Effects of Community Youth Teams Facilitating Participatory Adolescent Groups, Youth Leadership Activities and Livelihood Promotion...in Rural Eastern India (JIAH Trial): A Cluster-Randomised Controlled Trial

"[T]hey [adolescents] cannot share their problem with us [older adults] openly. Therefore, it is the yuva saathi with whom they are comfortable in sharing any issues. Any issue related to SRH [sexual and reproductive health] and about monthly periods, they are easily sharing with yuva sathi." – Accredited Social Health Activist

The Rashtriya Kishor Swasthya Karyakram (RKSK), India's 2014 flagship adolescent health promotion strategy, includes health facility- and community-based activities with a focus on adolescent participation and leadership. In 2017, this group of researchers developed a peer-led intervention (the Jharkhand Initiative for Adolescent Health, or JIAH) to improve adolescent health building on RKSK priorities and using principles of participatory learning and action (PLA). The purpose of the parallel group, two-arm, superiority, cluster-randomised controlled trial (RCT) with an embedded process evaluation that is described in this article is to evaluate whether and how community youth teams facilitating participatory adolescent groups, youth leadership, and livelihood promotion improved school attendance, dietary diversity, and mental health among adolescent girls in rural India.

JIAH was offered to girls and boys aged 10-19 years in 38 clusters (19 intervention, 19 control) in the 50 villages of West Singhbhum district in Jharkhand, India, where the RKSK had not yet been implemented. Formative research had identified four focal areas that were important to adolescents and their families and might also be influenced through a community intervention: participation in education, undernutrition, mental health, and violence. These focal areas were reflected in the design of the intervention, which was delivered by a trained and supervised community youth team comprising three types of staff: (i) peer facilitators called yuva saathi ("friend of youth"), (ii) youth leadership facilitators, and (iii) livelihood promoters. The intervention had three components:

1. Participatory adolescent groups: Female and male yuva saathi aged 20-25 years facilitated monthly participatory group meetings with adolescent girls and boys in a local community space over a period of 33 months. During the first five meetings, groups discussed local influences on adolescents' health, strategies to include the most vulnerable adolescents in meetings, and adolescents' own needs and expectations. Parents, teachers, and frontline health workers were encouraged to participate. Yuva Saathi and adolescent groups then worked through four consecutive "mini" participatory learning and action (PLA) cycles on education, nutrition, health, and mental health and violence. Gender equity was treated as a cross-cutting issue that featured in adolescents' experiences of education (e.g., girls having less opportunity than boys to complete secondary schooling), nutrition (e.g., inequitable intrahousehold allocation of food with girls receiving less nutritious food), health (e.g., sex-specific pubertal changes), and mental health and violence (e.g., girls experiencing street harassment). Each mini-PLA cycle had six meetings and was followed by a wider community meeting in which parents, teachers, and frontline workers were invited to hear about the adolescents' prioritised problems and support their strategies.
2. Youth leadership activities: These activities took place every two months and were promoted by the yuva saathis during PLA meetings. They were designed by local youth leadership facilitators who were recruited based on prior experience, and activities were intended to be fun, build adolescents' confidence, and keep them engaged in PLA meetings. Activities included nature walks, sports tournaments, cycling and group problem-solving conducted in the village, in local sports facilities or playgrounds, or in the surrounding forests and woodland.
3. Livelihood promotion: This final intervention component was offered to both intervention and control groups as a common benefit, while the first two components were offered only in intervention clusters. Livelihood promoters met with adolescents and their parents every three months in local community spaces, fields, or close to a local market for season-focused activities including practical demonstrations of paddy cultivation, multi-cropping, organic farming techniques, tree planting, kitchen gardening, and revival of "save the forest" groups (van samitiy). This third component aimed to provide adolescents with practical skills to improve their families' food security and income.

Adolescents could attend all or as many components as they liked. In all, the community youth team delivered 3,694 participatory adolescent group meetings and conducted 18 leadership training activities in 19 intervention clusters between June 2017 and March 2020. They conducted 12 livelihood promotion activities across all 38 clusters.

The researchers surveyed 3,324 adolescent girls aged 10-19 in 38 clusters at baseline, and 1,478 in 29 clusters at endline. Four intervention and five control clusters were lost to follow up when the trial was suspended due to the COVID-19 pandemic. Adolescent boys, who made up 40% of participatory adolescent groups, were included in the process evaluation only, which involved: (i) a review of project documents and (ii) qualitative interviews, case studies, and small group discussions conducted by the community youth team, intervention supervisors, a process evaluation officer, and process evaluation manager.

The trial's three primary outcomes were: (i) percentage of adolescent girls currently attending school or college; (ii) mean dietary diversity score (based on 24-hour recall); and (iii) mean score on the Brief Problem Monitor-Youth. Twelve secondary outcomes captured indicators on girls' empowerment and decision-making, emotional and physical violence, resilience and self-efficacy, school attendance, and uptake of school-related entitlements. Eight exploratory outcomes assessed nutritional and anthropometric indicators, menstrual hygiene, knowledge of sexual and reproductive health.

In intervention vs. control clusters, mean dietary diversity score was 4.0 (standard deviation (SD) 1.5) vs. 3.6 (SD 1.2) (adjusted difference (AD) 0.34; 95% confidence interval (CI) -0.23, 0.93, p = 0.242); mean Brief Problem Monitor-Youth (mental health) score was 12.5 (SD 6.0) vs. 11.9 (SD 5.9) (AD 0.02, 95%CI -0.06, 0.13, p = 0.610); and school enrolment rates were 70% vs 63% (adjusted odds ratio (AOR) 1.39, 95%CI 0.89, 2.16, p = 0.142). However, girls in intervention clusters were two times more likely to access at least one school-related entitlement (AOR 2.01; 95%CI 1.11, 3.64, p = 0.020). In other words, the intervention did not improve adolescent girls' dietary diversity, mental health, or school attendance, but it may have increased uptake of education-related entitlements (this was the only significant finding across 12 secondary outcomes tested).

Qualitative process data on group composition and contextual factors affecting the intervention lend further insight. In both study arms, over 75% belonged to scheduled tribe communities, the most common source of household income was daily wage labour, and fewer than 10% had access to toilet facilities in the home. Older adolescents, boys, and out-of-school adolescents attended group activities less frequently because they contributed to or supported household economic activity; some also felt embarrassed to come to meetings because they had dropped out of school and could not read or write. Younger adolescents, who had greater exposure to intervention activities, often asked for further clarification or simpler language during discussions, and they sometimes struggled to participate in activities that involved decision making and collective action. Thus, overall intervention delivery was feasible, but positive impacts were likely undermined by household poverty.

That said, qualitative data showed that the community youth team had helped adolescents and their parents navigate school bureaucracy, facilitated re-enrolments, and supported access to entitlements.

Reflecting on the findings, the researchers suggest that, through the intervention, adolescents were able to understand the determinants of health and obtain knowledge necessary to access help (functional health literacy) but not to progress to achieve greater autonomy and power in individual decision-making and self-efficacy (interactive health literacy) or collectively act on wider social determinants of health (critical health literacy). It is possible that younger adolescents, who were more likely to sustain participation over time, were less able to build self-efficacy without the role-modelling of older adolescents and less equipped to create change without the support of parents and other adults. Quantitative process evaluation data suggested that parents, health workers, and teachers had limited engagement with participatory adolescent group meetings and other intervention components, which may have undermined the ability to improve outcomes, given their central role as guardians and gatekeepers.

In conclusion: "India's RKSK remains a potential instrument for integrated facility and community-based programming and is the only existing policy which engages young people in the implementation of health intervention through peer educators."