Table 6 Main findings of research studies (N=12)

1

Evaluation of project design:

Project design of RSH counselling to married men and women, individuals or couples is feasible

Pre-existing community perceptions and community level educators (CLE’s) acceptability in community must be considered when choosing a CLE

More than expected time and effort is required to train rural volunteers, prepare manual for them to use in field, and test, modify, and finalize activities)

Continuous retraining was critical

Youth participation outputs:

89.3% attended at least 1 reproductive health education (RHE) session

76.2% attended 4 or more days of RHE

48.2% attended all RHE sessions

Clinical attendance outputs:

70% received clinical referrals thru RHE

33.3% received clinic referrals through counselling

29% received counselling referrals throught RHE

55% of those in counselling were coming for follow up

Knowledge and awareness outcomes:

Men’s and women’s awareness of various health issues (including menstruation, delivery, contraception, abortion) increased overall, but not for other issues covered in sessions

If individual did not attend a session, their awareness increased if partner did

Qualitative data suggests couples discussed RSH issues outside of sessions

2

Intervention of school-based AFHS increased client attendance from one year to next (43% to 60% among girls, 35% to 42% among boys)

Biologic measures at one year follow-up (no baseline recorded):

93.5% of girls were anemic (mean haemoglobin 9.6 grams)

14.8% of girls were below 5th percentile and 4% of girls were above 95th percentile for weight, mean body mass index (BMI) 19.1

82.3% of boys were anaemic (mean haemoglobin 10.7 grams)

29.3% of boys were below 5th percentile and 0.6% were above the 95th percentile for weight, mean BMI 18.0

A medical checkup with emphasis on assessment of reproductive health and nutritional status detected almost same number of reproductive health problems as reported by participants in survey (no statistical analysis done)

Disparities identified between those students who report health problems (72% of girls, 56% of boys), and those who voluntarily sought help at clinic at baseline (43% girls, 35% boys)

3

Reported percent change in health service utilization among young married women from baseline to endline: (*=significant)

Higher use of spacing FP methods: social mobilization group (SM) 14.4*, government services group (GS) 14.1*, SM+GS 12.4

More attendance to prenatal care check-ups: SM 40.5*, GS -17.8

-Higher use of high-risk delivery care: SM 4.7, GS 4.2, SM+GS 29.8*

More having received treatment for reproductive or sexual infection symptoms: SM 79.5, GS 44.8, SM+GS 98.2*

Percent change in awareness among young married women from baseline to endline of:

-Need for full ANC services: SM 66.1*, GS 18.5

-Need for prenatal care: SM 129.5*, GS 43.5, SM+GS 24.6

Survey of husbands showed that most husbands were aware of wife’s reproductive health needs (in terms of maternal health), yet even knowledgeable husbands unlikely to be involved in maternal care due to social norms that discourage their participation (no significance testing performed)

Interviews showed that mothers-in-law were more likely to be supportive by end of project than at baseline (no quantitative comparison performed)

Social mobilization relatively effective in improving young married women’s RH knowledge (on its own or with other government services)

Strengthening of government services alone did not perform significantly better than other sites on most outcomes

Also showed improvement in husbands' and mothers-in-laws' attitudes regarding young married women reproductive health needs in terms of maternal health

4

Significantly more adolescents used school-based clinic services than dispensary-based (33% versus 13.5%, p<0.01)

The majority of students using school-based clinics were 13-15y (60%) versus the majority of students using dispensary-based clinics were 16-19 (40%), p<0.001.

Majority of participants (80.8%) reported having a health problem during 3-months prior to survey. Of those, 38% were “psychological” problems (tension about career, studies, weight/height

64% of girls and 42.3% of boys sought help/care for health problems, but very few consulted a doctor (most approached friends or parents)

Most common problems presenting to clinic were psychological (29%), general health problems (25%), and behavioural (16%)

Significantly higher proportion of adolescents with psychological and behavioural problems reported in school-based clinic whereas higher proportion of medical problems were presented in dispensary based clinic (p<0.05)

5

Demand for contraceptive use increased from 25% baseline to 40% at follow-up in intervention community (unchanged in comparison)

Contraceptive use odds ratio 3.8 comparison vs. comparison communities

Knowledge that fertility varies during menstrual cycle and agreement that early child birth can be harmful, contraceptive use is necessary and safe for delaying first births higher in interventional than comparison communities (odds ratio 1.6-3.0)

6

Satisfaction level of clients in ARSH clinics varied by site:

Significantly higher proportion of ARSH clients at Chandigarh reported being very satisfied with service vs. those at other clinics (90% vs. 66%, p=0.004)

No significant differences between ARSH and other clinics in Delhi or Kolkata.

Accessibility of ARSH clinics varied by site:

Significantly higher proportion of ARSH clients at Chandigarh described easy accessibility of service vs. those at other clinics (70% vs. 54.3%, p value not reported)

No significant differences between ARSH and other clinics in Delhi or Kolkata.

ARSH clients in Chandigarh and Kolkata more frequently described comfortable waiting area (Chandigarh 50% vs. 34.4%, p=0.04, Kolkata 32% vs. 10.2, p=0.003),

Health care providers were generally better reviewed by users in AFHCs than other clinics, no significance levels reported.

7

Strategy of drawing adolescents to AFHCs at health posts amidst other clients for reproductive health services was feasible

Community sensitisation with involvement of gatekeepers was feasible and important

Peer volunteer approach not successful, but rather clients were referred to center by health care providers

IEC activities through local television network and pamphlets were not effective

1565 adolescents used services during 3 years research compared to 3250 over subsequent 3 year scale up phase

Attendance of boys at centers was lower than girls (specific numbers not indicated)

Proportions of health problems for which boys and girls sought services were compared between research and scale-up phases (No significance testing specified):

Boys: Seeking contraceptives: 17.4% during research vs. 4.3% during scale-up, information and counselling on growing up/sexual concerns 62% vs 67.5%

Girls: seeking contraceptives 21.8% vs. 11.6, information/counselling on growing up/sexual concerns 15.4% vs. 79.3%, menstrual concerns 20.8 vs. 9.5%

Increased knowledge of boys and girls on SRH issues (proportions or significance testing not specified)

Increased contraceptive acceptance to 86%

Increased awareness of ARHCs and range of services among boys and girls from 0% to 77% (no significance testing specified)

No baseline given, increased awareness of services). No comparison group.

8

Projection exercise shows substantial reduction of future population size with possible PRACHAR interventions in Bihar and Uttar Pradesh (including immediate slow growth of newborns, socioeconomically disadvantaged sections of population most benefit from communication interventions)

9

Main quantitative findings:

(1) Contraceptive use highest among couples in which both spouses were exposed to PRACHAR communications

(2) Intervention wives more likely to participate in contraceptive decision than comparison. Those with lower parity were more involved in decision-making

(3) Intervention participants less willing to marry before legal age, more likely to talk with parents about desired marriage age

(4) Intervention participants married 2.6 years later, had first birth 1.5 years later than non-participants. More participants used contraceptives to delay 1st birth and space 2nd birth than non-participants

Main qualitative findings:

Situation in Bihar is improving in terms of education, delayed marriage, small families; patriarchal norms still deeply rooted, PRACHAR played role in changing community perceptions on girls’ education, age, at marriage, SRH

Intervention participants had first birth 1.5 years later than non-participants.

10

Significant improvements observed between pre-test and mid-point and pre-test and follow-up scores; not between mid-point and follow-up scores

Satisfactory improvement in all 8 AWWs re: use of anemia self-assessment chart for screening of anemia, E-chart for vision, weighting scale and measure tape for BMI and record book keeping

Communication skills (better history taking re: menstruation, diet and effective health education also improved in all 8 AWWs)

Before study, no enrolment of adolescent girls in Anganwadis before study, no health check-up carried out by AWWs, no girls being given IFA tablets, no IEC activities related to AFHS found at Anganwadi centers

Baseline data of adolescent girls:

Mean KAP score was 28.56 out of 48 total-knowledge related the contraception, masturbation, reason of adolescent changes, and reason of initial irregular menstruation after menarche was unsatisfactory

Health seeking behaviour was poor (21% unaware that they are beneficiaries of Anganwadi and 11% unaware about facilities for their healthcare

Majority (82%) of adolescent girls were undernourished

11

Odds of contraceptive use were 5x higher in intervention group than comparison group for females; for males 3.6x higher.

Median age was 2.6 years higher in intervention females, 2.8 years higher in intervention males than comparison group.

Relative Risk of marriage by time of survey (after adjusting for schooling and caste differences) was 44% lower for females and 26% lower for males in intervention than comparison

Age at first birth also lower in intervention than control group (after adjusting for marriage, education, caste)

12

Majority of clients were satisfied with services they received from facility (Arajiline 82% vs. Hosakote 65%), relative change of utilization of services was significantly higher in Arajiline than Hosakote

More adolescents were aware of services in Hosakote (56-75%) vs. Arajiline (67% to 97%)