A Psychosocial Resilience Curriculum Provides the "Missing Piece" to Boost Adolescent Physical Health: A Randomized Controlled Trial of Girls First in India

"...adding a resilience program to an adolescent health program amplifies physical health improvements beyond those attained by a physical health program alone, without any additional content focused on physical health."

Although evidence suggests that attending to psychosocial development may be important not only for psychosocial but also physical wellbeing, the global development organisation CorStone contends that psychosocial wellbeing has been neglected in programmes for marginalised adolescents in low- and middle-income countries (LMICs). This paper describes a randomised controlled trial (RCT) of CorStone's Girls First - Bihar, which works to empower girls aged 12-16 in Bihar, India, who live in rural poverty and who tend to be at risk for marriage at 14-16 years of age. The RCT assesses the extent to which the programme equips participants with knowledge, skills, and support to improve their personal resilience and physical health and to self-advocate for their right to stay in school and delay marriage.

Girls First provides a holistic empowerment programme, combining personal resilience training with curriculum in adolescent health. The 6-month programme provides in-depth training through two evidence-based curricula: the Girls First Resilience Curriculum (RC) and the Girls First Health Curriculum (HC). RC focuses on goals and planning, social support, and identity, whereas HC includes information about sexual and reproductive health, common diseases, nutrition, gender equality, and substance use. Interventions are delivered through in-school peer-support groups, facilitated by trained pairs of community women with a 10th grade education and no previous experience requirements. A typical lesson combines 20-30 minutes of skill building, followed by 30 minutes of group discussion and problem solving.

Conducted in 2013-14, the RCT was designed to quantify effects on the emotional, social, physical, and educational wellbeing of 3,560 girls in VII-VIII Standards (7th and 8th grades) in 76 government schools in rural Bihar, India. This paper focuses on intervention effects on physical health and wellbeing outcomes only, immediately before and after each programme for 4 conditions: RC; HC; RC+HC; and SC, a school-as-usual control group (around 800 girls per arm).

The study found that the combined Girls First programme (RC+HC) improves physical health outcomes versus the control, and that the improvements made by Girls First girls were greater than those achieved by the individual programme components alone (RC or HC). RC+HC significantly improved health knowledge, gender equality attitudes, clean water behaviours, hand washing, menstrual hygiene, and health communication, versus the control. In addition, participants in RC+HC reported greater ability to get to a doctor when needed, less substance use, increased feelings of safety, and higher levels of vitality and functioning relative to the control.

Some specific improvements in emotional and physical well-being include:

• Emotional resilience increased 33%: Girls receiving RC+HC significantly improved their coping skills, self-confidence, courage, persistence, and ability to handle negative emotions relative to SC girls. Girls receiving HC alone increased their resilience just 4%.
• Health knowledge increased 99%: Girls in the RC+HC arm significantly improved their physical health knowledge of HIV/AIDS, pregnancy, menstruation, anemia, malaria, clean water, substance use, and health consequences of early marriage, relative to those in the SC arm. Health knowledge among girls receiving HC alone increased 78%. Both groups received the same amount of direct instruction about health issues.
• Attitudes about gender equality improved 18%. Girls in the RC+HC arm sigficantly improved their belief in gender equality, including their beliefs that it is equally important for boys and girls to attend school and that there are never times when a woman deserves to be beaten. Attitudes among girls receiving HC alone improved only 8%, even though both groups received the same amount of direct instruction about gender differences and women's rights. The researchers suggest that "combining the two strategies - giving girls the psychosocial foundation for internalizing their belief in their equality to boys (through RC), combined with giving them the factual information about their rights and gender differences (through HC) - is likely more effective than either strategy alone."
• Clean water behaviours improved 96%: Girls receiving RC+HC significantly improved the behaviours that girls use to keep their water clean, including filtering, boiling, or chlorinating. In contrast, clean water behaviours for girls receiving HC only improved 37%. Both groups received the same amount of direct instruction about how to keep water clean.

The paper's discussion section explores some of the potential reasons behind these and other findings. For example, in HC, although girls learned about the importance of getting to a doctor, when they would need to go, and what services the doctor would provide, they did not learn self-advocacy skills. In RC, girls learned communication skills and built confidence in self-advocacy, which may have enabled them to convince their parents to take them for care. Thus, it may not be surprising that girls in RC+HC and RC were more likely to tell an adult when they were sick than girls in HC (measured by health communication).

Girls First was designed with generalisability and scalability in mind from the outset. CorStone used resources (human and otherwise) that would likely be available in similar communities in India and other LMICs to enhance replicability. Accordingly, CorStone began scale-up programnes involving over 30,000 boy and girl students in standards 6th-8th in over 250 schools in Bihar began in partnership with the Bihar Education Project Council (BEPC). This next phase is called "Youth First", as it aims to impact the health and education - and positive life trajectory - of both boys and girls.

In conclusion: "This study provides...empirical evidence that psychosocial resilience represents a critical missing piece in efforts to improve LMIC girls' physical health. These findings clearly suggest that efforts to improve psychosocial wellbeing should receive broader support, not only from those interested in improving psychosocial outcomes but also from those interested in improving physical health outcomes."