Table 1.

Results from application of three-stage methods for development and testing of SEHER intervention.

Stage	Objectives	Outcomes
Evidence synthesis	Identify evidence on effective school-based health promotion interventions	School-based health promotion interventions have produced small to moderate effect sizes on range of adolescent health outcomes including: physical activity; tobacco, alcohol and drug use; bullying; sexual risk behaviours; and mental health Multi-component and whole-school interventions, delivered within a supportive school environment, show more potential for health promotion than only classroom-based curricula Provision of a Health Promotion Coordinator has been found to increase social connectedness, reduce health risks, and increase physical activity among students A school-based steering committee is essential for planning and designing health policies and activities
(2) Formative research
2A. Intervention development workshops	Develop a conceptual framework of the intervention Identify the intermediary and long-term outcomes Identify the specific components of the interventions Identify the selection, training, and supervision requirements of the delivery agents	Content of the intervention Focus of the intervention on building ‘school climate’ as the primary intermediary outcome Identified following long-term outcomes: reduction in substance use, sexual risk behaviours, bullying and violence, and depressive symptoms Identified four priority areas or foci for action: (i) promoting social skills among adolescents, (ii) engaging the school community in the school-level decision making processes, (iii) providing access to factual knowledge to the school community, and (iv) enhancing problem-solving skills among adolescents Intervention activities organized at three levels: whole-school, group, and individual Avoid duplication of existing intervention elements, and thus drop classroom-based life skills sessions (already being delivered by the TARANG programme in the study context) Added peer groups to intervention component to strengthen school-belongingness among students Selection, training and supervision of the delivery agents Two human resources identified for the role of health promotion coordinator: a new, low-cost human resource (the lay counsellor) and an existing human resource (a teacher) Selection criteria for lay counsellors: to be members of the local community, ≥21 years of age, have completed at least high school education, and have no professional health training Selection criteria for teachers: have a ≥5 years’ experience of teaching in secondary schools, have ≥12 years of service remaining, not teaching TARANG curriculum, and willing to undergo a weeklong residential training Six-day training curriculum to train lay counsellors and teachers; supplemented by monthly group meetings for lay counsellors and teachers Separate training and monthly group meetings to avoid contamination A combination of two planned and one unplanned supervisory school visits per month to each intervention school
2B. Content analysis of intervention manuals of adolescent health promotion	Identify evidence-based practices to implement the specific components laid out in the conceptual framework, and draft the standard operating protocols for each component	Adapted and defined standard operating guidelines for intervention components based on evidence-based practices to local context
(3) Pilot testing	Evaluate the acceptability and feasibility of the intervention, and identify the gaps and improvements needed	Acceptability Intervention activities were well accepted in most schools Perceived as meeting important needs of students Acceptance of both types of delivery agents One school dropped out as the school management perceived the reproductive and sexual health-related content inappropriate Feasibility High coverage of whole-school activities in both arms; higher intervention coverage in the lay counsellor arm relative to the teacher delivery arm Key facilitators: participatory nature of intervention activities, availability of platforms to raise students’ concerns, redressal of students’ complaints or problems while maintaining confidentiality, engagement and support of the headmaster, and involvement of other teachers in intervention activities Key barriers: lack of engagement of teachers in intervention activities, lack of male students’ participation, fall in students’ attendance in last months of the school year (after January), and non-availability of teachers during ‘unplanned’ supervisory visit due to their competing teaching responsibilities Strategies employed to address barriers Added teachers’ monthly meeting as a component to improve teachers’ engagement in intervention activities Added monthly intra-school competitions to increase boys’ participation Focus on completing all core intervention components between June and January Monthly unplanned supervisory visit per month changed to a planned visit to lend more support to teachers and lay counsellors