A multicomponent secondary school health promotion intervention and adolescent health: An extension of the SEHER cluster randomised controlled trial in Bihar, India

Autoři: Sachin Shinde aff001;  Helen A. Weiss aff003;  Prachi Khandeparkar aff001;  Bernadette Pereira aff001;  Amit Sharma aff001;  Rajesh Gupta aff001;  David A. Ross aff003;  George Patton aff004;  Vikram Patel aff001
Působiště autorů: Sangath, Porvorim, Goa, India aff001;  Population Council, New Delhi, India aff002;  MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom aff003;  Murdoch Children’s Research Institute, University of Melbourne, Melbourne, Victoria, Australia aff004;  Harvard Medical School, Boston, Massachusetts, United States of America aff005;  Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America aff006
Vyšlo v časopise: A multicomponent secondary school health promotion intervention and adolescent health: An extension of the SEHER cluster randomised controlled trial in Bihar, India. PLoS Med 17(2): e32767. doi:10.1371/journal.pmed.1003021
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003021



Strengthening Evidence base on scHool-based intErventions for pRomoting adolescent health (SEHER) is a multicomponent, whole-school health promotion intervention delivered by a lay counsellor or a teacher in government-run secondary schools in Bihar, India. The objective of this study is to examine the effects of the intervention after two years of follow-up and to evaluate the consistency of the findings observed over time.

Methods and findings

We conducted a cluster randomised trial in which 75 schools were randomised (1:1:1) to receive the SEHER intervention delivered by a lay counsellor (SEHER Mitra [SM]) or a teacher (Teacher as SEHER Mitra [TSM]), respectively, alongside a standardised, classroom-based life skills Adolescence Education Program (AEP), compared to AEP alone (control group). The trial design was a repeat cross-sectional study. Students enrolled in grade 9 (aged 13–15 years) in the 2015–2016 academic year were exposed to the intervention for two years and the outcome assessment was conducted at three time points─at baseline in June 2015; 8-months follow-up in March 2016, when the students were still in grade 9; and endpoint at 17-months follow-up in December 2016 (when the students were in grade 10), the results of which are presented in this paper. The primary outcome, school climate, was measured with the Beyond Blue School Climate Questionnaire (BBSCQ). Intervention effects were estimated using mixed-effects linear or logistic regression, including a random effect to adjust for within-school clustering, minimisation variables, baseline cluster-level score of the outcome, and sociodemographic characteristics. In total, 15,232 students participated in the 17-month survey. Compared with the control group, the participants in the SM intervention group reported improvements in school climate (adjusted mean difference [aMD] = 7.33; 95% CI: 6.60–8.06; p < 0.001) and most secondary outcomes (depression: aMD = −4.64; 95% CI: −5.83–3.45; p < 0.001; attitude towards gender equity: aMD = 1.02; 95% CI: 0.65–1.40; p < 0.001; frequency of bullying: aMD = −2.77; 95% CI: −3.40 to −2.14; p < 0.001; violence victimisation: odds ratio [OR] = 0.08; 95% CI: 0.04–0.14; p < 0.001; and violence perpetration: OR = 0.16; 95% CI: 0.09–0.29; p < 0.001). There was no evidence of an intervention effect in the TSM group compared with control group. The effects of the lay counsellor–delivered intervention were larger for most outcomes at 17-months follow-up compared with those at 8 months: school climate (effect size [ES; 95% CI] = 2.23 [1.97–2.50] versus 1.88 [1.44–2.32], p < 0.001); depression (ES [95% CI] = −1.19 [−1.56 to −0.82] versus −0.27 [−0.44 to −0.11], p < 0.001); attitude towards gender equity (ES [95% CI] = 0.53 [0.27–0.79] versus 0.23 [0.10–0.36], p < 0.001); bullying (ES [95% CI] = −2.22 [−2.84 to −1.60] versus −0.47 [−0.61 to −0.33], p < 0.001); violence victimisation (OR [95% CI] = 0.08 [0.04–0.14] versus 0.62 [0.46–0.84], p < 0.001); and violence perpetration (OR [95% CI] = 0.16 [0.09–0.29] versus 0.68 [0.48–0.96], p < 0.001), suggesting incremental benefits with an extended intervention. A limitation of the study is that 27% of baseline participants did not complete the 17-month outcome assessment.


The trial showed that the second-year outcomes were similar to the first-year outcomes, with no effect of the teacher-led intervention and larger benefits on school climate and adolescent health accruing from extending lay counsellor–delivered intervention.

Trial registration

ClinicalTrials.gov NCT02907125.

Klíčová slova:

Adolescents – Copulation – India – Questionnaires – Schools – Surveys – Teachers – Health promotion


1. Government of India. District Census 2011. Census Organization of India, New Delhi, India; 2011.

2. Roy K, Shinde S, Sarkar B, Malik K, Parikh R, Patel V. India’s response to adolescent mental health: a policy review and stakeholder analysis. Social Psychiatry and Psychiatric Epidemiology. 2019; 54(4): 405–414. doi: 10.1007/s00127-018-1647-2 30607452

3. Patton GC, Sawyer SM, Santelli JS, Ross DA, et al. Our future: a Lancet commission on adolescent health and wellbeing. Lancet. 2016; 387: 2423–2478. doi: 10.1016/S0140-6736(16)00579-1 27174304

4. Global Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. Summary. Geneva: World Health Organization; 2017.

5. Reducing global poverty through universal primary and secondary education. UNESCO/2017/ED/GEMR/MRT/PP/32. [cited 2018 January 10] Available from: http://unesdoc.unesco.org/images/0025/002503/250392E.pdf

6. Patton G, Bond L, Butler H, Glover S. Changing schools, changing health? The design and implementation of the Gatehouse Project. Journal of Adolescent Health. 2003; 33: 231–239. doi: 10.1016/s1054-139x(03)00204-0 14519564

7. Bond L, Glover S, Godfrey C, Butler H, Patton GC. Building capacity for system-level change in schools: lessons from the Gatehouse Project. Health Education and Behaviour. 2001; 28: 368–383.

8. Langford R, Bonell CP, Jones HE, Pouliou T, Murphy SM, Waters E, Komro KA, Gibbs LF, Magnus D, Campbell R. The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement. Cochrane Database of Systematic Reviews. 2014; 4: Art. No.: CD008958.

9. Shackleton N, Jamal F, Viner RM, Dickson K, Patton GC, Bonell C. School-based interventions going beyond health education to promote adolescent health: systematic review of reviews. Journal of Adolescent Health. 2016; 58: 382–396. doi: 10.1016/j.jadohealth.2015.12.017 27013271

10. Shinde S, Pereira B, Khandeparkar P, Sharma A, Patton GC, Ross DA, Weiss HA, Patel V. The development and pilot testing of a multi-component health promotion intervention (SEHER) for secondary schools in Bihar, India. Global Health Action. 2017; 10: 1385284. doi: 10.1080/16549716.2017.1385284 29115194

11. Shinde S, Weiss HA, Varghese B, Khandeparkar P, Pereira B, Sharma A, Gupta R, Ross DA, Patton GC, Patel V. Promoting school climate and health outcomes with the SEHER multi-component secondary school intervention in Bihar, India: a cluster-randomised controlled trial. Lancet. 2018; 392: 2465–2477. doi: 10.1016/S0140-6736(18)31615-5 30473365

12. General reports 2014. Planning Commission, Government of India, 2014. www.planningcommission.nic.in.

13. Taves DR. Minimization: a new method of assigning patients to treatment and control groups. Clinical Pharmacology and Therapeutics. 1974; 15: 443–445. doi: 10.1002/cpt1974155443 4597226

14. Scott NW, McPherson GC, Ramsay CR, Campbell MK. The method of minimization for allocation to clinical trials. A review. Control Clinical Trials. 2002; 23 (6): 662–674.

15. Chartier M, Stoep A, McCauley E, Herting J, Tracy M, Lymp J. Passive versus active parental consent: implications for the school-based depression screening to reach youth at risk. Journal of School Health. 2008; 78: 156–87.

16. Centre for Catalysing Change. Tarang Adolescence Education Program: Inroads to adolescent development. [cited 2018 June 15] Available from: http://www.c3india.org/what-we-do/girls-education-and-youthdevelopment/tarang/.

17. World Health Organisation. The health promoting school-a framework for action in the WHO Western Pacific Region. Manila: Regional Office for the Western Pacific; 1995.

18. Rajaraman D, Travasso S, Chatterjee A, Bhat B, Andrew G, Parab S, Patel V. The acceptability, feasibility and impact of a lay health counsellor–delivered health promoting schools programme in India: a case study evaluation. BMC Health Service Research. 2012; 12: 127–138.

19. Patton GC, Glover S, Bond H, Godfrey C, Di Pietro G, Bowes G. The Gatehouse Project: a systematic approach to mental health promotion in secondary schools. Australian and New Zealand Journal of Psychiatry. 2002; 34: 586–593.

20. Sawyer MG, Pfeiffer S, Spence SH, Bond L, Graetz B, Kay D, Patton GC, Sheffield J. School based prevention of depression: a randomized controlled study of the beyondblue schools research initiative. Journal of Child Psychology and Psychiatry. 2010; 51: 199–209. doi: 10.1111/j.1469-7610.2009.02136.x 19702662

21. Ganguly S, Samanta M, Roy P, Chatterjee S, Kaplan DW, Basu B. Patient health questionnaire-9 as an effective tool for screening of depression among Indian adolescents. Journal of Adolescent Health. 2013; 52 (5): 546–551. doi: 10.1016/j.jadohealth.2012.09.012 23299020

22. Bond L, Wolfe S, Tollit M, Butler H, Patton GC. A comparison of the Gatehouse Bullying Scale and the Peer Relations Questionnaire for students in secondary school. Journal of School Health. 2007; 77: 75–79. doi: 10.1111/j.1746-1561.2007.00170.x 17222158

23. Pulerwitz J, Barker G. Measuring attitudes toward gender norms among young men in Brazil: Development and psychometric evaluation of the GEM scale. Men Masculinities. 2008; 10: 322–338.

24. Cleland J, Ingham R, Stone N. Asking young people about sexual and reproductive behaviours. Geneva: World Health Organization;1998–99. [cited 2014 November 15 ] Available from: http://www.who.int/reproductivehealth/topics/adolescence/core-instruments/en/.

25. Hayes RJ, Moulton LH. Cluster Randomised Trials. 2nd ed. Boca Raton, FL: Chapman and Hall/CRC; 2017.

26. Mishra SK. Bihar’s education system in shambles: building history with the rubbles of my fading memory. The NEHU Journal. 2016; 14(2): 17–31.

27. Adelman HS and Taylor L. Mental health in schools: Engaging learners, prevention problems, and improving schools. Thousand Oaks, CA: Corwin Press; 2010.

28. Calear AL, Christensen H. Systematic review of school-based prevention and early intervention programs for depression. Journal of Adolescence. 2010; 33(3): 429–438. doi: 10.1016/j.adolescence.2009.07.004 19647310

29. Mackenzie K, Williams C. Universal, school-based interventions to promote mental and emotional well-being: what is being done in the UK and does it work? A systematic review. BMJ Open. 2018; 8: e022560. doi: 10.1136/bmjopen-2018-022560 30196267

30. Gaffney H, Farrington DP, Ttofl MM. Examining the effectiveness of school-bullying intervention programs globally: a meta-analysis. International Journal of Bullying Prevention. 2019; 1: 14–31.

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PLOS Medicine

2020 Číslo 2

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