Seeds of Prevention: The Impact on Health Behaviors of Young Adolescent Girls in Uttar Pradesh, India, A Cluster Randomized Control Trial

"Within the Indian context, boosting nutritional status, adherence to the legal age at marriage and reduction in fertility are critical to achieving population level improvements in women's health, but only if norms around these issues can be established early in life."

Identifying early adolescence as a "gateway" moment, the Saloni pilot study is a cluster randomised control trial to improve nutrition, hygiene, and reproductive health behaviours among underprivileged girls (ages 11-14) in 30 schools in rural Uttar Pradesh (UP), India. The goal of the study is to demonstrate accelerated changes in the health behaviors of adolescent girls that are epidemiologically associated with anaemia, maternal mortality, and undernutrition. The intervention aims to provide a foundation of healthy behaviours that will benefit two generations: young adolescent girls in their adulthood and their children.

A core principle of the Saloni pilot programme is the notion that successful change in one behaviour creates generalised self-efficacy to change other behaviours. The intervention is built on the observation that establishment of long-term behavioural patterns depends on both individual behavioural change and a supportive environment, particularly in Indian society where group influence is strong. The curriculum drew from an ancient Indian theory of communication called Sadharanikaran, which relates values of compassion, emotional well-being, and intergenerational communication to collective social norms. The usefulness of Sadharanikaran in the Saloni project stems from its rootedness in the local culture, as well as the way it integrates these core principles of effective communication into an ecological framework.

These principles guided the development of the Saloni intervention, including the design of the teacher's manual and the Saloni diary. For example, the Saloni diary was designed to evoke rasa or emotional wellbeing. The Saloni programme promoted intergenerational communication by including it in the Saloni teachers' manual and support audiovisual (AV) materials. Teachers were trained to encourage the girls to share what they learned with their parents after every session. Role-plays were used to demonstrate how to initiate Saloni discussions with parents. Typically, the principle of asymmetry acknowledges the hierarchical flow of communication from adult to child or man to woman. The Saloni intervention aims to reverse this hierarchical flow by empowering the girls to initiate dialogue on health-related issues with both their mothers and fathers. Furthermore, the intervention actively promoted compassion (sahridaya) towards young girls at the school and community levels; the teachers' training manual used sahridaya as the core construct around which the teachers' training was planned. Through these tools, the Saloni programme promoted concrete actions for the girls to adopt, such as asking for a second helping or asking for more quantities of food.

The Saloni pilot study was conducted in 30 schools in Hardoi, a primarily rural and economically poor district, in UP, India from January 2010 to October 2011. The cluster randomised control trial assigned 6 district blocks to either the intervention or control at 3 ranges of distance (< 20 km, 21-40 km, 41-60 km) from the district centre. Five schools were randomly selected within each block for a total of 15 intervention schools and 15 control schools. Within each school, 40 adolescent girls (11-14 years of age) were randomly selected for a total of 1,201 adolescent girls.

All schools receive the state government's adolescent health programme (Saloni Swasth Kishori Yojna, or SSKY), which included weekly IFA (iron-folic acid supplement) tablets, twice-yearly deworming doses and counseling sessions, and annual health check-ups. The Saloni pilot intervention was designed as an addition to this government programme to improve nutrition, hygiene and reproductive health by promoting 19 health behaviors (5 health seeking, 6 nutrition, 3 reproductive health, 5 hygiene). These behaviors included varied diet, regular use of health services, awareness of the legal marriage age, reduced number of desired children, and regular handwashing and bathing. The intervention group received 10 monthly one-hour instructional sessions using the aforementioned structured teacher's manual, and each girl in the group was provided with a personal diary.

Health competence results in more proactive and sustained health behaviour as a function a combination of facilitating factors; often this takes the form of adopting multiple health behaviours. Along these lines, the Saloni intervention showed significant adoption of 19 healthy behaviours: In the intervention group, the number of girls who practiced 13 or more of the 19 healthy behaviors increased significantly from 5% to 65%, whereas in the control group, the number of girls who practiced 13 or more healthy behaviours showed little change, from 3.5% to 4.5%. Most of the targeted behaviors improved more significantly for girls in the intervention group than for girls in the control group. For example:

• Among nutrition behaviours, the number of girls eating at least 3 meals plus a snack each day increased from 25.8% to 72.3% in the intervention group, compared to a smaller increase from 24.3% to 55.1% in the control group.
• Among health-seeking behaviours, the number of girls taking advantage of the free annual health check-up increased from 17.5% to 65.3% in the intervention group, compared to a decrease from 18.5% to 10% in the control group.
• Among reproductive health behaviours, the number of girls practicing daily genital hygiene increased from 9.4% to 36.2% in the intervention group, compared to a smaller increase from 6.5% to 21.5% in the control group.
• Among hygiene behaviours, the number of girls practicing daily handwashing increased from 14.6% to 46.8% in the intervention group, compared to a smaller increase from 13.2% to 21.6% in the control group.

In short, this culturally based, behaviourally focused, in-school programme, designed to improve health competence by integrating multiple behavioural inputs with structured activities and social support in schools and better communication in families, was found to effectively promote multiple concurrent healthy behaviours in young adolescent girls, and may lead to long-term changes in health knowledge, attitudes, and habits. Since the intervention builds on an existing government health programme that provides material health service resources (such as annual check-ups and deworming tablets), the researchers suggest that the girls have real opportunities to practice these healthy behaviours, even in rural and impoverished settings.

"Therefore, the next logical step is to expand this intervention strategy to more schools. The Saloni intervention does not require additional inputs of prophylactic (IFA tablets) or other health supplies, as these are already part of the SSKY program. What the Saloni strategy adds is an integrated intervention based on compassion, self-efficacy, emotional well being, peer and parental support, packaged in the form of short, easy-to-use instructional modules. It uses a diary to engage adolescent girls, articulate new social and behavioral norms and reinforce the daily practice of protective nutrition and hygiene behaviors. Sustainable, lateral adoption of multiple health behaviors in early adolescence will sow seeds of prevention resulting in many generations of healthy adolescent girls, women and children in Uttar Pradesh."