Evaluating the implementation of the Peer Educator Intervention for improving adolescent health in India's National Adolescent Health Programme

Lead Research Organisation: Public Health Foundation of India
Department Name: Grants Administration

Abstract

India is home to 243 million adolescents, yet there is a lack of data on several health indicators and no national data on current levels of knowledge, perceptions and practices of adolescents. In 2014, the Ministry of Health and Family Welfare (MOHFW), Government of India (GOI) launched a comprehensive National Adolescent Health Programme-Rashtriya Kishor Swasthya Karyakram (RKSK), to emphasize on community-based health promotion and strengthening preventive, diagnostic and curative service across health system related to 6 strategic priorities. RKSK interventions, which include a Peer Educator (PE) Programme component, are being implemented in a phased manner; the first phase targets 213 selected High Priority Districts in 28 states of India. The PE programme, rolling out in 2016, is designed to provide life-skills, increase knowledge and awareness among PEs and adolescents of: their needs under six strategic priorities and the availability of services and care at Adolescent Friendly Health Clinics (AFHC), which should lead to increased adolescents' attendance at AFHCs.
The proposed research aims to undertake impact and process evaluation of PE Intervention in 2 selected States of India. This implementation research will focus on evaluating impact and process of implementing PE programme. Process evaluation will aid in understanding implementation, causal mechanisms and the factors that shape desired outcomes. Surveys will study equitable coverage and implementation cost of PE intervention and these data will be summed up to develop vertical and horizontal scale up strategy to expand PE intervention at National and regional level. The outcomes of this implementation research will provide vital insights on effective components, processes and context that maximize the potential of PE Intervention and that need to be scaled up at all India level. They will also inform the field of implementation science for adolescent health and fill the evidence gap of 'What works in PE intervention-for whom, why and under what circumstances'?
Project aims:
1) Evaluate the Process of PE intervention to understand implementation, causal mechanisms and context of the PE programme of the RKSK in two Indian states.
2) Evaluate the effect of the PE intervention on primary outcomes at adolescent (knowledge, attitudes, life skills, practices) and parental levels (attitudes, communication skills) and impacts on PE (leadership and communication skills) and on AFHCS (trends in attendance numbers).
3) Provide specific guidance to MoHFW, GOI, and more generic guidance to other countries, on modifying, scaling up and sustaining the PE intervention.
This project aim has 2 sub questions:
i.What were the costs of implementing the PE intervention and how did costs associate with the quality of the intervention and its outcomes?
ii.What PE intervention components need to be prioritised for horizontal and vertical scale up at state and national level?
The evaluation will be guided by MRC's framework for conducting process evaluations. A mixed-methods design will be used to investigate implementation, mechanisms of impact and context and to assess impact of this intervention. Data will be collected through adolescent, PE and parent surveys, process measures and qualitative data collection methods along with routine RKSK data. The outcomes of the study will be presented at state scale up, national and regional dissemination workshops to various stakeholders including researchers, public health practitioners, programme managers, academicians, policy makers and state-level programme functionaries to highlight barriers to be addressed as well as opportunistic use of enablers in various settings to reach desired adolescent health outcomes. Apart from its applicability in India, the outcomes will be of relevance to other countries in the South East Asia Region, as several are adopting the GOI's RKSK framework to design their adolescent health programmes.

Technical Summary

India is home to 243 million adolescents, yet they remain an understudied population in India with lack of data on the health indicators for this age group and current levels of knowledge on adolescent health issues and effective approaches on reaching marginalized adolescents. In 2014, the Ministry of Health and Family Welfare (MOHFW), Government of India launched a comprehensive National Adolescent Health Programme (Rashtriya Kishor Swasthya Karyakram-RKSK), to emphasize on community-based health promotion and strengthening preventive, diagnostic and curative service across health system related to 6 strategic health priorities. RKSK includes a peer educator (PE) programme, which seeks to ensure that adolescents benefit from sustained peer education and is expected to improve knowledge, attitudes and life skills of adolescents. The PE programme is also expected to change parental and community norms towards the need for adolescent friendly health services, leading to increased attendance to Adolescent Friendly Health Clinics (AFHCs) and subsequently positive adolescent health outcomes. This study will evaluate the impact and process of PE intervention as an integrated component of the RKSK and also explore its interaction with other RKSK components. It will further undertake economic analysis of costs related to implementing PE intervention for guiding scale up. This implementation research will be conducted in 4 high priority districts of 2 Indian states (2 each in Madhya Pradesh & Andhra Pradesh). Mixed methods approach will evaluate the process of the PE programme and its effects on primary outcomes at the adolescent (knowledge, attitudes, life skills, practices) and parental (attitudes, communication) levels as well as impact on PE skills and attendance at AFHCs. The research project also aims to provide guidance to MoHFW on modifying, scaling up and sustaining the PE programme and share findings with countries adapting RKSK.

Planned Impact

This study will evaluate the implementation of the Peer Educator programme under India's National Adolescent Health Programme - Rashtriya Kishor Swasthya Karyakram (RKSK) through feedback on quality improvement, delivery costs, health seeking behavior outcomes and issues of equity. Since the Ministry of Health and Family Welfare (MoHFW), Government of India (GOI) is implementing RKSK, which is an evolving programme, and is implementing partner on this research, the outcomes of this research is expected to provide a basis for MOHFW to develop a National Scale up strategy for improved PE programme within RKSK, to reach a larger number of adolescents, more equitably and in a sustainable manner. It will further provide a more generic guidance to other countries, on modifying, scaling up and sustaining the PE intervention.

The timelines of this study coincide with the roll out of the PE programme under RKSK in 2016 and provides an excellent opportunity to assess the PE programme to provide important lessons for decision makers in India and similar interventions in other low-and middle-income countries.

MoHFW-GOI has been involved in these research discussions from the inception of this study. As a partner in this research, they will also be ultimate users of research outcomes. Vertical and horizontal scale up strategy developed as part of this study will be easily adopted by government for expanding PE programme in other non RKSK districts and remaining states of India. Principal Investigators of this study are appropriately positioned as members of MoHFW's Technical Review Group (TRG) for RKSK to disseminate outcomes of this research with other experts on the TRG and will work with the government for any proposed midcourse corrections necessary for RKSK scale up.

This evaluation provides a unique opportunity to understand impact of peer educators beyond its traditional utilization in the area of sexual and reproductive health to broader issues for adolescent health as enlisted under RKSK priorities and to understand interactions of PE intervention with other components of RKSK. Given that the PE programme under RKSK is a community-based intervention led by adolescents and intended for adolescents, the proposed research will assess adolescents as both beneficiaries and implementers. Therefore, the project will offer relevant community engagement and involve the intended beneficiaries on both the community and systems ends. To maximize the impact of PE intervention, a Community Advisory Board (CAB) at each study site will be formed. CAB will include adolescents, PEs, parents and community members, to ensure smooth implementation of intervention, enhance acceptance of RKSK and AFHCs and aid in scale up of PE intervention.


The results and outcomes of this implementation research will also be disseminated to multiple stakeholders including the participants of this study, public health scientists and practitioners, programme managers, academicians, policy makers and state-level programme functionaries. The outcomes of this research are expected to inform global adolescent health science and provide evidence informed programme and policy recommendations for improving adolescent health.

Publications

10 25 50
 
Title Study Tools and Mehodology 
Description The study will use mixed methods approach. The study data will be collected through observations of trainings/program activities, survey, FGD's and semi-structured interviews with key stakeholders. Also, the data will be collected through RKSK records at Adolescent Friendly Health Clinics (AFHCs). Collected data will include quantitative as well as qualitative data with respect to knowledge, attitude, behavior and perception related to six thematic areas of RKSK. 
Type Of Material Improvements to research infrastructure 
Year Produced 2018 
Provided To Others? No  
Impact No data collection for the study has started as the grant was suspended . 
 
Description Collaboration between Public Health Foundation of India (PHFI), Ministry of Health and Family Welfare-Government of India (GoI) and London School of Hygiene and Tropical Medicine (LSHTM): Evaluating the implementation of the Peer Educator (PE) Intervention for improving adolescent health in India's National Adolescent Health Programme 
Organisation London School of Hygiene and Tropical Medicine (LSHTM)
Country United Kingdom 
Sector Academic/University 
PI Contribution The study involves a multi-disciplinary team of established clinical and public health researchers from India and UK, who are research active, with expertise in epidemiology, implementation science, health economics and social sciences. A key element of this study is that the PHFI collaborated with MoHFW-GoI (as implementation partner) and its involvement in discussions right from the inception of this research proposal. The focus on Rashtriya Kishor Swasthya Karyakram's (RKSK's) Peer Educator (PE) program is at their expressed request. MoHFW will provide overall leadership and guidance to this. There has been continuous communication between Public Health Foundation of India, MoHFW (at Centre) and the Mission Directors (at State) and State National Health Mission teams, to initiate the process of state and district selection for this evaluation, further reiterating government's commitment to this evaluation. PHFI also collaborated with LSHTM on this study.
Collaborator Contribution The states for the study were selected in consultation with the MoHFW-GoI, based on health indicators, population size, contextual diversity, and variance of socio-economic status of the population. In consultation with the state governments, two High Priority districts (HPDs) from each state were identified, as representative of the states. Independent Project Steering Committee (IPSC) was formed as part of this study to provide guidance and continuous monitoring support to the study. The member of this Committee included independent academic members, representatives from central (senior officials from the Adolescent Health Division-MoHFW, GoI) and state government (Mission Director) & civil society and senior staff from the project team. PHFI's collaboration with LSHTM on this project also brings formidable multi-disciplinary experience in diverse research methodologies, health systems strengthening and knowledge translation, which are the foundations of this implementation research proposal.
Impact o The study states were selected in consultation with the MoHFW-GoI, based on health indicators, population size, contextual diversity, and variance of socio-economic status of the population. o Two high priority districts (HPDs) from each state were identified, as representative of the states, in consultation with the state governments. o The study design and sampling frame have been finalized. o The study tools (both qualitative and quantitative), Informed consents, study protocol and protocol for the systematic review have been developed in consultation with the collaborators and investigators. o Independent Project Steering Committee (IPSC) was formed as part of this study to provide guidance and continuous monitoring support to the study. The member of this committee included independent academic members, representatives from government & NGOs and senior staff from the project team. The first call with the members was held on January 23, 2017. o The study also got approval from PHFI's Institutional Ethics Committee, LSHTM Ethics Committee (Reference No: 13660) and Health Ministry's Screening Committee (HMSC). No publications resulted from this collaboration or partnership yet as the study was suspended due to Ministry of Home Affairs (MHA) clearance in India, which has now been received
Start Year 2016
 
Description Collaboration between Public Health Foundation of India (PHFI), Ministry of Health and Family Welfare-Government of India (GoI) and London School of Hygiene and Tropical Medicine (LSHTM): Evaluating the implementation of the Peer Educator (PE) Intervention for improving adolescent health in India's National Adolescent Health Programme 
Organisation Ministry of Health and Family Welfare
PI Contribution The study involves a multi-disciplinary team of established clinical and public health researchers from India and UK, who are research active, with expertise in epidemiology, implementation science, health economics and social sciences. A key element of this study is that the PHFI collaborated with MoHFW-GoI (as implementation partner) and its involvement in discussions right from the inception of this research proposal. The focus on Rashtriya Kishor Swasthya Karyakram's (RKSK's) Peer Educator (PE) program is at their expressed request. MoHFW will provide overall leadership and guidance to this. There has been continuous communication between Public Health Foundation of India, MoHFW (at Centre) and the Mission Directors (at State) and State National Health Mission teams, to initiate the process of state and district selection for this evaluation, further reiterating government's commitment to this evaluation. PHFI also collaborated with LSHTM on this study.
Collaborator Contribution The states for the study were selected in consultation with the MoHFW-GoI, based on health indicators, population size, contextual diversity, and variance of socio-economic status of the population. In consultation with the state governments, two High Priority districts (HPDs) from each state were identified, as representative of the states. Independent Project Steering Committee (IPSC) was formed as part of this study to provide guidance and continuous monitoring support to the study. The member of this Committee included independent academic members, representatives from central (senior officials from the Adolescent Health Division-MoHFW, GoI) and state government (Mission Director) & civil society and senior staff from the project team. PHFI's collaboration with LSHTM on this project also brings formidable multi-disciplinary experience in diverse research methodologies, health systems strengthening and knowledge translation, which are the foundations of this implementation research proposal.
Impact o The study states were selected in consultation with the MoHFW-GoI, based on health indicators, population size, contextual diversity, and variance of socio-economic status of the population. o Two high priority districts (HPDs) from each state were identified, as representative of the states, in consultation with the state governments. o The study design and sampling frame have been finalized. o The study tools (both qualitative and quantitative), Informed consents, study protocol and protocol for the systematic review have been developed in consultation with the collaborators and investigators. o Independent Project Steering Committee (IPSC) was formed as part of this study to provide guidance and continuous monitoring support to the study. The member of this committee included independent academic members, representatives from government & NGOs and senior staff from the project team. The first call with the members was held on January 23, 2017. o The study also got approval from PHFI's Institutional Ethics Committee, LSHTM Ethics Committee (Reference No: 13660) and Health Ministry's Screening Committee (HMSC). No publications resulted from this collaboration or partnership yet as the study was suspended due to Ministry of Home Affairs (MHA) clearance in India, which has now been received
Start Year 2016
 
Description Investigator Meeting between PHFI and LSHTM study team, interaction with stakeholders at national, state and district level and field visit to study site 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Study participants or study members
Results and Impact Investigator Meeting: Dr. James Lewis and Ms. Stefanie Dringus, co-investigators on this study from LSHTM visited India for investigators meeting during February 27-March 5, 2017. During this visit, team from PHFI and LSHTM, worked on study protocols, tools, study design and sampling frame. The team also interacted with senior officials (Deputy Commissioner-Adolescent Health Division)/RKSK team at the MoHFW-GoI (central level) to understand RKSK programme and to plan project activities. The team also visited Madhya Pradesh and interacted with various stakeholders, at state and district level, including: Mission Director (NRHM-MP), Deputy Director (Adolescent Health-NRHM-MP), State Consultant-RKSK; Peer Educators, frontline health workers (ASHAs, ASHA facilitators, ANMs), parents, NGO trainers, Counsellors, Village Sarpanch (elected by the village-level constitutional body). The team also visited Adolescent Friendly Health Clinic (AFHC), interacted with peer educators and observed PE activities.
A presentation on study overview and logic model of the study during the 11th World Congress on Adolescent Health: The International Association for Adolescent Health held during October 27-19, 2017 at New Delhi (India).
Year(s) Of Engagement Activity 2017