Seeds of Prevention: The Impact on Health Behaviors of Young Adolescent Girls in Uttar Pradesh, India, a Cluster Randomized Control Trial
An integrated, school-based intervention among girls in early adolescence led to healthier behaviors in nutrition, hygiene, reproductive health, and use of health services.
India is home to the largest number of adolescents (ages 10-19) in the world, yet little is known about the health of young adolescent girls in the country. Many adolescent Indian girls suffer from nutritional and health deficits, leading to higher rates of stunting, anemia and bacterial infection, and eventually to health problems among the next generation. The Saloni pilot intervention aimed to promote healthy behaviors among girls in early adolescence (ages 11-14), a critical “gateway moment” when girls experience rapid physical development and are likely to form long-term behavioral patterns. These patterns depend on both individual behavioral change and a supportive environment, particularly in Indian society where group influence is strong. The gateway approach can also develop health competence, such that learning how to successfully change one behavior can create generalized self-efficacy to change other behaviors. In this context, integrated community programs to address inter-related health concerns can lead to better gains than traditional adolescent health programs that target individual deficits. Thus, this intervention combined behavioral inputs for nutrition, reproductive health and hygiene.
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 curriculum used individual diaries to promote girls’ empowerment and self-efficacy, communication practices to enlist the support of families, and the school structure for distribution of health services. This randomized control study evaluated whether the Saloni pilot intervention improved the adoption of 19 healthy behaviors among adolescent girls in the rural Hardoi district in Uttar Pradesh, India.
The Saloni intervention showed significant adoption of 19 healthy behaviors in nutrition, health seeking, reproductive health, and 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.
- In the intervention group, the number of girls who practiced 13 or more of the 19 healthy behaviors increased significantly from 5% to 65%.
- In the control group, the number of girls who practiced 13 or more healthy behaviors 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 behaviors, the number of girls eating at least three 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 behaviors, 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 behaviors, 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 behaviors, 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, a culturally-based, behaviorally focused, in-school program to improve health competence by integrating multiple behavioral inputs with structured activities and social support in schools and better communication in families can effectively promote multiple concurrent healthy behaviors 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 program that provides material health service resources (such as annual check-ups and deworming tablets), the girls have real opportunities to practice these healthy behaviors even in rural and poor settings.
The Saloni pilot study was conducted in 30 schools in Hardoi, a primarily rural and poor district, in Uttar Pradesh, India from January 2010 to October 2011. The cluster randomized control trial assigned six district blocks to either the intervention or control at three ranges of distance (< 20 km, 21-40 km, 41-60 km) from the district center. 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 program (Saloni Swasth Kishori Yojna), 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 program to improve nutrition, hygiene and reproductive health by promoting 19 health behaviors (5 health seeking, 6 nutrition, 3 reproductive health, 5 hygiene). The intervention group received 10 monthly one-hour instructional sessions using a structured teacher’s manual, and each girl in the group was provided with a personal diary. The sessions were based on compassion, self efficacy, emotional well being, and peer and parental support, and included instruction and role-play on communicating with parents.