The intervention is a community youth team that delivers participatory adolescent groups, youth leadership activities and livelihood promotion. Additional file
1 describes the intervention’s full theory of change. Additional file
2 is a short video clip with Ekjut team members describing the intervention. Each cluster has a community youth team delivering parallel intervention activities. The team comprises a peer facilitator (
yuva saathi, meaning “friend of youth”) aged 20–25 years, a youth leadership facilitator (one for six clusters), and a livelihood promoter (one for ten clusters). The second member of the community youth team is a youth leadership facilitator who delivers fun, confidence-building activities for adolescents every 2 months. Activities are open to all girls and boys in the community and include sports events such as football tournaments, archery and run-a-thons, as well as problem-solving sessions and nature walks. Both intervention and control clusters have livelihood promoters, who are adults recruited for their skills in farming and environmental management. Livelihood promotion activities aim to provide adolescents with practical skills which they can use in later life and that improve food security for families.
The intervention engages and supports frontline health care providers by inviting them to participate in adolescent group meetings and facilitating referrals of adolescents from the community youth teams to community health services. An advisory committee involving representatives from local governmental and non-governmental adolescent services also advises and supports the community youth teams on child protection issues and referral services. We describe the community youth team’s activities further below.
Yuva saathis and participatory adolescent groups
The main role of the yuva saathis is to facilitate monthly participatory groups for adolescent girls and boys over a period of 36 months. Ekjut recruited 30 yuva saathis (20 females and 10 males) in total. The recruitment process involved a general knowledge test and face-to-face interviews with an assessed role-play. Yuva saathis were recruited on the basis of their ability to speak both Hindi and Ho (the most common local tribal language spoken in the study area), their performance on a general knowledge test, and their ability to demonstrate confidence and good communication skills during a face-to-face interview. We chose to recruit yuva saathis aged 20–25 years because our formative research findings suggested that adolescents preferred facilitators who were slightly older than them, and parents, teachers and health workers felt that facilitators in this age group would have more confidence to facilitate meetings. Yuva saathis are paid INR 5000 per month as an incentive and are trained by members of the Ekjut team. They are supervised by coordinators and supervisors who observe approximately 20% of group meetings and meet with yuva saathis fortnightly to debrief, troubleshoot and plan future meetings. If yuva saathis have any concerns about adolescents in their group, coordinators and supervisors help them organise referrals to health facilities or other services.
In each cluster, yuva saathis facilitate meetings which are mainly held in community meeting spaces. The first five meetings aim to introduce adolescents to the intervention. Groups discuss social and economic influences on adolescents’ health, how to identify and involve vulnerable adolescents in the intervention, gender norms and their consequences, and the adolescents’ own needs and expectations. These initial meetings are open to all community members, including adolescent girls and boys, their parents, teachers and frontline health workers, and yuva saathis actively mobilise community members to attend. All meetings involve participatory games and open discussion.
After the first five meetings, the groups work through four consecutive Participatory Learning and Action (PLA) cycles. We chose to use a PLA approach for these meetings because there was a consensus that building adolescents’ confidence and decision-making skills would be desirable, and Ekjut has substantial experience with this method. In earlier trials, PLA interventions enabled communities to improve the survival of newborn infants, increase the dietary diversity of pregnant women and young children, and reduce underweight in young children [
24‐
27]. PLA is now an approach used by the India National Health Mission to conduct health-related meetings in the community and may be extended to peer facilitators of adolescent groups [
28].
Each PLA cycle comprises five to seven meetings and has four distinct phases: (1) identifying problems affecting adolescents in the community (meeting 1), (2) identifying and deciding on strategies to address these problems (meetings 2–3), (3) implementing the strategies (meetings 4–6), and (4) evaluating the process (meeting 7). The same
yuva saathi facilitates each meeting. There is a PLA cycle for each of the following four themes: education, nutrition, health and violence. The themes were selected on the basis of our formative research and reflect the broad dimensions of adolescent health and development as well as the RKSK curriculum. At the start of each cycle, adolescents are given a choice of meeting in single-sex or mixed groups. A discussion is also held with local governance bodies, frontline health workers and teachers to seek their ongoing consent for the meetings, because topics (e.g., mental health, violence or sexual and reproductive health) are considered sensitive. In the first phase of each PLA cycle, in order to stimulate discussion,
yuva saathis use picture cards showing problems that adolescents might face. Problems represented on the picture cards under each theme are shown in Table
1 and are standardised across groups. Groups then vote on three problems that they would like to address, and they select one or two for further discussion. Problems mentioned by adolescents that are not represented on the picture cards are written down on blank cards and included in the voting exercise. In the second phase of each cycle,
yuva saathis use stories based on prioritised problems to help groups examine the causes of problems they identified in the first phase. The stories prompt groups to consider causes at the family, community and societal levels. Groups decide which of these causes they would like to address, develop appropriate strategies, and identify ways to evaluate these strategies. In the third phase, groups implement their chosen strategies. During this phase, groups also participate in meetings to explore some of the problems that were not prioritised but are considered relevant in light of the formative research. At the start of each meeting in this phase, the group devotes around 15 min to discuss and review their strategies, challenges faced, and strategies for overcoming these challenges. In the final phase, groups review their strategies, any challenges they faced, and how these challenges were overcome. They also organise a community meeting at the end of each PLA cycle, during which groups share their experience and learning and seek support from the wider community. Strategies implemented in earlier cycles continue to be implemented throughout the intervention implementation period. A community meeting is held at the end of each of the four thematic PLA cycles, and an overall evaluation meeting to discuss all strategies implemented and the way forward is also held at the end of the intervention.
Table 1Problems represented on picture cards used in Participatory Learning and Action cycles
Education | Gender norms related to education |
School drop-out |
Lack of access to school-related entitlements |
Nutrition | Anaemia |
Lack of access to nutrition-related entitlements |
Inadequate dietary intake and dietary diversity |
Intra-household food distribution |
Intra-household food insecurity |
Health | Lack of menstrual hygiene and menstrual disorders |
Early marriage and adolescent pregnancy |
Alcohol and substance abuse |
Depression and anxiety |
Behavioural disorders |
Lack of access to health entitlements |
Violence | Street harassment |
Physical and emotional violence |
Sexual harassment |
Not being able to voice their opinions |
Through the PLA cycles, we expect groups across the intervention arm to have devised and implemented a wide range of strategies to address key health and development problems affecting adolescents in their communities. The PLA cycles are expected to improve adolescents’ knowledge about health, education and nutrition (including services and entitlements), and gender equity. Through the meetings, adolescents are expected to gain confidence to share their needs and problems within the group, with their parents and peers, as well as to improve their problem-solving skills and ability to address issues related to their own health and development. Marginalised adolescents, especially those who are out of school, were identified during the five introductory meetings and specifically encouraged to join the groups. PLA cycles are also expected to have effects on adult members of the community, including increasing their knowledge about the health and development needs of adolescents, motivating them to support the adolescent groups and their strategies, and helping adults to recognise and appreciate adolescents as citizens of the community with their own rights and entitlements.
Youth leadership facilitators
Research from other settings in India suggests potential benefits of combining peer-facilitated interventions with complementary activities [
18], and that developing adolescents’ self-efficacy and psychosocial resilience is a ‘missing piece’ in improving girls’ health [
7]. Our formative research also indicated that adolescents would like opportunities to participate in cultural and sports activities in their communities. On this basis, the community youth team involves a youth leadership facilitator to deliver fun activities that build adolescents’ confidence and help to keep them engaged in the PLA cycle. These activities are also an opportunity to provide information related to adolescent health and development, and to reach out to the rest of the community. Activities are open to all girls and boys in the community and occur every 2 months. They run in parallel with the PLA cycle and include football tournaments and other sports activities, problem management sessions, cycling sessions and nature walks. Youth leadership facilitators are local adults recruited by Ekjut on the basis of their leadership skills, experience of working with young people, and understanding of the principles of PLA. Facilitators participate in monthly meetings with
yuva saathis, coordinators and supervisors in order to coordinate and plan intervention activities.
Through our formative research, adolescents and their parents informed us that they wanted opportunities to participate in livelihood training to develop practical skills related to farming and environmental management. We therefore engaged livelihood promoters, who are adults recruited for their skills and knowledge in farming practices and environmental management, to deliver a programme of livelihood promotion activities. Activities reflect the seasons, are selected in consultation with communities and include paddy cultivation, multi-cropping, compost-making and other organic farming techniques, tree planting, rainwater harvesting, and revival of farmers and save the forest groups (van samitiy). Activities will run approximately every 3 months in both intervention and control arms and are family-focused, involving both adolescents and their parents. The programme has three main aims: (1) to provide adolescents with practical skills that they can use in later life; (2) to improve food security for families, which will help to improve dietary diversity; and (3) to provide a common benefit to both intervention and control arms to help build support for the research across the trial arms.