Promoting wellbeing and empowerment via Youth First: Exploring psychosocial outcomes of a school-based resilience intervention in Bihar, India.

Youth worldwide are struggling with increased mental health concerns. As youth in low- and middle-income countries make up more than 20% of the world's population, finding ways to improve their psychosocial wellbeing is crucial. CorStone's Youth First program is a school-based psychosocial resilience program that seeks to improve the mental, physical, social, and educational wellbeing of early adolescents. The program is delivered via trained government schoolteachers who facilitate students' learning and development in small groups using a discussion and activity-based curriculum. In August 2021, a study among 322 adolescents was conducted to investigate and compare program participants' and non- participants' understanding and use of inter- and intra-personal psychosocial skills. Focus group discussions were held with students in eight intervention schools and four comparable schools not receiving the intervention (control). Through the focus group discussions, students provided their opinions, thoughts, and ideas about vignettes describing challenges that youth in their communities frequently face, including early marriage and financial pressures. Analysis integrated qualitative and quantitative approaches, consisting of an iterative thematic analysis process followed by quantizing data and conducting t-tests. Youth who had received Youth First had greater awareness of problems, perspective-taking, problem-solving strategies, helping approaches, awareness of their own strengths, and visions for the future, when compared with the control group. Findings provide insights into potential outcomes for measurement in future evaluations of mental health promotion and prevention programs among youth in low- and middle-income countries.

A psychosocial resilience curriculum provides the "missing piece" to boost adolescent physical health: A randomized controlled trial of Girls First in India.

RATIONALE AND OBJECTIVES: Despite a recent proliferation of interventions to improve health, education, and livelihoods for girls in low and middle income countries, psychosocial wellbeing has been neglected. This oversight is particularly problematic as attending to psychosocial development may be important not only for psychosocial but also physical wellbeing. This study examines the physical health effects of Girls First, a combined psychosocial (Girls First Resilience Curriculum [RC]) and adolescent physical health (Girls First Health Curriculum [HC]) intervention (RC + HC) versus its individual components (i.e., RC, HC) and a control group. We expected Girls First to improve physical health versus HC and controls. METHODS: Over 3000 girls in 76 government middle schools in rural Bihar, India participated. Interventions were delivered through in-school peer-support groups, facilitated by pairs of local women. Girls were assessed before and after program participation on two primary outcomes (health knowledge and gender equality attitudes) and nine secondary outcomes (clean water behaviors, hand washing, menstrual hygiene, health communication, ability to get to a doctor when needed, substance use, nutrition, safety, vitality and functioning). Analyses included Difference-in-Difference Ordinary Least-Squares Regressions and F-tests for equality among conditions. RESULTS: Girls First significantly improved both primary and eight secondary outcomes (all except nutrition) versus controls. Additionally, Girls First demonstrated significantly greater effects, improving both primary and six secondary outcomes (clean water behaviors, hand washing, health communication, ability to get to a doctor, nutrition, safety) versus HC. CONCLUSIONS: This study is among the first to assess the impact of a combined psychosocial and adolescent health program on physical health. We found that combining these curricula amplified effects achieved by either curriculum alone. These findings suggest that psychosocial wellbeing should receive much broader attention, not only from those interested in improving psychosocial outcomes but also from those interested in improving physical health outcomes.

Building psychosocial assets and wellbeing among adolescent girls: A randomized controlled trial.

We conducted a randomized controlled trial of a 5-month resilience-based program (Girls First Resilience Curriculum or RC) among 2308 rural adolescent girls at 57 government schools in Bihar, India. Local women with at least a 10th grade education served as group facilitators. Girls receiving RC improved more (vs. controls) on emotional resilience, self-efficacy, social-emotional assets, psychological wellbeing, and social wellbeing. Effects were not detected on depression. There was a small, statistically significant negative effect on anxiety (though not likely clinically significant). Results suggest psychosocial assets and wellbeing can be improved for girls in high-poverty, rural schools through a brief school-day program. To our knowledge, this is one of the largest developing country trials of a resilience-based school-day curriculum for adolescents.

Fostering emotional, social, physical and educational wellbeing in rural India: the methods of a multi-arm randomized controlled trial of Girls First.

BACKGROUND: There are 600 million girls in low and middle income countries (LMICs), many of whom are at great risk for poor health and education. There is thus great need for programs that can effectively improve wellbeing for these girls. Although many interventions have been developed to address these issues, most focus on health and education without integrating attention to social and emotional factors. This omission is unfortunate, as nascent evidence indicates that these factors are closely related to health and education. This paper describes the methods of a 4-arm randomized controlled trial among 3,560 adolescent girls in rural Bihar, India that tested whether adding an intervention targeting social-emotional issues (based on a "resilience framework") to an adolescent health intervention would improve emotional, social, physical, and educational wellbeing to a greater extent than its components and a control group. Study arms were: (1) Girls First, a combination of the Girls First Resilience Curriculum (RC) and the Girls First Health Curriculum (HC); (2) Girls First Resilience Curriculum (RC) alone; (3) Girls First Health Curriculum (HC) alone; and (4) a school-as-usual control group (SC). METHODS: Seventy-six schools were randomized (19 per condition) and 74 local women with a tenth grade education were trained and monitored to facilitate the program. Quantitative data were collected from 3,560 girls over 4 assessment points with very low rates of participant attrition. Qualitative assessments were conducted with a subset of 99 girls and 27 facilitators. RESULTS AND CONCLUSIONS: In this article, we discuss guiding principles that facilitated trial implementation, including integrating diverse local and non-local sources of knowledge, focusing on flexibility of planning and implementation, prioritizing systematic measurement selection, and striking a balance between scientific rigor and real-world feasibility. TRIAL REGISTRATION: Clinicaltrials.gov NCT02429661 . Registered 24 April 2015.

The impact of a lay counselor led collaborative care intervention for common mental disorders in public and private primary care: a qualitative evaluation nested in the MANAS trial in Goa, India.

The MANAS trial evaluated the effectiveness of a lay counselor led collaborative stepped care intervention for Common Mental Disorders (CMD) in public and private sector primary care settings in Goa, India. This paper describes the qualitative findings of the experience of the intervention and its impact on health and psychosocial outcomes. Twenty four primary care facilities (12 public and private each) were randomized to provide either collaborative stepped care (CSC) or enhanced usual care (EUC) to adults who screen positive for CMDs. Participants were sampled purposively based on two criteria: gender and, in the CSC arm, adherence with the intervention. The qualitative study component involved two semi-structured interviews with participants of both arms (N = 115); the first interview within 2 months of recruitment and the second 6-8 months after recruitment. Data were collected between September 2007 and November 2009. More participants in the CSC than EUC arm reported relief from symptoms and an improvement in social functioning and positive impact on work and activities of daily life. The CSC participants attributed their improvement both to medication received from the doctors and the strategies suggested by the lay Health Counselors (HC). However, two key differences were observed in the results for the two types of facilities. First, the CSC participants in the public sector clinics were more likely to consider the HCs to be an important component of providing care who served as a link between patient and the doctor, provided them skills on stress management and helped in adherence to medication. Second, in the private sector, doctors performed roles similar to those of the HCs and participants in both arms placed much faith in the doctor who acted as a confidante and was perceived to understand the participant's health and context intimately. Lay counselors working in a CSC model have a positive effect on symptomatic relief, social functioning and satisfaction with care in patients with CMD attending primary care clinics although the impact, compared with usual care, is greater in the public sector.

The explanatory models of depression and anxiety in primary care: a qualitative study from India.

BACKGROUND: The biggest barrier to treatment of common mental disorders in primary care settings is low recognition among health care providers. This study attempts to explore the explanatory models of common mental disorders (CMD) with the goal of identifying how they could help in improving the recognition, leading to effective treatment in primary care. RESULTS: The paper describes findings of a cross sectional qualitative study nested within a large randomized controlled trial (the Manas trial). Semi structured interviews were conducted with 117 primary health care attendees (30 males and 87 females) suffering from CMD. Main findings of the study are that somatic phenomena were by far the most frequent presenting problems; however, psychological phenomena were relatively easily elicited on probing. Somatic phenomena were located within a biopsychosocial framework, and a substantial proportion of informants used the psychological construct of 'tension' or 'worry' to label their illness, but did not consider themselves as suffering from a 'mental disorder'. Very few gender differences were observed in the descriptions of symptoms but at the same time the pattern of adverse life events and social difficulties varied across gender. CONCLUSION: Our study demonstrates how people present their illness through somatic complaints but clearly link their illness to their psychosocial world. However they do not associate their illness to a 'mental disorder' and this is an important phenomenon that needs to be recognized in management of CMD in primary settings. Our study also elicits important gender differences in the experience of CMD.

The acceptability, feasibility and impact of a lay health counsellor delivered health promoting schools programme in India: a case study evaluation.

BACKGROUND: Studies in resource-limited settings have shown that there are constraints to the use of teachers, peers or health professionals to deliver school health promotion interventions. School health programmes delivered by trained lay health counsellors could offer a cost-effective alternative. This paper presents a case study of a multi-component school health promotion intervention in India that was delivered by lay school health counsellors, who possessed neither formal educational nor health provider qualifications. METHODS: The intervention was based on the WHO's Health Promoting Schools framework, and included health screening camps; an anonymous letter box for student questions and complaints; classroom-based life skills training; and, individual psycho-social and academic counselling for students. The intervention was delivered by a lay school health counsellor who had attained a minimum of a high school education. The counsellor was trained over four weeks and received structured supervision from health professionals working for the implementing NGO. The evaluation design was a mixed methods case study. Quantitative process indicators were collected to assess the extent to which the programme was delivered as planned (feasibility), the uptake of services (acceptability), and the number of students who received corrective health treatment (evidence of impact). Semi-structured interviews were conducted over two years with 108 stakeholders, and were analysed to identify barriers and facilitators for the programme (feasibility), evaluate acceptability, and gather evidence of positive or negative effects of the programme. RESULTS: Feasibility was established by the high reported coverage of all the targeted activities by the school health counsellor. Acceptability was indicated by a growing number of submissions to the students' anonymous letter-box; more students self-referring for counselling services over time; and, the perceived need for the programme, as expressed by principals, parents and students. A minority of teachers complained that there was inadequate information sharing about the programme and mentioned reservations about the capacities of the lay health counsellor. Preliminary evidence of the positive effects of the programme included the correction of vision problems detected in health screening camps, and qualitative evidence of changes in health-related knowledge and behaviour of students. CONCLUSION: A task-shifting approach of delegating school health promotion activities to lay school health counsellors rather than education or health professionals shows promise of effectiveness as a scalable model for promoting the health and well being of school based adolescents in resource constrained settings.

The integration of the treatment for common mental disorders in primary care: experiences of health care providers in the MANAS trial in Goa, India.

BACKGROUND: The MANAS trial reported that a Lay Health Counsellor (LHC) led collaborative stepped care intervention (the "MANAS intervention") for Common Mental Disorders (CMD) was effective in public sector primary care clinics but private sector General Practitioners (GPs) did as well with or without the additional counsellor. This paper aims to describe the experiences of integrating the MANAS intervention in primary care. METHODS: Qualitative semi-structured interviews with key members (n = 119) of the primary health care teams upon completion of the trial and additional interviews with control arm GPs upon completion of the outcome analyses which revealed non-inferiority of this arm. RESULTS: Several components of the MANAS intervention were reported to have been critically important for facilitating integration, notably: screening and the categorization of the severity of CMD; provision of psychosocial treatments and adherence management; and the support of the visiting psychiatrist. Non-adherence was common, often because symptoms had been controlled or because of doubt that health care interventions could address one's 'life difficulties'. Interpersonal therapy was intended to be provided face to face by the LHC; however it could not be delivered for most eligible patients due to the cost implications related to travel to the clinic and the time lost from work. The LHCs had particular difficulty in working with patients with extreme social difficulties or alcohol related problems, and elderly patients, as the intervention seemed unable to address their specific needs. The control arm GPs adopted practices similar to the principles of the MANAS intervention; GPs routinely diagnosed CMD and provided psychoeducation, advice on life style changes and problem solving, prescribed antidepressants, and referred to specialists as appropriate. CONCLUSION: The key factors which enhance the acceptability and integration of a LHC in primary care are training, systematic steps to build trust, the passage of time, the observable impacts on patient outcomes, and supervision by a visiting psychiatrist. Several practices by the control arm GPs approximated those of the LHC which may partly explain our findings that they were as effective as the MANAS intervention arm GPs in enabling recovery.

The acceptability, feasibility, and effectiveness of a population-based intervention to promote youth health: an exploratory study in Goa, India.

PURPOSE: To evaluate the acceptability, feasibility, and effectiveness of a population-based intervention to promote health of youth (age: 16-24 years) in Goa. METHODS: Two pairs of urban and rural communities were selected; one of each was randomly assigned to receive a multi-component intervention and the other wait-listed. The intervention comprised educational institution-based peer education and teacher training (in the urban community), community peer education, and health information materials. Effectiveness was assessed through before-after population surveys at baseline and at 18 months. Outcomes were measured using a structured interview schedule with all eligible youth. Logistic regression compared each pair, adjusted for baseline differences, on prevalence of outcomes in the domains of reproductive and sexual health (RSH), violence, mental health, substance use, and help seeking for health concerns. RESULTS: In both intervention communities, prevalence of violence perpetrated and probable depression was significantly lower and knowledge and attitudes about RSH significantly higher (p < .05). The rural sample also reported fewer menstrual complaints and higher levels of help-seeking for RSH complaints by women, and knowledge and attitudes about emotional health and substance use; and, the urban sample reported significantly lower levels of substance use, suicidal behavior, sexual abuse, and RSH complaints. Although information materials were acceptable and feasible in both communities, community peer education was feasible only in the rural community. The institution-based interventions were generally acceptable and feasible. CONCLUSIONS: Multicomponent interventions comprising information materials, educational-institution interventions and, in rural contexts, community peer interventions are acceptable and feasible and likely to be effective for youth health promotion.

HIV prevention while the bulldozers roll: exploring the effect of the demolition of Goa's red-light area.

Interventions targeting sex-workers are pivotal to HIV prevention in India. Community mobilisation is considered by the National AIDS Control Programme to be an integral component of this strategy. Nevertheless societal factors, and specifically policy and legislation around sex-work, are potential barriers to widespread collectivisation and empowerment of sex-workers. Between November 2003 and December 2005 we conducted participatory observation and rapid ethnographic mapping with several hundred brief informant interviews, in addition to 34 semi-structured interviews with key-informants, 16 in-depth interviews with female sex-workers, and 3 focus-group-discussions with clients and mediators. This provides a detailed examination of the demolition of Baina, one of India's large red-light areas, in 2004, and one of the first accounts of the effect of dismantling the red-light area on the organisation of sex-work and sex-workers' sexual risk. The results suggest that the concentrated and homogeneous brothel-based sex-work environment rapidly evolved into heterogeneous, clandestine and dispersed modes of operation. The social context of sex-work that emerged from the dust of the demolition was higher risk and less conducive to HIV prevention. The demolition acted as a negative structural intervention; a catastrophic event that fragmented sex-workers' collective identity and agency and rendered them voiceless and marginalised. The findings suggest that an abolitionist approach to sex-work and legislation or policy that either criminalises this large group of women, or renders them as invisible victims, will increase the stigma and exclusion they experience. For the targeted HIV prevention approaches advocated by the National AIDS Control Programme to be effective, there is a need for legislation and policy that supports sex-workers' agency and self-organisation and enables them to create a safer working environment for themselves.

Integrating evidence-based treatments for common mental disorders in routine primary care: feasibility and acceptability of the MANAS intervention in Goa, India.

Common mental disorders, such as depression and anxiety, pose a major public health burden in developing countries. Although these disorders are thought to be best managed in primary care settings, there is a dearth of evidence about how this can be achieved in low resource settings. The MANAS project is an attempt to integrate an evidence based package of treatments into routine public and private primary care settings in Goa, India. Before initiating the trial, we carried out extensive preparatory work, over a period of 15 months, to examine the feasibility and acceptability of the planned intervention. This paper describes the systematic development and evaluation of the intervention through this preparatory phase. The preparatory stage, which was implemented in three phases, utilized quantitative and qualitative methods to inform our understanding of the potential problems and possible solutions in implementing the trial and led to critical modifications of the original intervention plan. Investing in systematic formative work prior to conducting expensive trials of the effectiveness of complex interventions is a useful exercise which potentially improves the likelihood of a positive result of such trials.

The psychological and social contexts of complaints of abnormal vaginal discharge: a study of illness narratives in India.

OBJECTIVE: Epidemiological studies have reported strong associations between psychosocial adversity and complaints of abnormal vaginal discharge (AVD) in South Asia. We aimed to explore the mechanism of these associations through qualitative research. METHOD: We carried out serial in-depth interviews with 42 married women with the complaint of AVD who were purposively selected from a sample of 2494 women recruited into a population-based cohort study in Goa, India. The interviews elicited illness narratives of their complaint, focusing on causal attributions and help-seeking behaviors. RESULTS: Women explicitly link their personal experiences of social adversity and stress (such as marital problems and heavy workloads) with their complaints of AVD. The complaint of tiredness, a core feature of depressive and somatoform disorders, and complaint of "tension" were commonly associated with AVD through bidirectional causal interpretations. Reproductive events, particularly related to the menstrual cycle and contraception, comprise another set of causal attributions. Many women hold multiple causal attributions. Most women sought health care, both biomedical and traditional, and their narratives indicate reinforcement of their causal attributions by health care providers. However, treatments were often discontinued or changed due to lack of symptomatic relief, side effects, or costs. CONCLUSIONS: Reproductive health policy and practice must explicitly acknowledge and integrate research findings on psychosocial associations of AVD to promote a holistic and evidence-based approach for this common complaint in women in South Asia.

Non-traditional lifestyles and prevalence of mental disorders in adolescents in Goa, India.

BACKGROUND: Adolescents comprise a fifth of the population of India, but there is little research on their mental health. We conducted an epidemiological study in the state of Goa to describe the current prevalence of mental disorders and its correlates among adolescents aged between 12 and 16 years. AIMS: To estimate the prevalence and correlates of mental disorders in adolescents. METHOD: Population-based survey of all eligible adolescents from six urban wards and four rural communities which were randomly selected. We used a Konkani translation of the Development and Well-Being Assessment to diagnose current DSM-IV emotional and behavioural disorders. All adolescents were also interviewed on socio-economic factors, education, neighbourhood, parental relations, peer and sexual relationships, violence and substance use. RESULTS: Out of 2,684 eligible adolescents, 2,048 completed the study. The current prevalence of any DSM-IV diagnosis was 1.81%; 95% CI 1.27-2.48. The most common diagnoses were anxiety disorders (1.0%), depressive disorder (0.5%), behavioural disorder (0.4%) and attention-deficit hyperactivity disorder (0.2%). Adolescents from urban areas and girls who faced gender discrimination had higher prevalence. The final multivariate model found an independent association of mental disorders with an outgoing 'non-traditional' lifestyle (frequent partying, going to the cinema, shopping for fun and having a boyfriend or girlfriend), difficulties with studies, lack of safety in the neighbourhood, a history of physical or verbal abuse and tobacco use. Having one's family as the primary source of social support was associated with lower prevalence of mental disorders. CONCLUSIONS: The current prevalence of mental disorders in adolescents in our study was very low compared with studies in other countries. Strong family support was a critical factor associated with low prevalence of mental disorders, while factors indicative of adoption of a non-traditional lifestyle were associated with an increased prevalence.

The explanatory models of depression in low income countries: listening to women in India.

INTRODUCTION: Women, and persons facing social and economic disadvantage, are at greater risk for depressive disorders. Our objective was to describe the explanatory models of illness in depressed women, in particular, their idioms of distress, and their views of their social circumstances and how this related to their illness. METHOD: We carried out a qualitative investigation nested in a population based cohort study of women's mental and reproductive health in Goa, India. We purposively sampled women who were ever-married and who had been found to be suffering from a depressive disorder on the basis of a structured diagnostic interview. In-depth interviews were carried out about six months apart exploring stressors in women's lives, a typical day in their recent lives, and their illness narratives (idioms of distress, causal models, impact of illness, help-seeking). RESULTS: 35 women consented to participate in the study, 28 completing both interviews. Women gave expression to their problems primarily through somatic complaints, typically a variety of body aches, autonomic symptoms, gynecological symptoms and sleep problems. There was frequent mention of overall "weakness" and tiredness. Economic difficulties and difficulties with interpersonal relationships (particularly related to marital relationships) were the most common causal models. However, women rarely considered biomedical concepts, for example, the notion that they may suffer from an illness or that their complaints were due to a biochemical disturbance in the brain. Despite the lack of a biomedical concept, most of the participants had sought medical help, typically for reproductive and somatic complaints. CONCLUSIONS: We recommend the use of somatic idioms as the defining clinical features, and a broader, psychosocial model for understanding the aetiology and conceptualization of the clinical syndrome of depression for public health interventions and mental health promotion in the Indian context.

Sex, studies or strife? What to integrate in adolescent health services.

If health services for adolescents are to be successfully integrated into the existing health care system, they will need to reach out to meet the needs that adolescents themselves perceive as salient. This paper describes a study aiming to elicit the needs of adolescents in higher secondary schools in Goa, India, in 1999-2000. The objective was to generate information which could guide the development of adolescent-friendly health services by integrating the health needs identified by adolescents themselves. The study began with free-listing, followed by focus group discussions and in-depth interviews to elicit areas of concern. Then, a survey of 811 students with a self-report questionnaire was carried out. The findings demonstrate that there is clearly an unmet need for information about sexual and reproductive health, but also a large, unmet need for psychosocial support for health issues ranging from violence in schools to poor relationships with parents, stress-related health complaints and educational difficulties, which are often perceived by adolescents to be of primary importance. Integrating these issues into programmes is likely to be an essential element in developing health services and programmes which can reach out to the majority of adolescents in school settings in India.

Efficacy and cost-effectiveness of drug and psychological treatments for common mental disorders in general health care in Goa, India: a randomised, controlled trial.

BACKGROUND: Common mental disorders are associated with substantial morbidity and disability in developing countries, but there are no data for efficacy of treatment. We aimed to assess the efficacy and cost-effectiveness of antidepressant and psychological treatment for common mental disorders in general health-care settings. METHOD: We did a randomised, placebo-controlled trial (double-blind for the antidepressant group) in general outpatient clinics in two district hospitals in Goa, India. Consecutive eligible adults who scored more than 15 on the Revised Clinical Interview Schedule (n=450) were randomly assigned to antidepressant (fluoxetine), placebo, or psychological treatment. Antidepressant or placebo was provided for up to 6 months. Up to six sessions of psychological treatment were provided by trained therapists. The primary outcome was psychiatric morbidity; secondary outcomes were disability and costs. Outcome measurements were done at 2, 6, and 12 months. Intention-to-treat analyses were done with linear regression. FINDINGS: 80% of patients were reviewed; the number of drop-outs was similar in all three groups. Psychiatric outcome was significantly better with antidepressant than with placebo at 2 months (p=0.02; standardised effect size 0.3), but not over the 2-12 month period (p=0.10); antidepressants were significantly more cost effective than placebo in the short term and long term (p<0.05). Psychological treatment was not more effective than placebo for any outcome during either period. INTERPRETATION: Affordable antidepressants such as fluoxetine should be the treatment of choice for common mental disorders in general health-care settings in India, since they are associated with improved clinical and economic outcomes, especially in the short term.