What makes multicomponent school-based health promotion interventions work? A qualitative study nested in the SEHER trial in Bihar, India.

Abstract

Background A cluster-randomized controlled trial in secondary schools in Bihar, India, reported the effectiveness of a multi-component, school health promotion intervention (SEHER) when delivered by lay counsellors (“SEHER Mitra” (SM); meaning “friend” in the local language), but not when delivered by a teacher (“Teacher as SEHER Mitra” (TSM)) compared with the government-run Adolescence Education Program (AEP). This nested qualitative study explored what key factors determined the effectiveness of the intervention and the difference in effectiveness by the delivery agent. Methods We purposively selected 12 intervention schools (6 each from the two intervention arms) based on the size of school. In these schools, we conducted semi-structured interviews with 12 principals, 12 AEP teachers, 12 other teachers, and 11 students who participated in SEHER counselling services. We conducted focus group discussions with girl students (n = 14), boy students (n = 12) SMs (n = 2), TSMs (n = 2), and supervisors (n = 1). Data analysis followed a framework approach to thematic analysis. Results Three overarching themes were identified – i.e. stakeholders’ understanding of SEHER; SEHER intervention planning and implementation, and other issues in the implementation process. All the stakeholders from both the arms strongly believed that the SEHER program was important in imparting health knowledge and life skills to secondary school students. The following factors facilitated the successful implementation of SEHER in SM-arm schools: a shared understanding of the SEHER program by the whole school community, influential school-level leadership, engagement of, and collaboration with, all stakeholders including students in program activities, the trust of the school community in the SMs, full-time availability of SMs for program activities, and prompt actions on students’ concerns by the SMs. Barriers to effective implementation of SEHER in TSM-arm schools included: lack of communication and poor relationship-building between the TSMs, principals and other teachers, TSMs’ perceptions that they were overburdened with academic and non-academic responsibilities, students’ lack of clarity about the TSM’s role, concerns about confidentiality, inaction on students’ concerns, and lack of support from other teachers and the department of education. Conclusions The embedded qualitative study identified important facilitators and barriers to the effective implementation of the intervention when delivered by two different delivery agents. Trial registration: www.clinicaltrials.gov/ NCT02484014