Engagement of Peer Educators from India’s National Adolescent Health Programme for the COVID-19 response activities: Qualitative findings from i-Saathiya study

Abstract

Background

The COVID-19 pandemic strained India’s healthcare system and health workers unprecedentedly.

Purpose

The extent of the contribution by peer educators (PEs) from India’s National Adolescent Health Programme-Rashtriya Kishor Swasthya Karyakram (RKSK) to COVID-19 response activities remains uncertain necessitating an imperative investigation. Within the overarching objective of the ‘i-Saathiya’ study (‘i’ signifies implementation science and Saathiya represents PEs in Madhya Pradesh), a key focus was to understand the role of PEs recruited under RKSK during COVID-19 in two Indian states, namely Madhya Pradesh and Maharashtra. The study states differ in sociodemographic characteristics and peer education implementation models.

Methods

In-depth interviews (IDIs) were conducted with stakeholders (n=110, Maharashtra: 57; Madhya Pradesh: 53) engaged in the implementation of RKSK’s peer education programme at state, district, block and village levels. Focus group discussions (FGDs) (n=16 adolescents, Maharashtra: 8; Madhya Pradesh: 8) were conducted with adolescents, part of the peer group of PEs (n=120 adolescents, Maharashtra: 66; Madhya Pradesh: 54). IDIs and FGDs were audio-recorded, translated, transcribed verbatim and analysed thematically. Adopting inductive and deductive approaches, a data-driven open coding framework was developed for thematic analysis.

Results

The PE recruited under RKSK took a central role that extended beyond their predefined responsibilities within the RKSK. They provided crucial support to healthcare workers in curbing the spread of COVID-19. Their diverse contributions, including COVID-19 pandemic response support, addressing community and adolescent needs, role in COVID-19 vaccination efforts, navigating access to the health system and facilitating health workers in the implementation of various national health programmes and campaigns during COVID-19.

Conclusion

The findings underscore the potential of PEs in bolstering the health system. Despite their unpreparedness for the context (COVID-19), PEs demonstrated tenacity and adaptability, extending their roles beyond their predefined responsibilities. Recognising PEs through awards and incentives, skill courses and additional grades, can enhance their visibility, sustaining impactful work within RKSK and beyond.

Strengths and limitations of this study.

• The study captures a wide range of perspectives of both programme implementers and beneficiaries for an in-depth understanding of the role of peer educators (PEs) during the COVID-19 pandemic in India.

• This is a novel study that focuses on a relatively unexplored area, the role of PEs beyond their programme role (ie, role in the Rashtriya Kishor Swasthya Karyakram (RKSK)) and their role in mitigating the impact of COVID-19 in India and their support to other national health programmes.

• The inclusion of beneficiary perspective, that is, PEs was also explored to understand how the PEs functioned within the context of the COVID-19 pandemic.

• The study relied primarily on qualitative data and may have limited generalisability.

• The reliance of the study on self-reported data from RKSK implementers introduces a risk of self-reporting bias, which may be subject to social desirability effects.

Introduction

Globally, there is a growing recognition of the need to invest in adolescent health given their vulnerability¹ to escalating health issues like substance use disorders, mental health challenges, road traffic injuries and more.² This vulnerability was further accentuated during the COVID-19 pandemic due to their distinct health needs and the potential long-term impact on public health. This emphasises the significance of preventive measures and tailored interventions to mitigate the spread of the virus among this demographic. Investing 1 dollar in adolescent health is expected to yield a 10-fold return in health, social and economic benefits.³ India has been a frontrunner by making significant commitments to address the diverse needs of adolescents through policies and programmes such as the Adolescent Reproductive and Sexual Health policy (2006),⁴ Reproductive Maternal Newborn Child and Adolescent Health (RMNCH+A) 2013,⁵ National Adolescent Health Strategy (ie, Rashtriya Kishor Swasthya Karyakram-RKSK).⁶ RKSK launched in 2014 by the Ministry of Health and Family Welfare-Government of India marks a critical milestone in India’s ongoing efforts to promote adolescent health and well-being. Programme uniqueness lies in the three-tier approach, besides the facility and school-based approaches, it includes a community-based approach involving the implementation of a peer education programme at the village level. This involves the selection and training of peer educators (PEs). 15–20 adolescents (aged 15–17 years in this case) are selected from each village through a multilevel selection process and trained by Auxiliary Nurse Midwife (ANM) and medical officer (MO). Once trained, the responsibilities of trained PEs include creating peer groups with adolescents from their village, conducting weekly village-level participatory sessions on RKSK’s thematic areas with adolescents of their village and referring adolescents to Adolescent Friendly Health Clinics (AFHCs) in their time of need. These sessions aim to increase adolescents’ knowledge, improve attitudes, health behaviours, life-skills and increase their engagement and access to health services. Additionally, PEs also participate in monthly Adolescent Friendly Club meetings with the ANM and support quarterly Adolescent Health and Wellness Days.^{6 7} These PEs act as a critical link between adolescents and healthcare service providers including MOs, Accredited Social Health Activists (ASHAs), ANMs and counsellors. However, RKSK has not been comprehensively evaluated. While there have been sporadic evaluations for AFHCs⁸ and other RKSK⁹ components like Adolescent Health and Wellness Days, none have evaluated the peer education programme. As the COVID-19 pandemic emerged, PEs expanded their roles taking on leadership in response activities related to COVID-19. Evidence from other countries highlighted that peer education programmes have contributed to enhance vaccine uptake among high school students in Poland,¹⁰ improved health literacy and adherence to preventive measures among vulnerable adolescents in Iran.¹¹ The extent to which PEs of RKSK in India contributed to COVID-19 response activities remains uncertain, but imperative to investigate as COVID-19 pandemic exerted an unprecedented strain on the healthcare system and health workers. In addition to their existing responsibilities, many community health workers were assigned additional tasks of tracing, tracking, monitoring, house visits to assist patients with COVID-19 and other associated tasks. PEs supported these community health workers in these additional tasks during the initial period of COVID-19 as seen in the situational analysis conducted as part of the i-Saathiya study.¹² The situational analysis was conducted with limited stakeholders and adolescents were not included. With this background, an in-depth qualitative study was conceptualised as part of the i-Saathiya study, an implementation research with an overarching research objective to explore the implementation of RKSK’s peer education programme during the COVID-19 pandemic. The specific objective was to understand the role of PEs beyond their programme activities during different phases of COVID-19 in two Indian states (Madhya Pradesh and Maharashtra) and how did their involvement impacted the COVID-19 response efforts. The states were selected in discussion with the central government. The qualitative approach was preferred over quantitative to understand ‘what’ and ‘how’ PEs recruited under RKSK contributed during the COVID-19 pandemic. The insights gained from this study will contribute significantly to the existing literature by emphasising the vital role of PEs as an integral part of the existing workforce in strengthening India’s public health system.

Methodology

Study design

This qualitative exploratory study adopted the interpretivism research paradigm aimed to understand the ‘what’ and ‘how’ aspects of how PEs recruited under RKSK extended their roles beyond their predefined responsibilities within the RKSK during COVID-19 in two Indian states, namely Madhya Pradesh and Maharashtra.

Study setting and participants

The study was carried out in two Indian states, that is, Maharashtra and Madhya Pradesh, with two study districts selected from each state. Madhya Pradesh is a large state in central India with a population of 72.6 million and a literacy rate of 69.3%. Maharashtra, in India’s western peninsular region, is the second-most populous state with a population of 112.3 million and an 82.3% literacy rate. The detailed description of state and district selection has been discussed in other i-Saathiya study publication.¹² The study districts included Panna and Damoh from Madhya Pradesh where the non-governmental organisation (NGO) model of the peer education programme is implemented. In Maharashtra, Nashik and Yavatmal were included where the Government model of the peer education programme is implemented highlighting the difference between study settings. In addition, the implementation status of the peer education programme was considered, that is, districts where the programme has recently commenced or has been implemented for several years. We also considered demographic indicators such as teenage pregnancy, literacy rates and unmet needs.13,15

Patient and public involvement

Patients or the public were not involved in the study design, or conduct, or reporting, or dissemination plans of our research.

Sampling strategy

The selection of study states was carried out in consultation with the Ministry of Health and Family Welfare-Government of India while two study districts from each state were selected in consultation with the respective state health department. From each district, four blocks were included based on probability proportional to size(PPS).¹⁶ From each block, villages were selected depending on the number of PEs at the village level. Thus, nine villages and five villages from each block of Madhya Pradesh and Maharashtra were selected respectively based on PPS. The routine programme data received from the programme officials highlighted that these villages had different PE training status that is, Panna (PEs recruited: 80; trained PEs: 47; proportion trained: 58.7%); Damoh (PEs recruited: 72; trained PEs: 32; proportion trained: 44.4%); Nashik (PEs recruited: 221; trained PEs: 104; proportion trained: 47.0%), Yavtamal (PEs recruited: 113; trained PEs: 106; proportion trained: 93.8%).

The State RKSK team nominated participants from the district who then nominated participants from the blocks and further participants at the village level. RKSK officials directly involved in programme implementation at the state and district levels were selected using purposive sampling. A snowball sampling technique was employed to select stakeholders engaged in the implementation of RKSK’s peer education programme at the block and village levels. These included ASHAs, ASHA facilitators, ANMs, Community Health Officers, NGO trainer mentors, NGO representatives, teachers, parents of both PEs and adolescents, MOs, counsellors, State RKSK coordinators and faculty from training institutes. The roles and responsibilities of each stakeholder recruited in the study related to the RKSK and peer education programme have been explained in our previous publication.¹² Additionally, PEs and adolescents enrolled under PEs were selected using a simple random sampling using a fishbowl method. Participants were sampled until no additional data was being reported by our study participants.

Data collection

The data was collected through face-to-face in-depth interviews (IDIs) (n=110) and focus group discussions (FGDs) (n=16) using interviews and FGD guides tailored to each group of participants. These guides included specific questions, probes and prompts, exploring the participants’ perspectives on the role and engagement of PEs beyond their RKSK’s roles and responsibilities during COVID-19 (online supplemental annexure 1). These guides were pretested with the participants who were not part of the main sample before the commencement of data collection to ensure they aligned with the research aims and to assess their clarity and feasibility. These discussions focused on research questions including: (1) What additional roles and responsibilities did PEs take on during the COVID-19 pandemic? (2) How did PEs adapt to their new roles? (3) What strategies did PEs use for COVID-19 response activities including to promote COVID-19 vaccination uptake and overcome vaccine hesitancy within their communities and adolescents? (4) What impact did the extended roles have on the overall COVID-19 response in their communities?

The data was collected between December 2021 and June 2022 by the six trained qualitative researchers, locally based, proficient in the local languages (Marathi for Maharashtra and Hindi for Madhya Pradesh) and audio recorded along with the field notes. The participants were asked to review and sign a consent form prior to participating in an interview or FGD. A prior household visits were conducted by the study team to facilitate this purpose. For participants under the age of 18 years, active informed consent was provided by a parent or guardian which was followed by active informed assent obtained from each participant.

Quality assurance

The research team maintained a strong focus on ensuring data quality throughout the study duration implementing rigorous checks to ensure high data quality representative of the included population. This commitment to quality assurance involved several steps. The team members were recruited based on their educational qualification, fieldwork efficiency and prior experience in data collection, particularly in the domain of public health, adolescent health and health systems. All interviewers underwent extensive training on qualitative data collection through IDIs and FGDs emphasising ethical considerations and expected data quality standards. The research team completed good clinical practice before commencing the data collection. To further enhance accuracy, approximately 10% of data was collected under the direct supervision of the lead qualitative researcher and an additional 10% underwent random rechecks.

Data analysis

Interviews were translated and transcribed verbatim and identifiable data were redacted and checked for accuracy. The accuracy of the translations was verified by native speakers of both local languages. Each transcript was read for familiarisation. We employed thematic analysis during which we systematically arranged, categorised and analysed the data through inductively and deductively derived themes.^{17 18} Deductively generated themes were derived from the qualitative guides developed using the outcomes of the situational analysis conducted as part of the study and aligned with the research aims. These preliminary themes were then refined and expanded throughout the data collection and analysis stages. Additionally, following the principles of the inductive approach, new themes were derived from the information gathered during the interviews and group discussions.¹⁷

The data were manually coded and organised thematically into a coding tree by a team of six researchers, each holding at least a Master’s degree in Public Health and having more than 3 years of qualitative research experience. To ensure the validity of interpretations, each researcher familiarised themselves with the data independently resulting in the identification of the codes. To ensure coding reliability, we employed an iterative coding process involving continuous discussions and refinements among the researchers through regular meetings. A subset of the data was independently coded by these six researchers and intercoder reliability was assessed to enhance the robustness of the coding process. Any identified discrepancies in coding and organising data among the six researchers were discussed and resolved in consultation with coauthors (SB, DB and HM). This collaborative and iterative process ensures the reliability and consistency of the data. Five themes were identified as presented to address our research objective to understand the role of PEs beyond RKSK during COVID-19. The overview of data collection and analysis is presented in figure 1.

Figure 1. Overview of data collection and data analysis. The figure was developed specifically for this study. FGDs, focus group discussions; IDIs, in-depth interviews; RKSK, Rashtriya Kishor Swasthya Karyakram.

Results

A total of 110 IDIs were conducted with stakeholders involved in the implementation of RKSK’s peer education programme. These interviews were distributed across the states of Maharashtra (N=57) and Madhya Pradesh (N=53). The participants included 69 women and 41 men representing various levels including state, district, block and village (table 1). The age range of participants varied from 11 to 60 years (Madhya Pradesh: 12–42 years; Maharashtra: 11–60 years) and the years of affiliation with RKSK ranged from 1 month to 5 years (Madhya Pradesh: 1–5 years, Maharashtra: 1–3 years). The average duration of each interview was from 45 to 90 minutes. Additionally, 16 FGDs with 120 adolescents active as peer group members with eight discussions held in each state and an average of eight adolescents per group. In Maharashtra, there were 66 adolescents (32 women and 34 men), while in Madhya Pradesh, there were 54 adolescents (24 women and 30 men), table 1. All the FGDs were done separately in both study states for boys (n=64) and girls (n=56). The interviews with RKSK officials were conducted within their respective offices while those with parents, PEs and adolescents within household settings.

Table 1. Details of study participants.

Participant	Number of participants		Gender
	Madhya Pradesh	Maharashtra	Male	Female
In-depth interviews (IDIs)
Participants at the village level
ASHA (Accredited Social Health Activist)*	4	4	0	8
ASHA facilitator*	4	4	0	8
ANM* (auxiliary nurse midwife)	4	4	0	8
Trainer mentor	4	0	2	2
Representative from non-governmental organisation (NGO)	2	0	2	0
Teacher	4	4	5	3
Peer educator (PE)/Saathiya†	12	12	12	12
Parent of PE (peer educators)	6	6	4	8
Parent of AEP (adolescents enrolled under peer educator)	6	6	4	8
Participants atblocklevel
Community health officer	4	4	3	6
Medical officer (MO)	2	2	3	1
Counsellor	4	4	2	6
Participants atstatelevel
Faculty in training institute	0	2	1	1
State RKSK coordinator	1	1	2	0
Total	57	53	41	69
FGDs
AEPs	54	66	64	56
Grand total	111	119	104	126

^*ASHAs, ASHA facilitators, and ANMs are all female cadre of community health workers.

^†Peer Educators are called Saathiya in Madhya Pradesh.

FGDsfocus group discussionsRKSKRashtriya Kishor Swasthya Karyakram

Five key themes emerged from the analysis highlighting that PEs during COVID-19 performed numerous activities, all of which extended beyond the scope of RKSK. These included: (1) COVID-19 pandemic response support; (2) meeting the needs of the community and adolescents during the lockdown; (3) role in COVID-19 vaccination uptake; (4) navigating access to the health system and; (5) supported other national health programmes and campaigns.

COVID-19 pandemic response support

The findings revealed that the selected PEs successfully adapted to the context (ie, COVID-19) and played a crucial role by supporting health workers such as ASHAs, ANMs, NGO trainer mentors in COVID-19 response activities. They sensitised adolescents and other community members to adhere to COVID-19 appropriate behaviours (CABs) like wearing masks, washing hands, using sanitisers and maintaining physical distancing. This sensitisation was done by adopting different strategies including household visits, conducting rallies, slogan writing, folk songs and wall paintings. Realising the importance of sanitisers and face masks in mitigating the COVID-19 pandemic, PEs distributed them in the community. The PEs, health workers and parents from both the study states shared that:

Saathiyas (Peer Educators) have done good work, they took out rallies, wrote slogans on walls to spread awareness in the society about the COVID-19-appropriate behaviours. NGO Trainer Mentor, Panna (Madhya Pradesh)

Saathiyas (Peer Educators) distributed it (masks) once or twice. They asked people to use sanitisers, wash hands frequently and also maintain a one-meter distance from each other. ASHA, Panna (Madhya Pradesh)

I had to tell everyone to wear masks and use sanitiser and wash hands with soap by visiting their homes to prevent the spread of virus. PE, 14 years, Nashik (Maharashtra)

They helped maintain migration and quarantine records of people (not COVID infected), migrating from urban cities to villages by undertaking household surveys. For example, an NGO trainer mentor in Madhya Pradesh reported that ‘Peer educators supported ASHA in distributing masks, preparing list of returning migrant workers and maintaining records and documents of individuals in quarantine during COVID-19 pandemic’.

The impact of knowledge dissemination by PEs was observed in terms of the change in practices among community members and adherence to the COVID-19 protocols as reported by a parent of a PE from Nashik (Maharashtra) who said, ‘People started wearing masks, using sanitiser. They maintained social distance and they didn’t get into contact with each other that much’.

Meeting the needs of the community and adolescents

During the lockdown period in India, when COVID-19 cases were high and movement was restricted, access to essential materials was limited. At this time, PEs supported ASHAs to address the unmet needs of the community. For example, they facilitated ASHAs in providing menstrual hygiene products to adolescent girls in the community as well as distributing essential grocery items to families living in the containment areas (where only essential activities were allowed with strict perimeter control ensuring no movement of people) or red zones (areas with high COVID-19 caseload).

Those who were in red zones were not able to go out and buy anything. So, they called us (PEs) for necessities like milk, bread, sanitary pads and even medicines. We left them (necessary items) outside their home. PE, 17 years, Nashik (Maharashtra)

PEs also took part in distributing medicines and food items to members of the community who were in need. As reported by one of the PEs of the Yavatmal district of Maharashtra, ‘I have distributed medicine and food during the Corona period. People benefited from my work as they were able to get food. They were able to get medicines’.

The PEs from Nashik (Maharashtra) also generated employment avenues for families by providing them with the task of making face masks, enabling them to live and thrive themselves amidst the pandemic, as described by one PE:

There was a rise in unemployment during COVID-19. We got a task from Gram Panchayat (a basic village-governing institute in Indian villages) to distribute masks, so we reached out to the families in our village and offered them the opportunity to use their sewing machines to make masks and sell them for monetary compensation.

Role in COVID-19 vaccination uptake

PEs played a positive role in the COVID-19 vaccination drive earning accolades from health workers. This recognition not only bolstered the morale of the PEs but also provided a sense of responsibility. The vaccination drive involved support from healthcare professionals, frontline COVID-19 workers, and, the general public including the PEs in the states. PEs created awareness among adolescents and the community to overcome COVID-19 vaccination hesitancy through rallies, posters, wall writings, Rangoli (a popular Indian art form), folk music.

When the vaccination-related responsibilities came along, it was new for us, and even Saathiyas (peer educators) took an interest in performing the tasks. If you continue to teach them the same thing for 2–3 months, they lose interest. But with COVID-related responsibilities, they were on their feet. They were spreading awareness of the myths and hesitancy related to the vaccination. This is an achievement because Saathiyas (Peer Educators) felt a sense of responsibility towards the village and work. NGO Representative, Damoh (Madhya Pradesh)

When the vaccination started many of our PEs helped the communities by motivating them to get vaccinated and raising awareness about COVID-19 vaccination and overcome hesitancy related to the vaccination along with our NGO Trainer Mentors. Our immunization rate was very good. Nodal Officer RKSK, Madhya Pradesh

One of the parents of PE from Yavatmal (Maharashtra) reported that ‘He (peer educator) convinced people above 18 years of age to get vaccinated by visiting every home. This is the responsibility of both ASHA and peer educators. They created awareness among people. Earlier, nobody was ready to get vaccinated as there was a rumour that vaccine causes death and also other vaccine related myths among the people’.

To overcome the challenge of vaccine hesitancy in one of the villages of Madhya Pradesh, PE played a crucial role in using traditional practices. They offered yellow rice from house to house as an invitation to visit the vaccination centre. This underscores the use of traditional efforts by PEs in Madhya Pradesh:

In our village, there is a practice to receive yellow rice as an invitation before visiting someone’s home, because of this, we distributed yellow rice to invite people to come to the vaccination site and take the COVID-19 vaccine. PE, 19 years, Damoh (Madhya Pradesh)

We composed songs to invite community members for COVID-19 vaccination to invite more people and make our village COVID-19 free. PE, 17 years, Damoh (Madhya Pradesh)

Besides this, PEs served as role models for the community boosting morale and encouraging COVID-19 vaccination. In some instances, PE aged 15–18 years, eligible for the vaccine, took the first dose of the vaccine conveying the message that the vaccine is safe and has no side effects as reported by a social worker and other PEs:

Peer educators got vaccinated and then told people that I got vaccinated and nothing happened to me, so nothing will happen to you as well. And if something does happen, there are doctors in our village to help. Social worker, Nashik (Maharashtra)

When vaccination had initially started, people were scared, so we created awareness for the vaccine and took people to the vaccination centre and supported ASHA didi also in the vaccination drive. Saathiya, 17 years, Panna (Madhya Pradesh)

Considering the technology competence of youth, PEs supported health workers in the registration process for beneficiaries on the CoWIN platform (Government of India web portal for COVID-19 vaccination registration).¹⁹ Their significant contribution was exhibited when they accompanied the beneficiaries to the vaccination sites using their resources (bikes). For instance, one of the PEs from Madhya Pradesh reported that:

Adolescents came to us for suggestions or advice when COVID-19 vaccination opened up for the under 18 years old. They (COVID-19 vaccination beneficiaries) were facing problems at the time of online vaccination registrations on COWIN; so, we talked to our mentor and helped all of them by registering them on the COWIN. Saathiya, 17 years, Panna (Madhya Pradesh)

One good thing that they (peer educators) did was dropping senior citizens (first to get vaccinated after frontline workers) to the vaccination centre on their bikes, or giving them umbrellas, etc. NGO trainer mentor, Panna (Madhya Pradesh)

The PE and NGO trainer mentor from the Panna district of Madhya Pradesh reported that the contribution of PEs in the vaccination drive led to an increased vaccine coverage of up to 90%:

My village in Panna District and 90% of people here have completed their first and second dose of vaccination as compared to other villages where this percentage is only 50% or even 0%; so, we helped in creating awareness about the vaccine and now we feel happy that our village is ranked first in vaccination in the whole district and we feel the work we did was useful.

The PEs wrote slogans on the wall like the COVID-19 vaccine is beneficial and will not cause harm. This was a nice thing because approximately 90% of the village is now vaccinated.

Navigating to access the health system

Data from both states demonstrated that during the COVID-19 pandemic, PEs continued to serve as the first point of contact for adolescents to solve their health issues. However, they also took on additional duties by acting as a navigator to assist young people with COVID-19 symptoms in linking and accessing the healthcare system or services by informing them about the nearest health facility that is, Primary Health Centre (PHC). In some cases, they also accompanied adolescents to AFHC. Since the PEs were already well integrated into the system, they were able to seek the assistance of ASHA workers, sarpanch (village head) or health staff from the AFHC to address the issues faced by adolescents in their respective villages as described by the following participants

They were telling peer educators that they have a cold, cough. Then peer educator suggested they visit PHC and get COVID-19 testing done. Parent of peer educator, Yavatmal (Maharashtra)

A boy came to me from far and had a fever. When he came to me, I took him to ASHA tai (ASHA worker). Then I took the boy to the nearest clinic. PE, 15 years, Yavatmal (Maharashtra)

If their (PEs) friends share their health issues with them, they let us know and then we convey that message to the staff at Primary Health Centre. ASHA, Nashik (Maharashtra)

If we (Saathiya) can’t handle their (adolescents) problem on our own then we contact an ASHA worker or Sarpanch (village head); if it is some health-related problem then we contact the AFHC/Umang Clinic (Kishor Swasthya Paramarsh Kendra) in District Hospital. Male Saathiya, 17 years, Damoh (Madhya Pradesh)

Supported national health programmes and campaigns

During the pandemic, when healthcare workers were facing immense pressure, PEs extended support to ASHAs and ANMs in accomplishing their role. PEs played a significant role in the implementation of national health programmes and campaigns in the community like the Maternal and Child Health Programme,⁵ Anaemia Mukt Bharat,²⁰ pulse polio campaign,²¹ deworming day campaign²² and discussed the importance of these programmes with the community members. For instance, an NGO representative from Panna (Madhya Pradesh) reported that: ‘Whatever health programmes are there, including the government programmes, the PEs supported these programmes at the village level and they motivated the people so that these programmes can reach out to the people and they too get connected with these programmes’.

One of the PE from Nashik (Maharashtra) also shared his support to the community health workers (ASHA Worker) in distributing the Iron–Folic Acid and albendazole tablets every Monday and I helped her in distribution of these tablets’.

PE from Maharashtra also shared their role in supporting ASHAs in Maharashtra by pasting stickers as part of the ‘My Family, My Responsibility’ initiative aimed at tracing and treating COVID-19.²³ The campaign aimed to survey and screen households to detect patients with COVID-19 and those with other pre-existing conditions (diabetes, cancer and hypertension) to break the chain of transmission ‘As part of the My Village, My Responsibility campaign, we helped ASHA to put stickers outside the houses in the whole village. On that sticker, we write the number of family members, with their age, and if anyone has any comorbidities like diabetes and if any member has a fever’.

Discussion

The uniqueness of our study lies in the fact that the PEs of the RKSK played roles during the COVID-19 pandemic that surpassed their originally defined roles and responsibilities within RKSK. To the best of our knowledge, this is the first study in the region to document the role of PEs in numerous initiatives during the COVID-19 response using rigorous scientific methodology.

The major CABs, including hand hygiene, physical distancing, use of face masks and avoiding greetings through physical contact, were promoted during this pandemic.²⁴ Our study findings highlighted that the PEs wholeheartedly embraced this mission and sensitised the members of their community resulting in tangible impacts such as improved adherence to recommended practices. The existing literature highlights the success of peer education programmes implemented during COVID-19 in generating awareness²⁵ and promoting adherence to CAB.²⁶ To the best of our knowledge, none of the studies conducted thus far has reported unintended outcomes stemming from a national programme like the one performed by PEs under RKSK (India’s National Adolescent Health Programme). The role undertaken by PEs during the COVID-19 pandemic was not originally intended or anticipated making it a unique and unprecedented contribution that has not been previously documented in the existing literature.

Our study findings highlighted that PEs strongly resonated with the quote ‘Periods don’t stop during a pandemic’.²⁷ They stepped up during this crisis period and provided menstrual hygiene products to girls and contributed to maintaining menstrual hygiene practices. ASHA workers and NGO trainer mentor adopted an innovative approach by creating dedicated WhatsApp groups to facilitate communication with these PEs. Through this channel, the prime objective was to sensitise PEs about CABs apart from RKSK themes. This constant communication proved to be a catalyst inspiring PEs to actively support health workers in various tasks. This underscores the significant role that digital platforms like WhatsApp can play in promoting community engagement and mobilisation for public health initiatives. Conducting in-depth research allow us to gain a more nuanced understanding of the role of digital communication platforms in public health efforts. This enables us to refine strategies, address potential limitations and maximise the positive impact on community engagement.

PEs acted as the first point of contact for resolving adolescents’ health-related queries and also acted as a bridge to the health system exemplifying the success of the RKSK. Literature also reiterates that PEs or peer facilitators have a better ability to communicate with adolescents than older adults and they are perceived as more credible sources of information.^{28 29}

The findings highlighted that vaccine hesitancy, a global concern, was effectively addressed by PEs through various innovative strategies such as awareness campaigns, role plays, wall paintings, folk songs, traditional gestures and slogans for community members and adolescents. The traditional gesture, that is, invitation by offering yellow rice, wall painting, street shows and slogans was done by PEs in the other 13 districts of Madhya Pradesh to overcome vaccine hesitancy. The significance of these initiatives was acknowledged by government officials as highlighted in a scientific publication.³⁰

In our study state, PEs gave high priority to the vaccination campaign and enthusiastically engaged by being among the first to receive the vaccine during the early phases of adolescent vaccination. This not only set an example but also led to an increase in vaccination uptake within their age group highlighting the PEs fostered changes in community behaviour. This likely stemmed from the rapport building by PEs and the trust built by respecting their community’s cultural context.³¹ Investing in the continuous development and mastery of PEs' skills is pivotal. It not only fortifies their ability to engage with the community but also strengthens their capacity to navigate and bridge the gap between adolescents and the health infrastructure. This strategic approach holds the potential to yield enduring positive changes in adolescent health outcomes and reinforces the vital role of PEs in the success of national health programmes like RKSK.

Overall study findings emphasised that PEs affiliated with RKSK stepped up during this grim time to contribute to the well-being of the adolescents and the community as a whole. Despite lacking formal training in handling COVID-19 response activities, they still exhibited effective communication and leadership skills. PEs likely acquired these skills through peer education programme activities like 6-day PE training, monthly Adolescent Friendly Club Meetings and continuous engagement with the health and community workers. The situational analysis conducted by the authors of the i-Saathiya study also highlighted that health workers stayed connected to PEs through WhatsApp and phone and disseminated knowledge related to COVID-19-appropriate behaviours apart from RKSK themes.¹² Furthermore, amidst the lockdown period, the PEs demonstrated their connectedness and support by actively engaging with both their fellow PEs and group members through phone calls and WhatsApp offering support whenever required.

Going forward, introducing a system of rewards and encouragement for PEs of RKSK. They may be encouraged through possibilities for public recognition, awards, skill enhancement (computer course) and rewards; social and recreational activities; exchange opportunities and programmes (travel); educational credits, and, as necessary, promotion within the programme. An example of this is the Family Planning Programme by the Ministry of Health Zanzibar³² which provides bicycles and other equipment to PEs to support their work as community-based distributors. As an incentive, they are permitted to rent out the equipment when it is not in use to supplement their income. In Kenya, another PE initiative called Y-PEER³³ has created annual awards to promote and honour them. Moreover, it is imperative to establish effective mechanisms to ensure continuous monitoring, evaluation and knowledge acquisition from the experiences of PEs. Regular assessments of the interventions’ impact should be conducted to identify potential areas for improvement. Furthermore, integrating the valuable inputs furnished by PEs into the development and refinement of adolescent health programmes and policies holds paramount importance. To maximise the performance of PEs, a support mechanism should be implemented to provide them with the necessary knowledge and skills required for success in their roles.

One notable strength of our study was the engagement of numerous stakeholders comprising both programme implementers and beneficiaries in understanding the role of PEs in the context of the COVID-19 pandemic. This approach enabled the gathering of diverse perspectives on the subject matter. This is a novel study that focuses on a relatively unexplored area, the role of PEs beyond their programme role (ie, role in the RKSK) and their role in mitigating the impact of COVID-19 in India and their support to other national health programmes. Despite the substantial findings in this work, a few study limitations must be taken into consideration. First, there can be reporting bias on the side of the participants due to their varied levels of involvement in the implementation of the programme. Second, there may also be self-reporting bias as they relied on self-reported data from implementers of the RKSK which may be subject to social desirability effects. Finally, as the study relied primarily on qualitative data, it may be less generalisable and the findings were not stratified based on state, district, gender, etc, potentially leading to variations in perspectives.

Conclusion

The study’s finding emphasised the significant role of PEs in the COVID-19 pandemic response even in the absence of formal training and preparedness for the specific context (COVID-19). To sustain and further enhance their motivation and keep the momentum of good work ongoing, it is vital to enhance their visibility and acknowledgement for their diverse roles through awards, incentives, skill-based courses, providing additional support through booster training and supportive supervision. Additionally, their ability to act responsibly and support frontline health workers underscores the potential of further honing their skills.

Data availability statement

Data are available upon reasonable request.