the scale of the programme by expanding the base of teachers, a “train-the-trainers” model is being employed. A small group of master trainers from the government school system are selected and trained at the district level. They, in turn, train one or two teachers nominated from each school to deliver the programme. Once trained, the teachers are responsible for implementing the programme in their respective schools.

Content The Drishti programme has two components. The first is education on life skills, delivered to 7th and 8th grade students through seven teaching modules (4 for 7th grade and 3 for 8th grade). These are listed in Table 4.2. The modules cover mental/emotional, social and physical health, as well as gender and sexuality. It is recommended that the modules be delivered in 45-minute sessions on a weekly basis throughout the course of a year. The second component of the programme is community involvement, which is facilitated by the Drishti teachers through media such as puppet shows, and rallies and fairs (mela) focusing on health-related issues. Drishti encourages a participatory learning approach and the use of theatre for education. The aim is to enable learners to identify their own problems, discuss solutions, and plan and ultimately execute effective action. The teaching methods include the provision of informational material such as fact sheets and posters, as well as participatory activities such as case studies, field visits, debates and panel discussions, story- telling, role-play and games, worksheets and projects. the drishti programme 81

Table 4.2. The Drishti syllabus

Module Topics 7th grade

Total health Introduction to life skills and total health

Mental/emotional Self-image/self-esteem, positive thinking health Positive thinking – concept and meaning

Social health Definition and aspects of good social health

Healthy relationships – skills required to maintain healthy relationships, communication guidelines, cooperation and compromise

Conflicts between adolescents and their peers

Decision-making: concepts, process and coping

Communication skills: concepts and types

Recognising good verbal communication, effective verbal communication, and taking on the onus of resolving conflict

Conversation starters, miscommunication, evaluating communication, non-verbal communication, listening skills

“Nobody listens to me”

Physical health Smoking: reasons for smoking among teenagers, forms of tobacco abuse, effects of smoking tobacco on the body

Eating healthy

8th grade

Social health Refusal strategies: how to say “no” and still be friends, 11 different strategies

Conflicts between adolescents and their parents

Time management and goal-setting

(continued) 82 s. shinde, d. rajaraman, m.a. siddiqui, d. kaur

Table 4.2. (continued)

Module Topics

Physical health Hygiene: guarding against infections, hygiene for boys and girls

Alcohol: effects of alcohol, pathway of alcohol through the body, effects of alcohol on health

Myths and facts about alcohol

Sexually transmissible infections

AIDS: introduction, modes of transmission, age-wise distribution of AIDS, diagnosis

Minor and clinical signs and symptoms of paediatric HIV infection

Myths and misconceptions about AIDS

Gender and sexuality Gender roles and stereotypes

Marriage and legal rights

The Drishti Case Study Evaluation Document review To generate evidence of the effectiveness of the programme, and identify the gaps and challenges that would need to be addressed in the future, Ritinjali carried out extensive analysis and documentation in the first five years of the programme’s implementation. The review covered nine monitoring and evaluation documents from the period 2006–10. These included annual reports, programme reports, baseline and end-line survey reports, training reports and an observational report. The details may be found in Table 4.3.

End-line qualitative evaluation To learn of the perspectives and experiences of the stakeholders involved in designing, implementing and supervising the programme, 26 the drishti programme 83 (continued) 90 teachers implementation in 37 schools Project students Details of number teachers, 1238 students implementation in 305 Programme 203 schools visits to Observation in Kota trainers 42 master 505 teachers (26 from Kota and 11 from Jhalawar) and 11 from Kota (26 from not provided and principals interviewed schools in Jhalawar Sample – – – – – – – – (described below) Study design/data source Study methods and quantitative Qualitative with teachers interviews Semi-structured and principals for test and post-intervention KAP pre- students data Process methods Quantitative for test and post-intervention KAP pre- students arm design with control Four-arm data and qualitative of quantitative Review and observation during training collected visits Document title Drishti Annual Report: 2005–06 Drishti Annual Report: 2007–08 Drishti Annual Report: 2008–09 Author Ritinjali Ritinjali Ritinjali Documents reviewed for the Drishti case study for Documents reviewed Year reports Annual/Programme 2006 2008 2009 Table 4.3. Table 84 s. shinde, d. rajaraman, m.a. siddiqui, d. kaur (continued) Programme implementation in 291 implementation in 291 Programme 268 teachers in a four- Baseline and end-line survey 51 schools students from 655 7th grade assigned randomly The 51 schools were made up of was arm control A fourth schools in Jhalawar and 492 in Kota and 492 in Kota schools in Jhalawar below) arm design (described in baseline and of Jhalawar in 4 blocks 583 of these students in end-line (in 9th this time) by grade arms, which intervention one of three to of supervision and degrees had varying Ritinjali support from the programme schools where selected some reason for not delivered was Sample – – – – – – (described below) Study design/data source Study data and qualitative of quantitative Review and observation during training collected visits methods Quantitative and post- KAP test, comparing pre- of students; four- results test intervention group arm design with control Document title Report Drishti Programme (scale-up phase) 2007–10 Report Baseline Survey Report End-line Survey ) continued ( Author Ritinjali Ritinjali Ritinjali Year 2010 reports Evaluation 2007 2009 Table 4.3. Table the drishti programme 85 305 teachers 505 teachers 635 in Kota 635 in Kota Sample – – 203 schools at least once – Visited and in Jhalawar – 615 sessions observed

Study design/data source Study methods Qualitative summary and participants’ Training feedback methods Qualitative and participants’ summary Training feedback methods Mixed Checklist, discussion with students informal of question box and circulation and teachers, students for Document title Report: Training Teacher Jhalawar Report: Training Teacher Kota Observation Classroom Report ) continued Author Ritinjali Ritinjali Ritinjali ( Year documents training Teachers 2007 2008 other activities and monitoring programme on Reports 2008 Table 4.3. Table 86 s. shinde, d. rajaraman, m.a. siddiqui, d. kaur respondents were interviewed individually. In addition, 12 focus group discussions (FGDs), which involved a total of 107 students from the 7th and 8th grades, were conducted to understand the perspectives of the target population of the programme. The interviews were conducted by a member of the Sangath research team during 6–28 October 2011. The details of the sample are shown in Table 4.4. The Ritinjali project manager for the Drishti programme and four field staff who played a critical role in designing and delivering the programme were purposively selected for interview. Master trainers, principals and teachers were randomly selected from each district (Kota and Jhalawar) to ensure a more balanced geographical representation. Five and seven FGDs, respectively, with male and female students from the 7th and 8th grades were conducted in the same schools from which teachers and principals were interviewed. The schools were selected on the basis of their distance from the main city and the availability of transport.

Table 4.4. Interviews conducted for end-line qualitative evaluation

Individual interviews Jhalawar Kota Total

Ritinjali programme staff, – – 1 Delhi

Ritinjali programme staff, – – 4 Rajasthan

Master trainers 2 2 4

District education officers 1 1 2

School principals 2 2 4

Teachers 5 6 11

Focus group discussions

Female students 3 groups 4 groups 7 groups (28 participants) (37 participants) (65 participants)

Male students 3 groups 2 groups 5 groups (25 participants) (17 participants) (42 participants) the drishti programme 87

Acceptability

The findings related to the acceptability of the programme are drawn primarily from the qualitative and quantitative research undertaken for the annual and training reports, internal evaluations of the programme and end-line qualitative evaluation.

Perceived need for the programme

The Drishti programme suffered a major setback in 2006 when, just two months after the introduction of education on sexual and reproductive health in secondary schools, the state of Rajasthan decided to ban it. The ban was justified on the ground that such education went against cultural norms, and would encourage immoral thoughts and behaviours among adolescents. As a result, the Drishti programme team had to revisit and redesign the syllabus, together with the training and classroom materials, in such a way as to ensure their acceptability in the districts where the programme was to be implemented. Thus, in spite of the state government’s wider decision to discontinue the AEP, the local government and civil authorities permitted the implementation of the Drishti programme in Kota and Jhalawar districts. These authorities watched the programme closely as it unfolded, and on observing its positive impact on students as well as their families, they approved its extension to the district of Baran. Indeed, the majority of the stakeholders interviewed – district education officers, principals, project management staff, master trainers and teachers – felt that education in life skills is an important component of the education of students. They were of the opinion that educating young men and women on gender issues and rights was a must in view of factors such as low literacy rates and low marital age among women, the high prevalence of violence against women and sexual abuse of women. According to them, the other issues that necessitated such a programme were poor practices with respect to health and hygiene, malnutrition among adolescents, a poor understanding of diseases, the prevalence of sexually transmitted infections among adults, and high levels of substance use among adolescents and their parents. Students also mentioned the need for interventions to address the use of tobacco and alcohol among their peers. In the words of one student: 88 s. shinde, d. rajaraman, m.a. siddiqui, d. kaur

. . . many students here, including girls, chew Vimal gutkha [tobacco]. Some students from my class also chew it. And older people consume everything: gutkha, cigarettes, beedi and alcohol . . . (Male student in 8th grade, Jhalawar)

A few female teachers highlighted the value of the programme for female students in particular. They had observed that the girls did not follow hygienic practices during menstruation and felt that the Drishti sessions could help them change their habits by providing appropriate information. The female teachers also believed that information on life skills, gender-related issues and women’s rights would catalyse social change and empower adolescent girls. Similarly, female students endorsed the value of such a programme in promoting female empowerment. In the words of a female student from the 8th grade:

Our [teacher] tells us about how women are equal to men, how women can also do things that men do. She also asks us a lot of questions regarding what boys and girls should do . . . so I enjoy the discussion in the class. She has also told us that girls should not get married before 18 years of age. After listening to her, I feel that all girls should study. This information is very useful for us. (Female student in FGD with 8th grade, Jhalawar)

Overall, the students participating in the FGDs described the Drishti programme as “very useful” and “helpful for future career”.

Attitudes and participation of stakeholders The majority of the Drishti master trainers and teachers interviewed for the end-line evaluation were glad to be a part of the programme. Very few expressed reluctance about undergoing training and delivering the programme. However, while most teachers were enthusiastic about the overall programme, there were mixed feelings with regard to teaching the modules on reproductive and sexual health. One the one hand, a couple of teachers reported that the training had made them feel more comfortable about teaching the modules on sexual and reproductive health and therefore, they were now confident about initiating a dialogue with the students on these issues. On the other hand, some teachers admitted that they felt reluctant to deliver these modules because of their own inhibitions, their fear of opposition from the parents, or the the drishti programme 89 opinion that 7th and 8th grade students were still too young to be given such information. As one teacher put it:

I do not give information about sexual and reproductive health. These students do not understand it. These are rural students; they are different from city students. Even if girls and boys study together, they do not interact like your urban students. If we provide this information to them without thinking, they will act on it. This information must be given, but not to 7th grade students. This information should be provided to 9th– 12th grade students. (Female teacher, Jhalawar)

Some students corroborated the fact that a few teachers had not taught the subject of reproductive and sexual health. Others mentioned that they themselves had an aversion to it. Speaking of his dislike of the topic, one student said:

. . . I do not like it when our [teacher] tells us about sex. I do not like the HIV/AIDS discussion. I feel very shy. Some guys in my class laugh all the time during that session. I do not understand what my teacher is telling us. (Male student in FGD with 7th grade, Kota)

The Ritinjali programme staff and some of the master trainers felt that selecting younger teachers would help to build a pool of Drishti teachers who would be more interested in the subject and comfortable teaching it. A few teachers and principals mentioned that parents and members of the community are not supportive and demand material benefits for their children rather than just information on life skills. For example, the villagers demand classrooms, water tanks, enrichment of the library, and sports aids. Some teachers expressed the fear that the parents and community in general might find the materials used by the programme offensive and forbid their children to attend the classes. The level of support that the Drishti teachers received from their fellow teachers and principals varied across schools. While some teachers felt that their colleagues were supportive, and they were allotted specific slots for teaching the Drishti modules, others reported that their colleagues lacked enthusiasm and even actively discouraged them from teaching the subject of sexual and reproductive health. Earlier, observational reports by the Drishti programme team had found that the students’ participation in the classes was very formal. 90 s. shinde, d. rajaraman, m.a. siddiqui, d. kaur

However, during the qualitative interviews in the end-line evaluation, the teachers mentioned that students enjoyed the classes and participated actively in the programme-related activities. According to one teacher:

. . . students really enjoy the discussions and group activities on communication and decision-making. I try to involve all of them. They show an interest. I think the main reason why students like these sessions is that nobody talks with them about these topics. Nobody tells them about relationships, conflicts, coping mechanisms. This is not included in their regular curriculum. They also enjoy the session on self-image. (Female teacher, Kota)

Several teachers and master trainers felt that students would pay greater attention to the programme’s sessions if the Drishti syllabus was included in the main curriculum. They also suggested that periodic examinations be held for the Drishti sessions to increase the students’ participation and motivation. One teacher suggested:

. . . if the Drishti syllabus is integrated into the school curriculum, everyone will take it seriously. I am not saying that it is not taken seriously, but the motivation of the teachers and students is not high. But if this is a compulsory subject and examinations are conducted for this subject, then everyone’s motivation level will be high. Though there is homework, worksheets and group discussion, some students are not interested in all these things. However, if there are periodic examinations, then the students’ participation level will increase. (Male teacher, Jhalawar)

Most students, however, stated that they enjoyed the classes and found them useful, and thought that they would help them later in their lives and in their careers.

Feasibility To assess the feasibility of the programme, a review was conducted of the Drishti programme reports from 2007 to 2010 to gather information on: the development and implementation of the teacher training programme; coverage of the programme in terms of the number of schools implementing it, the proportion of lessons taught in these schools, and the factors which impeded and facilitated implementation. The end-line qualitative evaluation aimed to assess the feasibility of the programme the drishti programme 91 by considering the stakeholders’ perceptions on the facilitators for and barriers to implementation.

Training

The master training sessions were conducted by the Ritinjali staff in the form of a ten-day non-residential workshop, spanning 80 hours of teaching and practice sessions. Between 2005 and 2011, 196 master trainers were trained. The master trainers were selected by the school principals, who were instructed by the district education office to take into account the teachers’ seniority, experience and/or previous training in adolescent education. Not all teachers who were selected to be master trainers were able to attend the training because some were stationed in remote areas with poor transport links. Thus, in 2007, only 42 of the 54 teachers who had been invited from Jhalawar and 42 of the 50 invited from Kota attended the training. Although lecturers from the District Institute of Education Training were invited, they could not come because their schedule clashed with the workshop. The teacher-training curriculum and format were similar to those for the training of master trainers. The master trainers conducted the training with the support of and under the supervision of the Ritinjali staff. Between 2005 and 2009, the programme trained 900 teachers from 1273 schools in the districts of Jhalawar and Kota. These teachers were trained in eight batches. Thirty were trained in 2005, 60 in 2006 and 305 in 2007 in Jhalawar, and 505 in 2008 in Kota. Refresher training was conducted for 40% of the trained teachers. At the time of the evaluation of the case study, the project was in the second phase of scaling up (2010–13) and training was being conducted in the district of Baran as well. By the end of 2011, the programme had trained 2213 teachers in three districts of Rajasthan. Overall, the feedback from the participants in the training for master trainers and Drishti teachers, along with the findings of the end-line qualitative evaluation indicated that the Ritinjali staff, district education officers, master trainers and teachers felt that the training programmes had succeeded in giving the participants a basic understanding of participatory methodologies and of the content of the Drishti programme. Several district education officers and master trainers observed a change in the teachers’ level of knowledge and attitudes in the course of the 92 s. shinde, d. rajaraman, m.a. siddiqui, d. kaur training, something which was confirmed by the Drishti teachers. One of the teachers said:

The experience at the training was superb. We learnt a lot through role- play, debates and activities. I have attended many other trainings, but this training was different. It was an encouraging training. We were told what women can do; they can do anything which a man is capable of. There were a lot of arguments of this type with men on one side and women on the other. The trainers were very good and intervened at the right time. (Male teacher, Jhalawar)

However, many also suggested that the training be strengthened. Almost all the Drishti teachers, master trainers and district education officers interviewed felt that the training period was too short for all the topics and activities to be covered, and that refresher training should be held at least annually. It was felt that refresher training would increase the teachers’ confidence about teaching the subject, help them to teach any new materials added to the syllabus, and serve to motivate them. In the words of a master trainer:

Refresher training must be conducted. They may be uncomfortable with certain topics and might skip those topics, so we should find ways of re-introducing these to them and explaining. This is not being done currently. The training takes place only once and then it is forgotten, so if they want to include something, refresher training has to be done at least once a year. (Male master trainer, Kota)

Several teachers also felt that more activities could be added to the training materials provided to them. As one teacher put it:

. . . we were given two books for teaching the 7th and 8th grades. These books are good, but including more detailed explanations will help the teachers – for example, more pictures, games and activities can be added. (Master trainer, Jhalawar)

Finally, a few teachers complained that they were given no feedback on their performance during the training sessions, even though tests had been administered to them. According to one teacher:

We must get more feedback. Our responses to the questions should be checked and we must get feedback the day after the training, telling us the drishti programme 93

that this should have been answered like this instead of this way. (Male teacher, Kota)

Coverage and implementation in schools

During the pilot phase, 90 teachers from 37 schools were trained. In the first phase of scaling up, the programme planned to cover all 1361 government schools in the districts of Kota and Jhalawar (942 in the former and 419 in the latter), offering programme modules to the 7th and 8th grades. Only 783 (57.5%) of these schools could be covered. A significant setback to scaling up the Drishti programme within the envisaged time frame was the state government’s decision to ban the AEP, just months after having introduced it. This required Ritinjali to revisit and revise the curriculum, methodologies, and training and classroom materials, as well as deal with uncertainty caused by frequent transfers of government officials from the district education offices. There was some initial confusion regarding the respective roles and responsibilities of the district education office and Ritinjali as far as scheduling and financially supporting the training was concerned. This delayed the plans for training somewhat. Another problem was that not all selected trainers were able to attend the training sessions due to conflicting schedules, as well as the lack of commitment of the staff of the district education office to ensure full participation of the schools in the programme. However, most of these issues were addressed in the second phase of scaling up, during which the coverage of the programme increased to almost 1300 schools in three districts of Rajasthan. On an average, the teachers took 11–18 classes for each student in the 7th and 8th grades in 2008–09. The programme organised one health mela, four puppet shows and 12 street marches in Jhalawar to spread awareness and sensitise the communities. No such activities were undertaken in Kota. In the qualitative end-line evaluation, the teachers named the following factors as facilitators for the implementation of the programme: self-motivation, the allocation of a weekly slot/period for delivering the Drishti curriculum, and support from the principal, teachers and programme staff. The most common reason cited by the teachers for inability to complete the syllabus was time constraints. This is illustrated in the following quotes: 94 s. shinde, d. rajaraman, m.a. siddiqui, d. kaur

The truth is that I have not taught the Drishti programme in the school. I do not get time as I am a physical education teacher. (Male teacher, Kota)

. . . no one can complete all the chapters as the teachers are engaged in other activities, like society work, school work and other tasks assigned by the government. A teacher has to do a lot of work. This is an extra activity. It is not included in the school syllabus. We have to take our regular classes and complete our syllabus at the same time; we have to do other school work. . . . We cannot complete it . . . we miss some portion of it. (Female teacher, Jhalawar)

Although it was envisaged that the principal would allocate a formal period for the teaching of the Drishti syllabus in all schools, this was not uniformly implemented. It was more difficult for teachers to complete the syllabus in schools where no period was devoted to life skills, as reported by a few teachers:

. . . we do not think that this is a course and it has a syllabus which we have to complete. If so, then children have to take exams for it. But there is nothing like that. (Male teacher, Kota)

. . . they [the Drishti programme staff] did not tell us the plan. We went there and they gave us some information. We listened, but they did not go on to tell us that with the help of this book, we have to take a period with the students every week or once a month. We were not told about a timetable or anything like that. There is some information which we already give to the students, but there is no fixed timetable. (Female teacher, Jhalawar)

Among the other problems reported by the teachers was that some schools did not have two teachers to deliver the syllabus. Particularly problematic was the fact that all schools did not have one male and one female trained teacher. The following were the common suggestions made by the master trainers and Drishti teachers for improving the implementation of the programme:

facilitate better engagement with students and retention of the • generation of visual aids and a students’ manual on life skills to content of the course

curriculum to motivate students and teachers • integrating the Drishti programme into the state’s examinable the drishti programme 95

contributions • financially incentivising Drishti teachers or publicly recognising their

• training more teachers of both genders to facilitate implementation comfortable with the subject material and could engage with students • selecting younger teachers for training as they would be more more easily

programme • training the principal so that he/she helps to increase support for the midwives to cover topics such as reproductive and sexual health, • involving local doctors, general nurses, midwives or auxiliary nurse which teachers may not be comfortable with.

Monitoring and supervision Monitoring of progress has been of critical importance in the process of building evidence for the development, implementation and improvement of the educational material on life skills for adolescents. The monitoring activities have included assessing the quality of training by testing the knowledge and attitudes of those who were trained as master trainers and Drishti teachers; telephone calls and/or monitoring visits to schools by the Drishti programme staff; and programme reviews as part of the annual reports. Between 2008 and 2010, the Drishti programme staff made at least one monitoring visit to 203 schools (89 from Jhalawar and 114 from Kota). During these visits, the staff members observed the Drishti classroom sessions, checked the programme delivery register and circulated a question box among the students for them to drop their questions into it. They also conducted an informal, unstructured conversation with the students to learn about the delivery of the sessions and any problem in this regard. These visits were useful in learning about the implementation of the programme, as noted by one of the Drishti staff members:

. . . it so happens that when you go to the schools, you will not find the checklist. No one knows where it has disappeared. We do not come to know whether the class was taken or not. In some schools, we do not get the registers but we manage to get it from 30%–40% of the schools. (Drishti programme field officer)

In the end-line evaluation, Drishti teachers who recalled having participated in the monitoring visits mentioned that they were not given 96 s. shinde, d. rajaraman, m.a. siddiqui, d. kaur any feedback on the quality of the sessions. They felt that feedback would have helped them implement the programme. Several teachers reported that there had been no monitoring visits in their school. The Drishti programme staff admitted that it was difficult to visit every school, given the small size of the supervisory team, the vast spread of schools and poor transport infrastructure in the region. All the teachers interviewed suggested that the programme should have a better reporting system and that periodic evaluations of performance should be conducted. They emphasised that teachers should be provided with feedback. Some of the other suggestions were the inclusion of and better coordination with government staff, such as the district education officer, block development officer and other related authorities, in the implementation, monitoring and supervision of the programme.

Evidence of impact Evidence of the programme’s impact was evaluated through, KAP assessments and examples of changes in the students’ knowledge and behaviour described in the qualitative end-line evaluation.

Knowledge, attitude and practice assessments Ritinjali conducted baseline KAP assessments in 2007, before the intervention was introduced, and an end-line assessment with the same set of students in 2009. The questionnaire was developed and the results analysed with inputs from the Centre for Studies in Ethics and Research. These assessments aimed to identify changes in the KAP indicators related to sexual and reproductive health that might be attributable to the instruction provided by Drishti in life skills. Fifty-one schools from Jhalawar were selected for evaluation. These were assigned to one of three intervention arms, which had received varying levels of support from the Ritinjali staff for the delivery of the classes. Those schools in which the progamme was not implemented served as the control arm, Table 4.5 presents the details of the intervention arms. The Drishti syllabus provided the basis for the development of the questionnaire, which included sections on socio-demographic details, mobility, decision-making and participation, emotional and social health, the drishti programme 97

Table 4.5. Schools and students included in the KAP assessments

Schools No. of Baseline End-line schools Boys Girls Boys Girls

Control Teacher could not attend training, 11 49 109 39 92 trained teacher transferred, or trained teacher did not implement the programme

First arm Ritinjali trained master trainers, 13 113 50 104 45 provided telephonic follow-up to ensure implementation, and conducted monitoring visits to observe classroom delivery

Second arm Ritinjali trained master trainers, 13 105 47 93 43 facilitated teacher training

Third arm Ritinjali trained master trainers, 14 120 62 111 56 facilitated teacher training, and facilitated classroom implementation

Total 51 387 268 347 236 interpersonal relationships, gender, nutrition and exercise, substance abuse, and HIV/AIDS/STIs and adolescents. Summary statistics (mean and proportions) were computed from the assessments both of the control and other three arms and were compared. The comparisons of the baseline and end-line results and of the intervention and control arms suggest that the Drishti programme has been effective in increasing the young adolescents’ knowledge regarding the prevention of HIV/AIDS, reproductive health, puberty and bodily changes, harmful effects of substance abuse, importance of hygienic practices and a healthy diet, and gender roles and stereotypes. For example, only 10% of students in the intervention and control arms were 98 s. shinde, d. rajaraman, m.a. siddiqui, d. kaur aware of HIV/AIDS at baseline, but at end-line, the percentage was 65 in the intervention schools, compared to 41 in the control group. Table 4.6 lists a few sample questions to compare percentages among the control and intervention arms. The results of the KAP assessment suggested that greater supervision of students was associated with an improvement in their understanding of issues, and that the intervention had been effective in changing their knowledge and attitudes in a number of areas. However, the end-line KAP assessment also revealed that a high level of stigma continued to be attached to menstruation, STIs, HIV/AIDS, gender roles and sexuality, about which there were several misconceptions,. Furthermore, the relationship between changes in knowledge and attitudes and the short- term implementation of the newly acquired knowledge in terms of displaying more healthy and empowered behaviours is not yet known.

Qualitative end-line evaluation All groups of stakeholders (district education officers, programme staff, principals and teachers) reported that the programme had brought changes in the students’ attitudes, knowledge and behaviour. They felt the programme had been effective because the teaching methods employed, such as storytelling, role-plays, short skits and games, were engaging and the information was of practical use to the students. A few teachers pointed out that they had observed a greater degree of positive change among girls than boys. The changes observed by the teachers included an increase in self-confidence, especially among female students; greater general participation in class by girls; more open communication and better relationships between students and teachers; improved hygiene and greater cleanliness; improvement in verbal communication skills; and a reduction in the use of substances such as tobacco and gutkha in the school premises. The teachers felt that the students had become more aware of the physical, emotional and mental changes associated with puberty. Several teachers reported that their students were implementing the principles of gender equality both in schools and at home. The following observations illustrate the views of the teachers:

. . . The girls here used to chew large quantities of jardha [tobacco]. There were only two or three girls in each class who did not chew it, otherwise all the rest did. Post the Drishti programme, when I told them [about it] the drishti programme 99 2 1 94 18 97 92 27 59 19 10 26 End-line Girls 3 4 2 94 49 77 77 56 70 10 15 Baseline Interventions 6 3 89 22 94 93 33 64 20 18 30 End-line Boys 2 5 0 90 52 71 71 52 59 11 14 Baseline 5 2 75 44 66 65 56 46 20 19 39 End-line Girls 2 7 1 95 49 72 72 48 54 12 16 Baseline Control 7 6 60 51 53 50 56 54 34 20 40 End-line Boys 2 4 3 0 8 91 35 55 55 42 57 Baseline Changes in perceptions about gender roles and stereotypes and substance abuse before and after the intervention and after and substance abuse before and stereotypes about gender roles in perceptions Changes Issues (%) attaining puberty school after attend may Girls important education is more Boys’ outside/pursue a career work may Girls do household chores to should also be asked Boys food nutritious more should be given Boys/men work physical do more they if yes: Reason, abuse Substance Smoking Use of tobacco Gutkha Alcohol at least one of the above to Students addicted Table 4.6. Table 100 s. shinde, d. rajaraman, m.a. siddiqui, d. kaur

and conducted sessions regarding alcohol and substance use, most of the girls stopped chewing jardha. Otherwise, too, many good changes have taken place in the girls. (Male teacher, Jhalawar)

. . . The positive changes that I have seen in them are that they are come to school very clean and tidy. They now take a daily bath, wear clean clothes and keep themselves very clean. These are the major changes that I have seen after this programme. (Female teacher, Kota)

. . . this [the programme] has changed the students in [terms of] deciding on their goal, in taking decisions, in expressing their views freely, and children who were unconfident and shy have become talkative. They want to talk about their problems with me. (Male teacher, Kota)

. . . A benefit of this [programme] is that boys and girls play together. They sit together and learn at ease. Even if they fight with each other, there is no sexual or gender connotation to it. Children tend to fight while playing. The division of work which was there – that this work will be done by only girls or boys – is changing now. Boys are doing household work. There are changes in them because they have started interacting and playing with each other. Otherwise in rural areas, it happens that girls sit on one side and boys sit on the other side. We explain [issues related to] gender to them, and their hesitation regarding each other and wrong thoughts about each other have started fading away. (Female teacher, Kota)

I have observed certain changes since the time the programme was introduced in our schools. Earlier, students did not participate in class. Now, they ask questions and raise their hands to ask questions. There are a couple of students who also came to me with their personal problems. Through this programme, I have gained the trust of my students. (Male teacher, Kota)

All the master trainers, district education officers and programme staff members who were interviewed felt that the changes in the students’ attitudes and knowledge, as well as the empowerment of the teachers, were major achievements of the programme:

. . . I feel that teachers are also benefiting from this programme. When we meet at the training programme, we discuss many issues which would not be discussed in the schools. The biggest achievement is that teachers have also started speaking about sexual and reproductive health. They tell us that they were unaware of a lot of things but now know about HIV/ the drishti programme 101

AIDS, STIs . . . this programme is good for everyone. (District education officer, Kota)

One opinion shared by all stakeholders was that as a result of the Drishti programme, students had become ambassadors of change in their family and community. Students shared the information provided through the life skills programme with their parents and community members, which was fuelling a process of change. This was described by a female student as follows:

I like the sessions on the roles of boys and girls, communication and relationships. Everywhere in our village, in every household, girls are discriminated against. I have to help in all the household work and my brother does not do anything. But now I tell my mother that he should also help in the household work. I tell my father not to chew tobacco as it is not good for his health. I got all this information from Drishti classes. I like it. (Female student in FGD with 8th grade, Jhalawar)

While most stakeholders felt that the programme had resulted in positive changes, a few pointed out that in the short-run, it is difficult to discern changes in attitudes to issues such as gender equality and girls’ education. A couple of teachers believed that the programme had brought about negative changes in the attitudes and behaviour of students. For example, one said:

. . . we have got a few cases of parents complaining about the students. These students, who have never heard about sexual and reproductive health issues, HIV and AIDS, go and start talking about all this. They start talking about puberty and bodily changes. Their information-seeking behaviour and curiosity have increased. This curiosity can be positive as well as negative – negative in the sense that they ask the villagers or other children from the village or some other people about these issues. So this has a bit of a negative impact. So many times, the parents catch hold of the child and bring him to school, wondering what’s happening in the school that the child should want information on sex. They report that the kid has a lot of cheap literature in his school bag. This might be a light matter for you, but it is a huge issue in the village. (Male teacher, Kota)

. . . The boys have become very impatient. Discipline among boys has become an issue and I have lost control over them after the introduction of this programme. (Female teacher, Jhalawar) 102 s. shinde, d. rajaraman, m.a. siddiqui, d. kaur

Summary The partnership between the Department of Education, Rajasthan and Ritinjali, New Delhi resulted in significant achievements within a span of five years. These can be summarised as follows:

for adolescents in selected districts of Rajasthan, despite obstacles • Development of a syllabus and methodology for education in life skills posed by the government to the provision of education in reproductive and sexual health to adolescents

and effective training of 196 master trainers and over 2200 teachers • Transition from a pilot programme to a scaled up one, with recruitment in three districts of Rajasthan (Jhalawar, Kota and Baran)

more than 1300 schools in the three districts • Delivery of the Drishti programme to 7th and 8th grade students in behaviour of the students covered by the programme with respect to • Measured and observed changes in the knowledge, attitude and sexual and reproductive health, gender equality, substance use, self- confidence, and hygiene and cleanliness

and reproductive health, and in their interactions with students • Observed changes in the teachers’ knowledge of and attitudes to sexual NGO provided technical support for the development and oversight of • Successful establishment of a public–private partnership, in which an a health promotion programme and the government education system was used to implement the programme.

The achievements apart, certain problems were identified in the implementation of the programme. Some of the major issues were the extent to which the teachers were comfortable teaching topics related to sexual and reproductive health; their skills in delivering the subject material; and their motivation to implement the programme. The evaluation of the case study suggests that many teachers were still inhibited about teaching sexual and reproductive health and/or felt that students in the 7th and 8th grades are too young to be given such information. Such attitudes hinder the teachers’ ability to deliver the Drishti sessions. Further, most teachers felt that the duration of their training was not long enough to instil in them the requisite confidence to deliver the programme, especially given the absence of feedback on their performance in the classroom setting. All stakeholders strongly the drishti programme 103 recommended that refresher training be conducted to increase the teachers’ motivation, knowledge and comfort level. The effectiveness and efficiency of the programme could also be improved by strengthening oversight of the teachers by the school management and district education office. In addition, it would be useful if the latter could provide greater support to the teachers. Currently, much of the responsibility for the supervision and evaluation of the programme lies with the Drishti programme staff members, who are struggling to cover a large geographical area and are unable to ensure that all schools are monitored and receive support regularly. They have also had difficulty providing teachers with individual feedback on their performance. Placing the entire responsibility of monitoring on the Ritinjali team is not only inefficient, but is also likely to limit the scalability and sustainability of the programme since Ritinjali is grant- funded. Training of principals in the Drishti syllabus might augment the pool of school staff who can deliver the programme, while also equipping the school management with the necessary knowledge to provide stronger oversight. In addition, it is likely that a better understanding of the programme’s goals and mechanisms will increase the principals’ interest in Drishti, so they may give greater support to teachers for its implementation, as well as recognise the good work done by them. Further, greater involvement of the district education office in monitoring implementation would ease the burden on the Drishti programme team, while also increasing government ownership of the programme and the sustainability of the programme. It may also improve the coverage of the programme, as the significant barriers to meeting the targets for scaling up included lack of commitment on the part of the staff of the department of education, as well as misunderstandings between the Department of Education and Ritinjali with respect to their roles and responsibilities. Ultimately, it is essential for the programme to be acceptable to the community if it is to be effective in changing health behaviours and outcomes. Teachers still receive complaints from parents about the component on reproductive and sexual health. This can be a deterrent to the delivery of these sessions. Although mobilising community members and generating awareness among them are meant to be a part of the programme, the evaluation of the case study suggests that Drishti has not been too active in this area. Teachers operate under significant time constraints, which make it difficult enough for them to deliver the 104 s. shinde, d. rajaraman, m.a. siddiqui, d. kaur classroom syllabus, to say nothing of leading community campaigns over and above that. Since it is unrealistic to expect teachers to take on this responsibility, stronger partnerships could be forged between the Drishti teachers and government health workers, as well as other NGOs working on similar issues, to help promote collective efforts for community mobilisation. In the next phase, the impact and long-term sustainability of the programme can be enhanced by focusing on strengthening the skills and motivation of the teachers, providing supportive supervision and oversight, increasing government ownership and networking with other partners in the field. 5

TheSachin PrayatnaShinde, Divya Rajaraman, programme Jaya, Gracy Andrew

The Setting: Multiple states in India The Indian government’s National Policy on Education, 1986 [54] called for the establishment of residential co-educational schools that would provide free education to students in the 6th–12th grades, in order to foster the best talent in the rural areas. These schools are known as Jawahar Navodaya Vidyalaya (JNVs). By January 2014, there were 595 JNVs across India.5 The objectives of the JNV schools are to:

• Foster the ideals of excellence, equity and social justice children from different parts of the country to live and learn together, • Promote national integration by providing opportunities to talented and to realise their full potential

values, physical education and opportunities for adventure activities, • Provide good-quality modern education, a grounding in culture and and inculcate environmental awareness

three languages.6 • Ensure that all students attain a reasonable level of competence in Students of JNVs must pass an entrance test. Three-quarters of the seats of the JNV system are reserved for children from rural areas and a

5 The state of Tamil Nadu has refused to establish JNVs in protest against the JNV policy of making Hindi a compulsory subject. 6 The regional language is generally the medium of instruction from the 6th–8th grades, while from the 9th grade onwards, it is English for science and mathematics and Hindi for the humanities subjects. 106 s. shinde, d. rajaraman, jaya, g. andrew third for girls. Further caste- or tribe-based reservations are determined by the population distribution in the district. The schools are managed by the Navodaya Vidyalaya Samiti (NVS), an autonomous organisation under the Department of Secondary and Higher Education in the Ministry of Human Resource Development. The NVS functions through an executive committee under the chairmanship of the Union Minister of Human Resource Development. Between 2009 and 2011, Prayatna, a psycho-social intervention to train staff nurses in basic counselling skills, was initiated in JNVs in five states of India: Bihar, Madhya Pradesh, Maharashtra, Orissa and Rajasthan. The selection of these states was made by the funder of the programme, the UNFPA. Apart from Maharashtra, these are all Empowered Action Group states, which have been prioritised by the Indian government for intensive population stabilisation activities since 2001. There is substantial variation in the socio-economic and health indicators of the states, as shown in Tables 5.1 and 5.2. The annual per capita income ranges from $447 in Madhya Pradesh to $1818 in Maharashtra. There are also marked differences between the states in terms of access to electricity, the quality of housing and population density. Overall, Maharashtra is better off than the other four states with respect to most indicators. In these states, between a third and a half of the population lives in poverty. The health indicators in Maharashtra are also better compared to the other states and the national average. Bihar and Rajasthan are well below the national average with respect to most of the educational indicators, Madhya Pradesh is close to the national average, while the performance of Maharashtra is better. The female literacy rates are particularly low in Bihar and Rajasthan, where just above half the adult women can read and write. This is also reflected in the fact that a much lower proportion of girls are enrolled in primary schools in Bihar than boys (69 girls per 100 boys). In Bihar and Rajasthan, the gender gap in high school is striking, with 54 and 58 girls enrolled per 100 boys, respectively. The retention rate of students from primary to secondary school is the lowest in Bihar (42%), followed by Rajasthan (52%). The educational indicators are summarised in Table 5.2. All the state governments have been making substantial efforts to improve education since the expansion of day schools in rural areas under the Central Government’s Sarva Siksha Abhiyan (Education for All) the prayatna programme 107

Table 5.1. Health indicators of Prayatna states and India

Indicators Bihar Madhya Maharashtra Orissa Rajasthan India Pradesh

Crude birth rate 28.9 28.5 18.1 21.4 27.2 22.8 (per 1000)

Infant mortality 56 72 33 69 59 53 rate (per 1000 live-births)

Children immunised 32.8 40.3 58.8 62.4 27 62.4 (%)

Anaemia in women 67.4 56 48.4 62 56.1 56.2 (%)

Underweight in 54.9 57.9 32.7 39.5 36.8 41.5 children under 3 years (%)

Antenatal care 59.3 7.2 85.6 64.1 73 50.7 received (%)

Institutional 27.7 73.8 64.6 39 39 40.8 deliveries (%)

Sources: SRS 2009, DLHS 2008, NFHS-3 2006 initiative. The school mid-day meal programme is being implemented in primary schools in all the five states. It is envisaged that this will help to increase school enrolment and improve the nutritional status of the children.

The Prayatna school-based counselling programme History The JNVs are co-educational residential schools which cater to adolescent students studying in the 6th–12th grades. Because of their residential nature, these schools employ trained staff nurses, who are responsible for overseeing the health and well-being of the students. The UNFPA 108 s. shinde, d. rajaraman, jaya, g. andrew

Table 5.2. Educational indicators of five states and India

Indicators Bihar Madhya Maharashtra Orissa Rajasthan India Pradesh

Overall literacy rate 63.8 70.6 82.9 73.5 67.1 70.04

Male literacy rate 73.5 80.5 89.8 82.4 80.5 82.14

Female literacy 53.3 60 75.5 64.4 52.7 65.46 rate

Primary to 42.3 95.5 89.9 62 51.7 71 secondary school retention rate

Number of girls 69 89 93 88 89 88 per 100 boys in primary school

Number of girls 54 77 90 84 58 80 per 100 boys in upper school

Sources: Census 2011 data and Government of India decided to tap the potential of the JNVs, and proposed in the UNFPA Country Programme (2008–12) that the staff nurses could be trained to serve as a resource for providing counselling services to the students. It was recognised that this training would not create a cadre of professional counsellors; rather, it would enhance the staff nurses’ ability to better address most of the adolescents’ concerns, as well as identify and refer cases that require professional help. As a funding agency, the UNFPA invited proposals from organisations interested in supporting the initiative. Sangath, a Goa-based NGO, responded to the invitation. Sangath was already involved in the design and delivery of counselling services for adolescent students through the SHAPE programme in Goa (see Chapter 2). The Prayatna school-based counselling programme thus grew out of the interest of the NVS and UNFPA in promoting counselling for the students of JNVs, along with Sangath’s interest and experience in the prayatna programme 109 developing and testing interventions to promote adolescent health and mental health. The specific objectives of the programme were to:

• Develop an appropriate training curriculum and resource materials Maharashtra, Orissa and Rajasthan) in counselling skills • Train staff nurses from JNVs in five states (Bihar, Madhya Pradesh,

• Provide continuing supervision and support to the trained staff nurses services. • Monitor and evaluate the feasibility and acceptability of the counselling Being a residential school, a JNV is assigned a staff nurse, a resource that is not usually available in government day schools. The Prayatna programme makes use of this resource to deliver youth-friendly counselling services to the students. During their training, the staff nurses are asked to reflect on and assess their beliefs and values with respect to the reproductive health, sexuality and psycho-social concerns of adolescents. They are trained to not allow their values and attitudes to compromise the basic sexual and reproductive health rights to which the students are entitled, or the quality of health and counselling services offered to them. The Prayatna intervention comprised three major components: the training of staff nurses, delivery of counselling services by the staff nurses, and supervision of the services. The Prayatna programme was implemented in two phases between 2009 and 2012. A summary of each phase follows. Pilot phase (2009–10): At the request of the NVS and UNFPA, a pilot phase was implemented for a year in 58 JNVs in the Pune region (JNVs from the states of Maharashtra and Gujarat and the Union Territories of Diu, Daman and Silvasa) and Chandigarh region (JNVs from Jammu and Kashmir, Himachal Pradesh and Punjab) Training sessions were conducted over 10 days to orient staff nurses to the programme. Thirty- two staff nurses were trained from the Chandigarh region in July 2009 and 26 from the Pune region in December 2009. During the orientation in the case of both regions, the JNVs were assigned to one of two groups – the supervision (support) and non- supervision (non-support) arms – so as to be able to evaluate the effectiveness of the counselling services provided by the staff nurses, with and without supported supervision. In the support arm, the staff nurses were supervised through fortnightly telephone calls from a 110 s. shinde, d. rajaraman, jaya, g. andrew programme coordinator, who reviewed any challenging cases before the staff nurse and formulated management strategies to deal with these cases. Staff nurses in the support arm were also given refresher training of three days, three to six months after the orientation. Scaling-up phase (October 2010–August 2012): During this phase, the programme was extended to 154 JNVs across five states, which were nominated by the UNFPA. As mentioned earlier, these were Bihar, Madhya Pradesh, Maharashtra, Orissa and Rajasthan. On the basis of the findings of the pilot study, it was decided to provide all staff nurses with support and supervision. Between October 2010 and October 2011, six regional training programmes were conducted to orient the staff nurses to the programme. In addition, two rounds of refresher training were conducted per state. The first round was conducted within three to six months of the orientation sessions and attended by 108 staff nurses, while the second was conducted towards the end of the scaling-up phase and attended by 139 staff nurses. Post-scaling up phase (2013): The UNFPA is in the process of documenting an internal process evaluation report of the project, which will inform the agenda for expanding the programme to other states in the next cycle of funding.

The delivery team The NVS authorised the implementation of the programme in JNVs and provided administrative support, besides support with the logistics and human resources. It selected nurses for training, made arrangements for the orientation programmes and refresher training, and sanctioned the provision of counselling services by staff nurses as a part of their job description. The UNFPA supported the programme financially and was responsible for the overall monitoring of the project, as well as coordinating between the NVS and Sangath for the organisation of training. The UNFPA programme officer was the primary contact between the NVS and Sangath. Sangath’s role was to develop and deliver the training curriculum and materials, and provide supportive supervision to the staff nurses. The orientation programme and refresher training were conducted by two clinical psychologists from Sangath. These psychologists had extensive the prayatna programme 111 experience in the delivery of mental health services for adolescents and the youth, as well as in capacity-building. A senior clinical psychologist who was involved in the training and/or the project coordinator made monthly telephone calls to the staff nurses to discuss any difficult cases before them and the challenges they faced in implementing the programme, and to collect the monthly reports. The Sangath clinical psychologists were also responsible for on-site supervision of a sub- group of the staff nurses (the composition of which is described in the section on programme monitoring), and telephonic supervision for any challenging cases identified by the staff nurses. The Sangath project coordinator worked with the UNFPA to coordinate the sessions for orientation and refresher training, collected monthly data on the delivery of the programme from the staff nurses, and liaised between the staff nurses and clinical supervisors to facilitate supervision. Once trained, the staff nurses were expected to spread the word among the stakeholders that counselling services were available in their respective schools, and to provide these services when required. The staff nurses were expected to maintain case records and registers, report to the programme coordinator on a monthly basis, request, and refer serious cases to specialist healthcare providers, as appropriate. They were free to seek the help of the Prayatna clinical psychologist for difficult cases, The NVS and school principals did not play any official supervisory role, as the staff nurses reported on programme-related activities directly to the Prayatna programme coordinator and clinical psychologists from Sangath.

Content The training curriculum was developed to enhance the staff nurses’ knowledge of and skills in basic counselling. The curriculum also included project-specific components, such as supportive supervision and reporting of requirements and processes. The staff nurses had already been trained under the AEP and the materials used for this training, along with the counselling manual developed by Sangath, formed the basis of the Prayatna training. The Prayatna orientation training package covered basic counselling skills; life skills and problem-solving; and counselling in specific situations. The entire training course was divided into eight modules, 112 s. shinde, d. rajaraman, jaya, g. andrew which were further subdivided into 21 topics. These included substance abuse, risk of suicide, issues related to the reproductive and sexual health of adolescents, and bullying. The curriculum of the training workshop is summarised in Table 5.3. During refresher training, an attempt was made to identify and address the challenges faced by the staff nurses while practising their counselling skills. They were given feedback from the group, as well as supervisory feedback. Their counselling skills were assessed through role-plays on key counselling skills, including rapport-building, maintaining confidentiality, expressing empathy, paying attention to one’s body language, making clarifications for the client, understanding the feelings expressed by the client, and summarising the session for the client.

Programme monitoring One of Sangath’s aims in providing technical support was to strengthen monitoring and evaluation to ensure that the programme would be of good quality and wide coverage, and to assess the feasibility, acceptability and impact of the provision of youth-friendly counselling services by staff nurses to students in JNVs. Process indicators to monitor the delivery of the programme were collected through telephonic supervision and monthly reports on the counseling services and activities to raise awareness. The project coordinator documented the number of cases handled by each staff nurse, number of contacts made by the coordinator in a month, types of issues addressed during the supervision, and challenges faced by the staff nurses while counselling clients. Real-time support was provided to the staff nurses through scheduled and ad hoc telephone calls, during which they could discuss difficult cases and problems. The Sangath delivery team also made 32 monitoring visits to a sub- group of JNVs. Approximately six schools were purposively selected from each of the five states, depending on the feasibility of travelling to those areas from the district capital. The purpose of the monitoring visits was to review the implementation of the Prayatna programme; assess the quality of and ethical standards employed in the counselling; review the staff nurses’ record-keeping; and identify and eliminate the barriers to the implementation of the programme. The clinical supervisors also conducted informal FGDs with students from the 9th–12th grades, as the prayatna programme 113

Table 5.3. Prayatna programme: Training curriculum

Module Learning objectives/competencies

Introduction to Sangath and 1. Understanding how the course will be the Prayatna project structured 2. Defining and understanding the objectives of the Prayatna programme 3. Understanding the learning objectives of the training 4. Defining the role of the staff nurse 5. Sensitisation to issues concerning adolescents

Counselling skills 1. Learning basic skills of counselling 2. Learning about one’s own attitudes and values and how these affect counselling

Counselling skills 1. Learning about ethical issues in counselling 2. Learning how assessments are made

Counselling skills 1. Learning ethics (general case studies and issues) 2. Understanding how to assess cases or clients

Counselling skills 1. Understanding how to obtain information related to the client (case history, family background, surroundings and peer group) 2. Applying problem-solving skills

Counselling in specific 1. Building awareness of issues concerning situations adolescents 2. Making counselling services youth-friendly 3. Understanding the need to look after oneself 4. Relating life skills to counselling

Documentation 1. Keeping case notes 2. Understanding the monitoring mechanism (monthly reports) 3. Telephonic supervision 114 s. shinde, d. rajaraman, jaya, g. andrew well as semi-structured interviews with house masters and principals to gather further information on the perceptions and delivery of the programme.

The Prayatna Case Study Evaluation Document review The following reports were included in the review of the documents pertaining to the case study: the pilot phase report from 2009–10, five orientation training reports from 2010–12 and the final report of the Prayatna programme (Table 5.4).

Qualitative end-line evaluation In the qualitative end-line evaluation undertaken by the Sangath case study research team, information on the programme was gathered from the programme staff, staff nurses, principals, students who had accessed counselling services, and groups of students from the intervention’s target population. A total of 44 in-depth interviews and 10 FGDs were conducted. Of the 154 schools in which the Prayatna programme was delivered, 20 were selected for the end-line evaluation. In each state, one JNV was randomly selected and three proximate JNVs were purposively selected. This cluster sampling strategy was employed because it would have been logistically unfeasible to conduct interviews across all parts of the state within the given time frame, considering the large size of the states and the poor transport infrastructure. In each of the 20 sampled schools, the staff nurse was interviewed. In addition, 10 principals were randomly selected for interview (two in each state), and 10 students who had accessed counselling services (five males and five females from each state) were purposively selected to be interviewed. The students were from the 6th–10th grades and in the age range of 12–16 years. In each state, FGDs were conducted with students (males and females separately) from the 6th–9th grades. In-depth interviews were also conducted with three programme staff members of Sangath and the programme officer from the UNFPA. The details of those interviewed are shown in Table 5.5. The interviews and FGDs were conducted by members of the Sangath research team between 31 March and 30 April 2011. the prayatna programme 115

(continued) Sample 17 principals and Quantitative: 35 nurses 7 principals, 16 Qualitative: students and 8 staff nurses Madhya 21 staff nurses from Pradesh Rajasthan 16 staff nurses from Orissa 26 staff nurses from Study design/data sources sources design/data Study methods and qualitative Quantitative questionnaires self-administered Structured, acceptability and measuring feasibility, implementation quality of programme In-depth interviews methods and qualitative Quantitative and feedback survey knowledge Pre-post trainees from methods and qualitative Quantitative survey knowledge and post-training Pre- trainees from and feedback methods and qualitative Quantitative survey knowledge and post-training Pre- trainees from and feedback Document title Document Youth-Friendly Providing Services: Pilot Counselling Phase Report of the SN Training Report Madhya Programme: Pradesh of the SN Training Report Rajasthan Programme: of the SN Training Report Orissa Programme: Author Sangath Sangath Sangath Sangath Prayatna reports included in case study document review included in case study reports Prayatna Year 2009–10 Scale-up phase 2010 2011 2011 Table 5.4. Table 116 s. shinde, d. rajaraman, jaya, g. andrew Sample Bihar 32 staff nurses from 32 staff nurses 31 staff nurses orientation data from Evaluation and process training and refresher data of the project Study design/data sources sources design/data Study methods and qualitative Quantitative survey knowledge and post-training Pre- trainees from and feedback methods and qualitative Quantitative survey knowledge and post-training Pre- trainees from and feedback methods and qualitative Quantitative survey knowledge and post-training Pre- trainees from and feedback methods and quantitative Qualitative and teachers with principals, Interviews staff nurses assessment and and post-training Pre- forms feedback training visits and telephonic monitoring Data from supervision calls Document title Document of the Staff Nurse Report Bihar Programme: Training of the SN Training Report Madhya Programme: Orissa, Rajasthan Pradesh, Pradesh and Andhra of the SN Training Report Maharashtra, Programme: Bihar and Pradesh, Madhya Pradesh Andhra of the Prayatna Final Report Programme ) continued Author Sangath Sangath Sangath Sangath ( Year 2011 2011 2011 2010–12 Table 5.4. Table the prayatna programme 117

Table 5.5. Respondents interviewed for end-line qualitative evaluation

Stakeholder Number

Prayatna programme staff 4

Principals in JNVs 10

Staff nurses in JNVs 20

Students who accessed counselling services 10

FGDs with male students 5 (55 boys)

FGDs with female students 5 (52 girls)

Acceptability Perceived need for programme The findings related to the acceptability of the programme are drawn from the report of the pilot study, five orientation training reports, the final report of the programme and the end-line qualitative evaluation. During the monitoring visits and end-line qualitative evaluation, the staff nurses, teachers, principals and programme staff all expressed the view that it is important to provide students with counselling services as they require support for handling their behavioural, emotional, social and academic concerns. Such support was considered particularly important in view of the residential nature of the schools and the socio- economic background of the students. Almost all staff nurses felt that many JNV students had difficulty getting used to the residential school environment, in which they had to follow new school rules and regulations, adjust to a new timetable and different food, and look after themselves. Consequently, it was common for new students to feel homesick. The staff nurses also noted that a few students found it difficult to adjust to the physical and emotional changes accompanying puberty, and required counselling to understand and cope with these changes. Another point raised by the staff nurses was the need to counsel the students on issues related to relationships. In the words of a staff nurse: 118 s. shinde, d. rajaraman, jaya, g. andrew

. . . since this is a co-educational school, there are boys and girls who have reached puberty. They feel attracted towards each other, which is natural. But once a boy and a girl start spending time together in the school or on campus, other students start teasing the girl. Everyone would be discussing the boy and girl. Another important issue is the menstrual cycle. Before girls come of age, we educate them on the menstrual cycle and hygiene. However, some girls experience anxiety. Some girls cope with it very well, while others do not. When the physical changes start, some students develop problems about their self-image, especially the way they look. So counselling is definitely required for these children. (Staff nurse, Maharashtra)

The staff nurses also mentioned that some students found the competitive educational environment in JNVs challenging. In such cases, counselling would help to promote better studying practices and reduce anxiety related to examinations. Obtaining lower grades than their classmates also negatively affected the self-image of some of these students. These observations were echoed by the principals and students. As one student said:

. . . I was putting too much pressure on myself to perform better. I was really working hard, but I am weak in maths. I constantly felt the pressure of doing well in the examination and that affected my health. (9th grade female student, Madhya Pradesh)

In the FGDs conducted during the monitoring visits as well as end- line interviews, the students said that the counselling services were important to them, in that they provided them with an opportunity to share their problems with an adult, reduced their anxiety and depression, and had the potential to help them improve their academic performance. Some students said they were hesitant to approach the teachers/ house masters to discuss personal issues, especially because of the school policy of expelling students involved in romantic relationships. The counselling services provided under the Prayatna programme were especially important in the light of this, offering as they did the students the opportunity to discuss their relationships with an adult in a confidential setting. While the majority of stakeholders who were interviewed affirmed the desirability of counselling services for adolescents in the JNV setting, a small minority of nurses from Bihar, Madhya Pradesh and Rajasthan the prayatna programme 119 who were not convinced of the need for such services. In their opinion, the JNVs provided an extended family setting in which the adolescents did not face any emotional, psychological or behavioural problems. For example, one of the staff nurses said:

In my opinion, there is no need for counselling services in the JNV. There are no cases here related to tobacco or alcohol use, or relationships between boys and girls. No such cases happen here. All the children from this school are good. They get homesick. So if someone is homesick, we send them home for a few days. Most of the students here come from a rural background. They are simple and they adjust here very well. I do not think that they face any problems here. (Staff nurse, Bihar)

A few principals felt that the programme did not address all the needs of the students, and should also cover career guidance, personality development and skills in public speaking.

Attitudes and participation of stakeholders The report of the pilot study and final programme report noted that the participation of staff nurses, teachers and principals varied across and within the states. In the end-line qualitative evaluation, half of the staff nurses interviewed reported that the principals and house masters/ mistresses were very cooperative and supportive, and referred any student who showed signs of behavioural or emotional problems for counselling. In the words of a staff nurse:

. . . I get a lot of referrals from house masters/mistresses. As I have explained the programme in a couple of assemblies, the teachers and principals are very cooperative. They refer students who have behavioural or emotional problems to me. For example, if a student is not paying attention in the classroom, then the teacher will tell me about that student. All are aware about the counselling services that I provide and are helpful. (Staff nurse, Bihar)

These staff nurses also said the students were satisfied with the counselling services and even sought help on their own. One of the staff nurses described the situation as follows:

. . . earlier, I never interacted with the students on a regular basis. They used to come to the clinic, if required, and I used to give them some 120 s. shinde, d. rajaraman, jaya, g. andrew

medicines. If someone required help in the night, then we used to go to their dorms and offer help. But since the programme has started, I interact with them more often. I think they also feel comfortable with me. Some of the students have come to seek help for their personal problems. I think the students trust me. (Staff nurse, Maharashtra)

However, the principals’, teachers’ and students’ level of participation in the programme, as well as the level of their support for it, were sub-optimal in many schools. This was because they were not aware of the existence of the programme, or of the details of its content and delivery; the principals’ scepticism about the staff nurses’ ability to counsel the students and their consequent unwillingness to refer cases to the nurses; the principals’ disregard of the need to maintain the students’ confidentiality; and the male students’ uneasiness about discussing issues related to reproductive and sexual health with female staff nurses. A major issue in many schools was the fact that the members of the school management and staff were ill-informed about the programme. A few principals equated the Prayatna programme with the AEP, which indicated their lack of awareness regarding the counselling services. Similarly, of the 32 schools in which teachers were interviewed during the monitoring visits, only 12 had information that counselling services were being offered by the staff nurses. Only two were clear on the roles and responsibilities of the staff nurse as a counsellor and the kinds of cases that should be referred. In view of this, a few nurses suggested that training be conducted to sensitise principals and teachers to the programme to ensure greater cooperation and support:

The principal is the key person. We tell him everything, but the programme should give them some training. The principal should be informed about the goals of this programme, the type of training conducted for staff nurses, our role as a counsellor. Even the house masters and mistresses should be sensitised by the programme staff. That will improve the acceptance of the programme. (Staff nurse, Maharashtra)

However, several principals spoke about their lack of faith in the staff nurse’s competencies. For example, one said:

. . . I have completed a master’s degree in education, sociology and psychology. I have learnt how to do counselling in my course. I feel the the prayatna programme 121

staff nurse is not the appropriate choice for delivering the counselling services. They do not understand the nitty-gritty of behaviour. They are just nursing graduates. These staff nurses do not come in contact with students like house masters or house mistresses. I don’t know how she conducts counselling . . . (JNV principal, Bihar)

A few staff nurses from all five states reported during refresher training that their school principals did not respect the students’ confidentiality and discussed the students’ personal problems in front of other staff members. The staff nurses of some schools also said that the house masters/mistresses did not always seek their help for cases in which counselling could be beneficial. About half of the staff nurses interviewed in the end-line qualitative evaluation reported that male students did not open up with them and were more comfortable broaching topics related to sexual and reproductive health with their house masters or science teachers:

. . . I feel comfortable discussing issues related to reproductive health, sexuality, gender and violence, but only with girls. I do not feel comfortable discussing these issues with boys. I have noticed that even the boys are not comfortable discussing them with me. They prefer to talk to their house master about these issues. (Staff nurse, Orissa)

Feasibility To assess the feasibility of the programme, the reports of the training and final programme report were reviewed for information on coverage (in terms of the number of schools implementing Prayatna and number of students counselled in these schools), and barriers to and facilitators for the programme’s implementation. The end-line qualitative evaluation focused on assessing the perceived barriers to and facilitators for the implementation of the counselling services.

Training Orientation training The sessions for the orientation of the staff nurses were conducted by the state during September 2010 and March 2011. In the scaling up phase, 180 JNVs were selected for the implementation of the programme, 122 s. shinde, d. rajaraman, jaya, g. andrew

Table 5.6. Participation in the Prayatna programme trainings

States JNVs SNs in SNs in Round SNs in Round orientation I refresher II refresher training training training

Madhya Pradesh 48 37 14 35

Rajasthan 32 27 18 25

Orissa 30 29 11 21

Bihar 38 38 38 30

Maharashtra 32 23 27 28

Total 180 154 108 139

as shown in Table 5.6. However, only 154 staff nurses (142 female and 12 male) participated in the training, which was conducted in six batches. The reason for this was that there were vacant posts in some of the selected schools, while in others, staff nurses were on leave or had temporary contracts. The training reports indicated an improvement in the staff nurses’ knowledge of and attitudes to mental health problems among adolescents and in their counselling skills following training, as shown in Table 5.7. There was an improvement in the average pre- and post-training scores of the staff nurses in all six batches trained, although the improvement was statistically significant in only three batches. In the evaluation of the training, the majority of staff nurses (95%) considered the overall quality of the workshop “good”. They felt that the sessions on self-awareness, assessment and the management of problems, such as depression, suicidal behaviour and educational problems, were relevant to their work. In their feedback on the orientation sessions, they spoke of an improvement in their knowledge of the issues faced by adolescents and the skills required to handle these, and said they were better equipped to provide youth-friendly counselling. This was consistent with the feedback provided by them during the end-line the prayatna programme 123

Table 5.7. Average scores obtained by staff nurses at pre- and post- orientation training

Training Number of Mean score participants (min-max score: 0–25)

Pre-training Post-training

Madhya Pradesh 21 17.3 20.8*

Rajasthan 16 13.5 19.1*

Orissa 26 16.2 17.8

Bihar 32 15.3 16.1

Madhya Pradesh, Orissa 30 17.1 19.2* and Rajasthan

Bihar, Madhya Pradesh 29 17.3 18.6 and Maharashtra

* statistically significant difference (p<0.001), using paired t-test evaluation. In addition, many staff nurses expressed their appreciation of the participatory approach. A few confessed that they used to counsel students without a proper understanding of what counselling entails, but that this had changed following the Prayatna training. For example, one said:

When we give advice to someone, we think that we are counselling them. But we carry a lot of values and biases. The orientation programme was really helpful in understanding the real counselling process. Both the [trainers] helped us understand all the stages of counselling. I now have a better understanding of the counselling process. Similarly, they explained the importance of providing counselling on all the issues that students face. I have started interacting with students and they now open up with me. They share all their problems with me. This has been possible only because I apply the skills that I learn in the training programme. (Staff nurse, Rajasthan) 124 s. shinde, d. rajaraman, jaya, g. andrew

The suggestion made most commonly by the staff nurses was that the duration of the orientation programme be extended. They also suggested a reduction in the number of lectures and were in favour of having more demonstrations and role-plays. Further, they advocated the use of audio- visual aids in the training. In the words of a staff nurse:

. . . the training programme was good. I learnt a lot from it. But they did not conduct many mock sessions. There were few demonstrations on how to provide counselling. It was good, but I still do not feel confident about handling the severe cases. I can now very well handle a case of "homesickness", but if there is a severe case like teasing or a relationship between a boy and girl, it is very difficult. I cannot handle those cases. (Staff nurse, Rajasthan)

Most staff nurses recommended that DVDs containing demonstrations of counselling sessions be provided, as they could refer to these whenever they were in doubt. A few staff nurses, especially from Bihar, Madhya Pradesh and Rajasthan, suggested that the training programmes should be conducted in the vernacular language to maximise learning.

Refresher training

A total of 108 staff nurses from the five states (Table 5.6) attended the first round of refresher training. In addition, three from Maharashtra, who had been unable to attend the orientation programme, attended the first round of refresher training. In their feedback, the staff nurses expressed the view that the sessions on the basic skills of counselling and the problem-solving approach were very relevant to their work. The other topics that were considered useful by most staff nurses were anger management, study skills, helping adolescents manage examination anxiety and managing severe emotional problems, such as depression and suicide. During the end-line evaluation, the staff nurses mentioned that the refresher training had helped to raise their level of confidence. The following was among the sentiments commonly expressed:

I thought the second training of three days was much better than the 10-day training. In the 10-day training, concepts were discussed, but in the second training everyone was asked to share one case. They asked us to demonstrate the actual sessions and everyone was asked to give the prayatna programme 125

feedback. The staff nurses who participated in the mock sessions and role-plays received instant feedback on what is good, what is bad. So it helped. And we also learnt from each other as everyone shared cases.” (Staff nurse, Madhya Pradesh)

The programme staff also mentioned that the rounds of refresher training had been effective in imparting skills to and boosting the confidence of the staff nurses because of the practical training they involved. The staff nurses expressed a strong interest in continued refresher training to help them maintain and strengthen their counselling skills. The second round of refresher training, one in each state, was attended by 139 staff nurses. Participants from Madhya Pradesh, Rajasthan and Maharashtra were assessed on their basic counselling skills. The findings are presented in Table 5.8. The average scores suggest that the majority of staff nurses lacked important basic skills of counselling. In the same training sessions, the staff nurses were asked to rate themselves. Three per cent from Madhya Pradesh, 10% from Rajasthan and 34% from Maharashtra rated themselves as excellent counsellors. Nine per cent from Madhya Pradesh, 14% from Rajasthan and 28% from Maharashtra rated themselves as very good, while 55% from Madhya Pradesh, 43% from Rajasthan and 38% from Maharashtra rated themselves as good. Thirty-three per cent of nurses from Madhya Pradesh and 33% from Rajasthan rated their performance as satisfactory, saying it needed to be improved. Almost all nurses felt that they required continuing support, supervision and refresher training.

Coverage and uptake

In the pilot and scaling up phases, the coverage of the programme is reported in terms of the total number of cases handled by the staff nurses. The following details were gathered from each staff nurse through monthly telephone calls: details of the cases handled every month, such as the age, class and gender of the client, type of problem being experienced by the client, date of the visit, and details pertaining to referral. In the scaling up phase, 154 nurses handled 339 cases (62% females and 38% males). Of these cases, 46% were referred by teachers and 126 s. shinde, d. rajaraman, jaya, g. andrew

19.3 30.9 30.66 Total score score Total (min 24; max 64)

3.9 2.5 ing 0.59 Summaris-

1.0 3.3 3.1 ing Paraphras-

1.3 2.8 3.1 Reflection Reflection of feelings

4.2 3.0 4.2 ing Clarify- 4.5 4.6 5.0 Body Body language 1.9 4.2 4.2 Empathy

2.1 4.2 3.5 tiality Confiden- 3.3 4.6 4.7 Rapport N 35 25 28 Mean scores obtained by staff nurses during assessment of counselling skills at second round of refresher staff nurses during assessment of counselling skills at second round obtained by Mean scores training

Table 5.8. Table Rajasthan Maharashtra State State (min 3; max 8) mean State-wise Pradesh Madhya the prayatna programme 127

33% were self-referred. Forty-three per cent of cases were referred for emotional problems, 20% for health issues, and 15% for behavioural difficulties. In Bihar and Maharashtra, girls were about twice as likely to be counselled as boys. Staff nurses who required mentoring for counselling could turn to the Sangath programme team, which provided them with telephonic supervision. However, the data on telephonic supervision indicate that the majority of the calls were related to the administrative challenges faced by the staff nurses or their personal problems with the authorities. Very few staff nurses discussed their cases or methods of strengthening their counselling skills. In two years, the staff nurses made only eight calls to seek support for the delivery of counselling services. (Of these, four related to adolescents’ problems with relationships and three to academic difficulties, while one was about a suicidal adolescent.) During the end-line qualitative evaluation, the staff nurses attributed the poor uptake of counselling services primarily to insufficient support from the school management and staff (the details have already been described in the section on acceptability). Another factor identified by many staff nurses was the limited time available to implement the programme because of their other responsibilities. In the words of a staff nurse:

. . . I would like to see more cases, but it is very difficult. We do not get time. I am also a house mistress. I have a lot of responsibilities as a house mistress. I am like a mother to 100 students. (Staff nurse, Madhya Pradesh)

Another possible reason for the low number of recorded cases was under-reporting. A few staff nurses claimed that they had counselled many more cases than they had reported, saying that this was because the case register was checked by the principal and they feared that this could lead to a breach of confidentiality. In addition, the nurses said that they often did not record cases which they considered routine and not very serious, such as cases of homesickness. All staff nurses felt that the implementation of Prayatna could be strengthened by more frequent visits for supportive supervision by the programme staff, as well as sensitisation of the principals and house masters/mistresses to the issues faced by the adolescents and the counselling services offered by the staff nurses. They also felt that a 128 s. shinde, d. rajaraman, jaya, g. andrew financial incentive or public recognition of their services would enhance their level of motivation.

Monitoring and supervision The school management played no direct role in supervising the staff in the provision of counselling. It was the Prayatna project team that was responsible for providing support and supervision to the staff nurses, over the telephone. The staff nurses could submit their monthly report via e-mail. However, during the two years of the scaling up phase, the project team was able to make telephonic contact with less than half of the staff nurses with one call. The staff nurses explained that the lack of telephonic contact was due to poor mobile phone connectivity in some schools, as well as the NVS policy, which limited the utilisation of mobile phones by the staff during the working day. During the qualitative evaluation, six out of 20 staff nurses reported that they had stopped submitting their reports through e-mail or over the telephone: four said that they thought it was not that important, while two reported that they had lost the registers they used to maintain for the programme. The programme staff mentioned several obstacles to the collection of monthly reports. These included power cuts, limited access to the Internet, poor mobile phone connectivity in remote areas, under- reporting of cases, and misreporting of health cases as counselling cases. The wide geographical spread of the schools made it difficult to cover enough schools for the on-site monitoring visits. In 2011–12, the programme staff visited only 32 out of 154 schools for monitoring. Because of limited on-site monitoring and the inconsistent monthly reports submitted by the staff nurses, the programme staff was not able to provide real-time feedback to them. A common suggestion made by the staff nurses and principals was that the programme staff should make more monitoring visits and the principals should receive feedback on the staff nurses’ performance. The lack of feedback was de-motivating some of the people involved in the programme, as is illustrated by the following quote:

There is no use recording all the cases; we do not get any feedback from the Sangath staff. Now, I have stopped sending the monthly reports because of that. (Staff nurse, Madhya Pradesh) the prayatna programme 129

A member of the programme’s staff suggested that training the principals in counselling and giving them the responsibility of conducting first-level supervision and monitoring would be a pragmatic way of improving the implementation of the programme.

Evidence of impact The evidence on the impact of the programme is drawn from the end-line qualitative evaluation. About half of the staff nurses reported that the project had had a very positive impact on students who had utilised the counselling services. Students who had been for counselling reported that they were satisfied with the advice offered by the staff nurses. Most of these students said that the counselling was “helpful” in solving their dilemmas in matters such as coming of age and anxiety about academics. This is reflected in the following quotes:

I was confused and did not understand what was happening to me. My chest was getting bigger and I was worried about it. So when I went to the nurse, I couldn’t tell her what was happening to me. But she understood it. She explained everything. She explained the changes that occur when a boy and girl enter puberty. She also referred me to a doctor in XXX. That doctor has prescribed some medicines to me. (9th grade male student, Maharashtra)

. . . when I came here, I was a good student. I always used to score around 90%. But my maths was never good and my fear of it increased day by day. The atmosphere in the JNV is very competitive. All the students are brilliant and they want to top the class. This fuelled my problem. My maths teachers helped me a lot, but I guess I started neglecting maths. I just did not want to study it. One day, during our assembly, the staff nurse announced that students who have problems can go to her and seek help. So I decided to seek her help. When I told her my problem, she understood it. She talked to my maths teacher and both of them prepared a plan for me. My maths teacher and the staff nurse helped me overcome my fear of maths. Now I take an interest in solving the problems. (10th grade female student, Maharashtra)

All the students interviewed reported that they felt more relaxed after discussing their personal problems with the staff nurse and felt 130 s. shinde, d. rajaraman, jaya, g. andrew confident that their discussions would remain confidential. A few girls also said during the FGDs that the staff nurse conducted a monthly session on issues concerning adolescents and had been very supportive to the students.

Summary As India and other South Asian countries continue to scale up school- based health promotion programmes, the Prayatna programme has provided valuable evidence on the acceptability and feasibility of providing counselling services to adolescents in residential schools through an existing resource, such as a staff nurse. The need for counselling services for adolescents was widely acknowledged by the stakeholders. The evidence showed that the training improved the staff nurses’ knowledge of issues concerning adolescents, as well as their ability to provide counselling services. The Prayatna programme has successfully trained 154 staff nurses from JNVs in five states in just two years. Staff nurses across the states were extremely satisfied with the orientation programme and refresher training. Students who accessed the counselling services found them helpful. However, the reported uptake of counselling services was very limited, with only 339 students being counselled by 154 staff nurses between October 2010 and December 2012. The evaluation of the case study identified several obstacles to the effective implementation of the programme. The uptake of counselling services was hampered by a widespread lack of awareness among the school management and teachers of the programme and of the specific role of the staff nurses (as counsellors). Due to this lack of awareness, several cases were not referred to the staff nurses, which lowered their confidence. At the same time, even those principals who were aware of the programme sometimes felt that the staff nurses were not qualified to handle the cases. In addition, the principals’ lack of regard for maintaining the confidentiality of students and the harsh school policies with respect to relationships between students deterred students from seeking counselling and the staff nurses from reporting the cases they had handled as part of the programme. While the staff nurses were happy with the training they had undergone, the model of supportive supervision through monthly telephone calls was not very effective. the prayatna programme 131

This was partly because of the limited coverage of mobile phones and because teachers were not allowed to use their mobile phones during working hours. In addition, many staff nurses were not motivated to send monthly reports, whether over the telephone or by e-mail, due to the absence of incentivisation, limited support for their services in the school, and the lack of real-time feedback on their reports from the Sangath programme team. It is not feasible for the programme team to provide on-site supportive supervision to all staff nurses, given the small size of the team and the wide geographical area in which the programme operates. A few ways of strengthening the implementation of the programme are to engage more closely with the principals, raise awareness of and support for the programme, and request the principals to perform supervisory and line-management functions in the sphere of counselling. This would not only enhance their sense of ownership of the programme, but would also result in closer oversight of the counselling services and improve reporting on the programme at the school level, thus giving rise to a more sustainable system. Given its relatively low cost of delivery, the Prayatna programme could serve as a scalable model for expanding the provision of youth- friendly counselling services to all adolescents in residential schools. However, the ultimate effectiveness of the model will depend, to a very large extent, on the ability of the NVS and its partners to address the challenges related to ownership, engagement and supervision in the next phase of the programme. 6

Divya Rajaraman, Sudipta Mukhyopadhyay, Sachin Shinde, VikramConclusion Patel

Interventions for the promotion of reproductive health among adolescents aim to reduce the possible adverse consequences of early sexual activity, as well as improve the quality of young people’s sexual relations in the present and future [55]. While there is a growing global body of evidence on the impact of school-based health promotion interventions on the knowledge, attitudes and behaviours of adolescents [13,16,17,56,57], the variation in the content and delivery models of programmes, the contexts in which they operate and the quality of measurement make it difficult to generalise the findings across different settings. Interventions for the promotion of reproductive and sexual health among adolescents are relatively new in India, having first been introduced at scale in the 1990s, largely through school-based initiatives for education on HIV [3]. These programmes have expanded in scope and scale, but there has been limited documentation of their achievements and the lessons learnt over the past decade.

Key features of the school health promotion case study programmes

The four case studies profiled in this book highlight the diversity of approaches that can be taken to developing, implementing and scaling up school-based health promotion programmes, as mentioned in Table 6.1. The initiatives differ in setting, scope, scale and content, and there conclusion 133 ) continued ( Prayatna Pradesh, Madhya Bihar, Orissa and Maharashtra, Rajasthan for a programme develop To counselling services providing students staff nurses to through in government enrolled secondary schools, residential and its feasibility evaluate and assess its acceptability, impact in the 6th–12th Students studying residential in government grades schools Samiti, Vidyalaya Navodyaya UNFPA–Sangath SHAPE Goa a health-promoting develop To by delivered school programme school health counsellor, a lay and its feasibility evaluate and assess the acceptability, of its evidence preliminary impact in the 5th– Students studying in government- 12th grades aided schools of Goa, Sangath Archdiocese Drishti and Baran Jhalawar Kota, districts in Rajasthan adolescents, empower To and entire teachers parents, enhance communities, and to of quality of life the overall helping them by these groups choices better make to learn to in the 7th Students studying in government and 8th grades schools Department of Rajasthan Ritinjali Education, UDAAN Jharkhand adolescents’ improve To of reproductive knowledge the facilitating health by introduction state-wide and of education in sexual health in reproductive schools secondary in the Students studying in 9th and 11th grades schools government AIDS Control State Jharkhand Department Jharkhand Society, Resource of Human India CEDPA Development, Comparison of key characteristics of four school health promotion programmes programmes school health promotion of four characteristics of key Comparison Table 6.1. Table Setting Programme goal Target population Implementing partners 134 d. rajaraman, s. mukhyopadhyay, s. shinde, v. patel group counselling services group Youth-friendly individual and and individual Youth-friendly training residential 9-day training Annual refresher Prayatna – School staff nurse – – Advisory Board, healthy healthy Board, Advisory school policies, annual visual assessment and nutritional camps, anonymous screening voice students to for box letter concerns and ask questions skills life students counselling for school health lay for counsellors Sangath, to reporting weekly supervision ongoing weekly a clinical psychologist by School Health Promotion Promotion School Health in training Classroom-based and group Individual (320 hours) training 40-day and visits from Monitoring training Annual refresher SHAPE – – – school health counsellor Lay – – – covering emotional, physical emotional, physical covering and and social health, gender sexuality in the community awareness trainers master for (80 hours) in 4–5 days Ritinjali to reporting Education in life skills, skills, in life Education and generating Involving model of training Cascade training residential 10-day teachers train trainers Master and visits from Monitoring Drishti – – School teacher – – – – ) programme focusing on on focusing programme and adolescent sexual health and reproductive substance use students’ group facilitate activities trainers master for training in 5 days teachers district to and reporting education office and CEDPA Extracurricular club to club to Extracurricular model of training Cascade (50 hours) residential 5-day nodal train trainers Master visits from Monitoring UDAAN – Classroom-based – School teacher – – – – continued ( Content by Delivery and Training supervision Table 6.1. Table conclusion 135 are also differences in the model of delivery, as well as the system of training and supervision. While the UDAAN programme is the largest, covering the entire state of Jharkhand, the Drishti programme has also achieved considerable scale, extending to three districts of Rajasthan. The Prayatna programme achieved medium scale in its pilot phase, extending to all residential Navodyaya Vidyalaya Samiti (NVS) schools in five states (Bihar, Madhya Pradesh, Maharashtra, Orissa and Rajasthan). The SHAPE programme remained a smaller pilot project, implemented in 10 schools in Goa. Starting in 2014, a modified version will be delivered and evaluated in Bihar as part of the SEHER progamme. Although the design of the UDAAN and Drishti programmes includes a non-classroom/community component, the primary focus of implementation thus far has been on classroom-based education in life skills, imparted by school teachers. Prayatna is different in scope, with staff nurses in residential schools providing individual counselling to the students, as part of a larger package of health services. Education in life skills is not explicitly linked to this intervention, although it may be provided in some schools through the AEP. The SHAPE programme was the most comprehensive in scope and followed WHO’s guidelines on health-promoting schools. It included health screening and health promotion activities at the whole school level; training in life skills, health education and the provision of tools and tips for learning through classroom sessions and group workshops; and individual and group counselling. The programme solicited inputs from the stakeholders through mechanisms such as the SHPAB, which included the school management, teachers, parents and students. Further, it drew on the networks of the supporting NGO to involve the community members and external institutions (for example, the Goa Medical College and Goa College of Nutrition) in the delivery of the activities related to the intervention. It was possible for the SHAPE programme to have such a wide scope primarily because of the availability of a dedicated lay SHC, who was trained to deliver/facilitate the different activities, while the intensive supervision and engagement were facilitated by a smaller scale (i.e. fewer schools and students covered). The training and supervision models differed across the programmes. These were dictated largely by the resources available and the scope and scale of the programmes. Of course, the delivery agent and prevailing system of supervision and reporting within the schools also had an 136 d. rajaraman, s. mukhyopadhyay, s. shinde, v. patel influence. For example, the SHAPE programme, which was smaller in scale and recruited new and dedicated SHCs, was able to provide training of a longer duration and establish a strong system of supervision and support. In the case of the other programmes, the duration of training was shorter and it was not clear whether it would be feasible to provide regular refresher training because of the resource implications. In Prayatna, the training focused primarily on adolescent-friendly counselling. The responsibility of supervising all the programmes lay primarily with the district education offices and/or NGOs providing technical support. The principals had a role to play in some of the programmes, in terms of forwarding reports to the district education office/NGO providing technical support. In most cases, they did not have a formal supervisory role.

Impact of the school health promotion case study programmes Each programme has met with success in some areas and come up against certain challenges, and these offer insights into how to strengthen and scale up adolescent health promotion. Most importantly, the case studies provide evidence of how school-based interventions for the promotion of health are effective in influencing and changing students’ knowledge, attitude and behaviour (Table 6.2). The UDAAN and Drishti programmes have resulted in modest (and in some instances, statistically significant) improvements in the students’ knowledge of and attitudes to reproductive and sexual health. The same goes for gender equity, peer pressure indicates that the programmes have also had a positive influence on the and common diseases. Qualitative evidence from the case studies acquisition of important life skills. Some examples of this are students feeling less shy and awkward with the opposite sex, an improvement in menstrual hygiene, changes in girls’ attitudes to early marriage, and the diffusion of health-related knowledge from the students to their families and communities. Parents and teachers have also noted improvements in the students’ behaviour, for example, healthier nutritional habits, respect for elders and better behaviour in the classroom. The experience with the SHAPE and Prayatna programmes suggests that counselling is an acceptable and effective intervention. Students who accessed this service reported satisfaction, relief from anxiety and depression, as conclusion 137 attitudes to issues concerning issues concerning attitudes to adolescents and in their ability counselling services deliver to counselling services reported being satisfied with the services Improvement in school nurses’ in school nurses’ Improvement accessed Students who Prayatna – – referred to health services health services to referred of diagnosis confirmation for of visual and and treatment problems nutrition-related to of issues related a range school policy infrastructure, students with the and individual boxes help of speak-out improvements behavioural among students, such as in habits, classroom nutritional elders and attitude to behaviour from relief counselling reported and anxiety and depression, academic outcomes improved Significant number of students Significant number of students School management addressed noted and teachers Parents accessed Students who SHAPE – – – – and knowledge as a result of the of the as a result and knowledge training of in knowledge improvements health and reproductive sexual among students for teachers, by observed participation greater example, better in the classroom, and of sexual knowledge health, and reproductive in substance use decrease Change in teachers’ attitudes attitudes in teachers’ Change Modest, inconsistent, though changes behavioural Positive Drishti – – – Comparison of four school health promotion programmes in India: Evidence of impact in India: Evidence programmes school health promotion of four Comparison and knowledge as a result of the of the as a result and knowledge training in students’ improvements and of reproductive knowledge health sexual of and attitudes to knowledge pressure peer equity, gender and common diseases and awkwardness shyness better sex; with opposite communication with teachers; among in hygiene improvement attitudes change in girls’ girls; knowledge marriage; early to students diffused to by gained and communities families Change in teachers’ attitudes attitudes in teachers’ Change in Modest improvement in students’ decrease Reported Table 6.2. Table UDAAN – – Statistically significant – – 138 d. rajaraman, s. mukhyopadhyay, s. shinde, v. patel well as improved academic outcomes. As a result of the health screening component of the SHAPE programme, a substantial number of students were referred to health services for the confirmation of diagnosis and treatment of problems related to vision and nutrition. The teachers and counsellors who delivered health promotion interventions reported that they also benefited from the interventions, as they led to measurable increases in their own knowledge of health, as well as changes in their personal attitudes to sexual and reproductive health and gender-related issues.

Key considerations for school health promotion interventions The case studies revealed that there was a range of facilitators for and barriers to the introduction, implementation and scaling up of school- based interventions for the promotion of adolescent health. Some key themes that emerged across the case studies were the need for strong partnership and engagement; a balance between rapid scalability, sustainability and effectiveness in relation to the programme’s scope and model of delivery; and improving the quality and coverage of the programme. Another important issue was the need to increase the level of comfort of those imparting education on reproductive and sexual health to adolescents.

Partnership and engagement It is important to recognise that school-based interventions for health promotion function within the platform of the existing school systems, with their strengths and weaknesses. The leadership of the state departments of human resource development/directorates of education, district education offices and the Goa Archdiocese Board of Education was of critical importance in making the introduction and implementation of the programmes possible. Also, in the face of the given capacity constraints of the government systems, the technical support provided by the NGO partners for the design, training, oversight and evaluation of the programmes was crucial for the establishment of the programmes’ activities and the strengthening of implementation over time. The external agencies played a significant role in ensuring conclusion 139 buying in by diverse stakeholders and regular liaison with various agencies, institutions and school systems. These agencies also provided valuable technical skills for the development of tools and systems for implementation, monitoring and evaluation. Further, they took the responsibility of reviewing the overall quality of the content of the programmes, as well as their implementation. This included reviewing the curriculum materials, planning the training of teachers and providing supervision. Given the fact that the school systems face resource constraints and that many health behaviours are shaped outside of the school environment, school-based programmes for the promotion of health also need to build strong partnerships with community-based organisations, health services, village health committees and the wider community. In these early years of building such programmes, the focus has rightly been on defining and refining the curriculum and strengthening the delivery of the programme in school; in the next phase, it will be essential to establish stronger community partnerships to reinforce learning so as to increase the impact. In addition, while the education sector may lead in school-based health promotion, multi-sectoral action and alignment is required for successfully addressing the determinants of young people’s health. Future school-based programmes for the promotion of health should explore ways in which to share resources and expand the current scope of activities. The health sector, in particular, plays a key role in ensuring access to youth-friendly health services and reaching out to adolescents in school. The Ministry of Women and Child Development is responsible for the implementation of schemes related to nutrition and health education that are specifically targeted at adolescent girls, and delivered in the community. Engaging key stakeholders is essential for gaining acceptability and results in important contributions to the content of the programme. Despite the fact that the case study programmes were implemented during a period of substantial backlash against education in sexual and reproductive health, the majority of the stakeholders interviewed for the case study evaluations (district education officers, principals, project management staff, master trainers and teachers) perceived of education in life skills as an important part of students’ education. The consultative and participatory design of the programmes facilitated the involvement of a variety of stakeholders, including students, teachers, health and 140 d. rajaraman, s. mukhyopadhyay, s. shinde, v. patel education officials in the government, parents and the community. In some cases (for example, the Drishti syllabus and some of the SHAPE schools), this led to modifications in the content related to reproductive and sexual health, the aim being to increase the comfort level of the local stakeholders. In addition to initial consultation at the leadership level, ongoing engagement with the stakeholders, including the school management, teachers and parents, is important for ensuring greater acceptability and effectiveness of the programmes. One of the problems in some schools has been the limited involvement of the school management and teachers in the programme activities. Lack of support from the management could adversely affect the motivation of the staff, create problems in implementation, lead to low uptake of services, and result in weak oversight of programme activities and reporting. The current monitoring strategies of school-based programmes for the promotion of health rely primarily on the submission of monthly reports by the staff or principals to the district education office/technical support staff. The latter may also conduct monitoring visits. However, monitoring visits are often difficult to schedule and for the most part, have not resulted in real-time feedback on performance to the implementers. In the scaled up programmes, it has been difficult to enforce accountability in reporting, there being no clear system for reporting on the delivery of other school activities. Carrying out a situational analysis to assess the readiness of schools to initiate a programme can help to involve other school staff and the management, and prepare the entire school for the introduction of new activities.

Scope and model The scope of each of the four programmes studied was influenced by the reasons for which they were initiated, the sponsoring/implementing organisations’ capacity, and the resources available. The UDAAN and Drishti programmes were developed to facilitate the implementation of the AEP by the government, and they consequently focused on the design, delivery and implementation of classroom-based interventions to provide health education and training in life skills. The SHAPE and Prayatna programmes both included a non-classroom component on mental health, consisting of the provision of individual counselling services to students. conclusion 141

While mental health is increasingly being recognised as a critical element of programmes for the promotion of health among young people, there is little evidence on how this component can be implemented in resource- constrained settings. Sangath had a strong interest in this area, and was in a good position to develop such an intervention and introduce it in schools, given its previous organisational experience in providing mental health services to the youth. The pilot nature of the SHAPE project also allowed for close supervision and refinement of the intervention over a period of two years, which would not have been possible in a scaled up programme. The preliminary evidence from the SHAPE programme has already helped to build a case for mental health interventions in schools, and the Directorate of Education in Goa has introduced a school counsellor programme in government and government-aided schools. Under this programme, school counsellors will be trained to provide support and services to a cluster of schools (rather than having one counsellor per school). The scope of the programmes was also highly influenced by the human resource delivery model. The UDAAN, Drishti and Prayatna programmes were all delivered by the existing school staff members, who were either qualified teachers or nurses. Drawing on the existing staff resources ensures sustainability and allows for a rapid scale-up of activities. At the same time, this approach can limit the scope of a programme because the staff has other responsibilities, as shown by these case studies as well as evaluations conducted in other settings. In the UDAAN and Drishti programmes, the scope of the activities was limited mostly to classroom sessions because of the teachers’ other responsibilities. Similarly, the Prayatna programme focused only on individual counselling as the primary responsibility of the nurses was to staff the school clinics. If the staff members delivering the programme have another primary responsibility, the effectiveness of implementation may be affected by their competing priorities, resulting in incomplete delivery of programme activities. The SHAPE programme was delivered by lay school health counsellors (SHCs) who were dedicated to promoting health at different levels in the schools, so that their engagement in identifying and addressing the determinants of the students’ health and well-being was much deeper and wider. The programme activities included not only classroom-based training in life skills, but also formulating policies 142 d. rajaraman, s. mukhyopadhyay, s. shinde, v. patel for a healthy school, addressing the students’ concerns and grievances, holding workshops to promote health and a healthy school environment, screening for nutrition- and vision-related problems and referring students found to have such problems, involving the school management, staff, teachers and parents in determining the school’s health priorities, and providing individual counselling services. The coverage achieved in the case of all the activities was high. In the context of the global shortage of human resources for health, WHO has endorsed the concept of ‘task-sharing’, which involves the delegation of tasks and responsibilities from more specialised to less specialised cadres. The successful implementation of task-sharing requires clearly defined roles, as well as robust systems of supervision and referral [22]. While peer education programmes are popular among students, the evidence on their effectiveness has been mixed. Further, the creation of a system for training, supervising and supporting peer educators requires significant investment [55]. In settings in which school-based promotion of adolescent health is constrained by a shortage of teachers, health educators and qualified counsellors to implement the programmes, a lay SHC could provide a scalable option. This could be a partial answer to the problems created by the competing priorities of teachers and nurses. It could also help to make up for the lack of resource people to teach the classroom sessions due to frequent staff turnover. However, in an already resource-constrained system, greater evidence on the cost and relative benefits of introducing a dedicated new cadre of health promoters in schools is required to inform policy decisions about resource allocation. For any intervention to be able to succeed in changing the school environment and creating a greater and more lasting impact, regardless of the model of human resource delivery, an effort must be made to adopt a comprehensive approach which addresses the curriculum, teaching and learning, school organisation and environment, and the school community.

Training and staff motivation

While the case studies revealed many successes, there were also a number of potential barriers to the delivery and quality of the programmes, including too short a training period for the staff (nodal teachers), the conclusion 143 need for more teaching aids and learning materials, and poor motivation among the staff. In the UDAAN and Drishti programmes, the nodal teachers’ training lasted 4–5 days, while in Prayatna, the staff nurses received nine days’ training, which focused on individual counselling. In addition, the staff nurses received annual refresher training. In UDAAN and Drishti, it was more feasible to conduct training of a shorter duration, given the resource implications of conducting residential training at scale. However, many teachers felt that this did not allow them enough time to become conversant with participatory teaching methods. One of the common requests made was for supplementary teaching materials, especially visual aids. The staff nurses trained in the Prayatna programme spoke of their appreciation of the refresher training, which made them feel more confident about counselling. The SHAPE training lasted a month and was broader in scope than the other interventions. One of the concerns raised in some schools was the level of motivation of the staff to deliver the interventions. While many of the staff members implementing the activities appreciated the personal benefits and were happy to see the impact on the students and community, some viewed the programme as an external mandate and as an additional burden on their already heavy workload. It has been suggested that in the case of programmes delivered by school staff members who have other primary responsibilities, financial incentivisation or greater public recognition may increase motivation. However, it is uncertain whether raising funds for such incentives would be feasible in the medium or long term. An alternative approach would be to work towards collective engagement at the national and state levels to advocate for pre-service and in-service training on health promotion activities for educationists. This would not only improve the teachers’ capacity to deliver programmes, but also internalise the concept that promoting the health of students falls within the purview of educational institutions and their staff. Another frequent suggestion for improving the motivation and performance of teachers and students is to make the topics in the programmes’ curriculum an examinable subject, either on its own or as part of other subjects. This would further internalise the notion that the promotion of health and life skills is part of a formal education curriculum. It would also ensure that adequate resources are allocated for the implementation of the programme. 144 d. rajaraman, s. mukhyopadhyay, s. shinde, v. patel

As mentioned in the section on partnership and engagement, engaging the school management in the delivery of programme activities is of critical importance. Involving the school principals in training and assigning them a formal supervisory role would yield multiple benefits. For example, it would increase the number of people in the school who could deliver the programme, enhance support for the programme activities and consequently, staff motivation, and provide a more feasible method of oversight and feedback.

Acceptability of sexual and reproductive health education

Significant challenges still stand in the way of the delivery of education on sexual and reproductive health in a classroom setting. There is conflict of opinion on the curriculum that should be developed for this subject, with teachers and governments raising objections on the ground that young people should not be receiving such information. The Drishti programme had to operate in the face of a state-wide ban on programmes for adolescent sex education, and implementation was possible only because modifications were made to the initial syllabus and individual district administrations thus became amenable to supporting the programme’s continuation. It becomes clear, then, that the process of curriculum development and the nature of the curriculum are an important aspect of school health programmes. Adequate time and resources will be required to build a consensus with respect to the design, adoption and delivery of the curriculum. While critics of large- scale school health programmes have claimed that mainstreaming can result in the exclusion of important topics from the curriculum, the case studies showed that it was still possible for each programme to include a variety of topics related to sexual and reproductive health, even within the constraints. Among the hitches is the fact that many teachers and other health promoters continue to feel uncomfortable addressing these issues, something which has been widely reported in other countries as well [58]. In the case studies, it was found that some teachers omitted teaching reproductive and sexual health, while some students had an aversion to the subject. Comprehensive coverage of sexual and reproductive health remains a battleground at the state level, and this is even more so in the case of specific topics relating to sexuality and sexual health. conclusion 145

It is, therefore, essential to ensure that programmes include supportive mechanisms to increase the comfort level and capacity of the teachers and counsellors addressing sexual and reproductive health issues. For example, partnerships could be forged with local resource agencies that have expertise in working with young people on sexual and reproductive health issues. This could also help to partially address the problem of matching the teachers’ gender with that of the students to facilitate the discussion of specific issues, when a school does not have a trained male or female teacher. The school or district education administration could create mechanisms whereby local organisations can assist the school to strengthen its teachers’ capability to address topics related to sexual and reproductive health. In addition, health programmes and services could work more closely with the programmes to help schools impart education in this aspect of life skills.

Summary Promoting adolescent health is a priority for the Indian national government, and schools provide a valuable platform for reaching young people with health-related information, training and services. The case studies presented in this book clearly establish the acceptability and feasibility of the current school-based interventions. The scope and delivery model of the interventions may vary depending on the financial and human resources available, the prior existence of health promotion programmes and health services in the schools, the timeline for scaling up, and the reasons for introducing the programme. The factors that facilitate the effective implementation of interventions include political commitment, partnerships, strong support from and involvement of the school management, dedicated human resources, and well-designed training, supervision and monitoring mechanisms. The case studies have also provided quantitative and qualitative evidence on the potential impact of such interventions on the knowledge, attitude and behaviour of students regarding sexual and reproductive health, hygiene, nutrition, classroom behaviour and social integration. The ancillary benefits of the interventions are an increase in the knowledge and changes in the attitudes of the staff who deliver them, as well as diffusion of knowledge within the community. As much of the evidence on the impact of the interventions is still qualitative, 146 d. rajaraman, s. mukhyopadhyay, s. shinde, v. patel there is a need to generate more robust (preferably experimental) data on the outcomes of these programmes. Much of the global literature on interventions to promote sexual and reproductive health among adolescents has noted a need for more rigorous and theory-based research to evaluate the effectiveness of interventions in changing health behaviours and outcomes [56,57,59–61]. While such evaluations will require planning, consensus and substantial resources, they will play a critical role in overcoming the existing apathy towards rolling out/strengthening the implementation of the interventions [55]. Further research on the costs and benefits, using validated measures of effectiveness, will be important for decisions on how to allocate resources for school-based programmes for health promotion. Longer- term tracking of the school environment and the health outcomes of the programme’s beneficiaries will also be important, as many of the potential benefits will not be measurable in the short term. The SEHER initiative, a partnership between the Bihar Department of Education and Sangath (with financial support from the MacArthur Foundation and UNFPA), is currently being launched in Bihar. Designed as a randomised controlled trial, it aims to provide evidence on the teacher-led versus lay counsellor-led model of promoting adolescent health, with the latter model including counselling services for students. The TARANG programme, which follows a curriculum-based approach similar to UDAAN, is also being implemented in Bihar, through a partnership between the Department of Education and CEDPA India. School-based programmes have a huge role to play in improving the health of young people, and the current initiatives provide the other states of India with a variety of approaches and models that can be adapted to the local context. The education system can serve as the focal point for collaboration between several sectors for the promotion of health, academic achievement and social development. It should be noted, however, that a comprehensive approach to adolescent health goes far beyond the school platform. First, the most vulnerable adolescents are often not enrolled in school and it is, therefore, important to reach them by developing and implementing interventions that involve the community, NGOs and health services. Second, sexual health behaviours are affected by a range of structural factors, including the physical, social, cultural, organisational, community-related, economic, legal or policy- related aspects of an individual’s environment [62]. Therefore, it will conclusion 147 be of critical importance to ensure that initiatives for the promotion of adolescent health extend across various sectors. In this way, adolescents can have access to youth-friendly health services, as well as education on appropriate nutrition and supplementation. Moreover, such an approach will create an enabling social environment which empowers girls and women. It will also facilitate targeted initiatives to reach the most vulnerable youth. APPENDIX A

Partner questionnaire on school health promotion programmes SHAPE programme, Sangath questionnaire on school health promotion programmes

1. Name of organisation Full address Telephone E-mail Website Contact person and contact information, website

2. School health programme coordinator Name Position E-mail Telephone

3. Are there other organisations working with you on this programme? If yes, please specify their names and contact details.

4. Location of school health project

5. Year started appendix 149

6. Number of schools covered in current academic year

7. Type of schools covered (government, government-aided, NGO-run, private)

8. Target age/class (number of children covered, if available)

9 Will your school health programme be carried out in 2010/11 (Yes/No)

10. Primary objectives of the project (for example, to improve knowledge of nutrition, hygiene, sexual health behaviours)

11 Key strategies used in the health programme (for example, life skills training by teacher, workshops conducted by NGO, health camps run by primary health centre)

12. Does you programme have any ongoing monitoring and evaluation mechanisms? If yes, please specify what indicators are being captured.

13. Have any evaluations been conducted of your school health programme? If yes, please specify the details (when, by whom) and send us the report, if possible. 150 appendix No from from partner response response period operating operating No school No school evaluation evaluation programme programme in proposed in proposed programme targeted not health- not health- Intervention Intervention period during during proposed proposed Unable to Unable to evaluation evaluation participate participate promotion x study for case case for Selected Selected health school to Programme details Programme on youth- focuses The programme counselling services, delivered friendly counselling and group in individual school staff nurses trained sessions by and supervision telephonic receive who The programme an NGO. support from Vidyalaya students of 158 Jawahar serves talented schools for Samiti residential students. rural

Location of Location of programme Bihar, Madhya Pradesh, Maharashtra, Orissa and Rajasthan responses

of Name and Name and of date start programme Prayatna, 2010

Navodaya Vidyalaya Samiti, UNFPA and Sangath Implementing/ partner organisation APPENDIX B Summary questionnaires appendix 151 No from from partner response response (continued) period operating operating No school No school evaluation evaluation programme programme in proposed in proposed targeted not health- not health- Intervention Intervention period during during proposed proposed Unable to Unable to evaluation evaluation participate participate x x study for case case for Selected Selected Programme details Programme and Promotion The School HeAlth is (SHAPE) programme Empowerment health promoting based on the WHO schools model. It implements activities emotional of physical, the promotion for and mental health at the school, classroom 5th–12th grade for levels and individual students in 12 government-supported coordinated are schools. Most activities school lay a trained by and delivered from with supervision health counsellor, principals, and support from a local NGO, partners. staff and external teaching implements activities The programme and skills and reproductive life to related health in about 1500 secondary sexual with in partnership schools in Jharkhand, Department of Education the Jharkhand the AEP and is from It evolved and JSACS. It targets teachers. trained by delivered students in the 9th and 10th grades. Location of Location of programme Goa Jharkhand ) continued Name and Name and of date start programme SHAPE 2009 2005 UDAAN, ( Sangath, Sangath, MacArthur Foundation Jharkhand of Department JSACS Education, and CEDPA Implementing/ partner organisation Appendix B. Appendix 152 appendix No from from partner response response period operating operating No school No school evaluation evaluation programme programme in proposed in proposed targeted not health- not health- Intervention Intervention x x period during during proposed proposed Unable to Unable to evaluation evaluation participate participate x study for case case for Selected Selected

Programme details Programme in partnership with The programme, Department of Education, the Rajasthan skills and students’ life improve aims to of reproductive their knowledge increase an enabling as create health, as well It is being implemented environment. secondary in about 1400 government It targets teachers. trained schools, by students in the 8th and 9th grades. teachers train aims to The programme secondary schools to in government-run education on adolescent health, provide subject in curricular an examinable Nadu. Tamil schools CBSE from trained are Teachers skills and adolescent health in life in 15–20 schools operating programme and other schools. The in Maharashtra students in the targets programme 5th–9th grades.

Location of Location of programme Rajasthan (districts of Baran, and Jhalawar Kota) Nadu Tamil Maharashtra and other states ) continued Name and Name and of date start programme DRISHTI, 2006 Schools Health Total Programme 2006–07 ( Rajasthan Rajasthan of Department and Education Ritinjali Nadu Tamil of Department and Education HEPI IL&FS Education and Technology Services Ltd, Mumbai and Akanksha Foundation Implementing/ partner organisation Appendix B. Appendix appendix 153 No from from partner response response (continued) x x period operating operating No school No school evaluation evaluation programme programme in proposed in proposed targeted not health- not health- Intervention Intervention period during during proposed proposed Unable to Unable to evaluation evaluation participate participate study for case case for Selected Selected Programme details Programme on life focused which The programme, a healthy of tobacco, skills, avoidance was environment, diet and a safe in about 800 schools implemented delivered It was Delhi and other states. and modelled on an teachers trained by a randomised for developed intervention (2004–06). It targeted trial controlled The DADA students in the 6th–8th grades. physical aimed at promoting programme, being people, was among young activity planned at time of discussions in 2011. is implementing a programme VIMHANS skills, education in life aimed at providing on the mental as an intervention as well health of school students, in 140 schools. model the WHO follows The programme School Mental Health for Framework students in the It targets Programmes. 7th–11th grades.

Location of Location of programme New Delhi and 14 other states New Delhi ) continued Name and Name and of date start programme MYTRI, 2002, Diabetes and Education Prevention Education, 2011–13 VIMHANS, 2001 ( HRIDAY–SHAN Delhi VIMHANS, Appendix B. Appendix Implementing/ partner organisation DADA : "Delhi Active – Daily Active" – Daily : "Delhi Active DADA 154 appendix No from from partner response response x x x x x x x period operating operating No school No school evaluation evaluation programme programme in proposed in proposed targeted not health- not health- Intervention Intervention period during during proposed proposed Unable to Unable to evaluation evaluation participate participate study for case case for Selected Selected Programme details Programme skills impart life aims to This programme in the 6th–10th grades. girls rural to available No information available No information available No information available No information available No information available No information

Location of Location of programme Rural Maharashtra, 7 tribal blocks ) continued Name and Name and of date start programme Gaining Girls Ground, 2008 ( Bhavishya Bhavishya Alliance and Institute Health for Management, Pachod Delhi Prerana, Smile Foundation GAP NIMHANS Trust Belaku Tata Dorabji Trust Implementing/ partner organisation Appendix B. Appendix appendix 155 x x x x x No from from partner response response period operating operating No school No school evaluation evaluation programme programme in proposed in proposed targeted not health- not health- Intervention Intervention period during during proposed proposed Unable to Unable to evaluation evaluation participate participate study for case case for Selected Selected Programme details Programme available No information available No information available No information available No information available No information Location of Location of programme ) continued Name and Name and of date start programme ( The American The American India Foundation 2001) (founded Association of and Adolescent in Care Child India Action Poverty Lab Sahyog (NGO) SHARP School Health Annual Report Programme Implementing/ partner organisation Appendix B. Appendix References

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PATEL SHINDE RAJARAMAN

School Health Promoti on: Case Studies from India off ers evidence-based insights and recommenda ons to those engaged in addressing the social determinants of health at the school level. The book provides an overview of school health SSCCHHOOLOOL promo on and adolescent health in India, and presents case studies of four programmes: SHAPE, UDAAN, Drishti and Prayatna. Together, these programmes cover seven states of India, and are characterised by diff erent types of human resource delivery, levels of engagement with the school and students, and systems HHEEAALTLTH for monitoring and supervision. The case studies provide valuable lessons for strengthening exis ng programmes and developing new approaches. The target audience includes educa on and health policy-makers, administrators, PPROMOTIOROMOTION researchers and prac oners in government, academic ins tu ons, funding agencies, non-governmental organisa ons and civil society.

BYWORD BOOKSTM ` 595