A systematic review of the evidence on peer education programmes for promoting the sexual and reproductive health of young people in India

Abstract In the context of a growing adolescent population globally, it is imperative to understand which interventions will most effectively advance their sexual and reproductive health (SRH). In India and globally, peer education is often utilised as an intervention for promoting the SRH of young people. Globally, the evidence of its effectiveness is mixed. A systematic review of the literature from the Indian context gave insight into the knowledge, attitudinal, and behavioural (KAB) outcomes affected by peer education, as well as the inputs, coverage, content, and context of such interventions. Out of the over 1500 publications initially identified through the database and bibliographic searches, 13 were included in the review; no quality assessment was done, given the dearth of publications matching the inclusion criteria. Analysis of the included publications highlights the multiple ways that peer education is implemented in the Indian context, as part of multi-component programmes and as a stand-alone intervention. The KAB outcomes from these initiatives are mixed, with some multi-component and some stand-alone initiatives affecting statistically significant outcomes and others not–a finding consistent with global literature reviewed for this paper. Despite the mixed results and the limited effects of behaviour relative to knowledge, this paper proposes that peer education has a place in an overall response to improving the SRH of young people. It calls for better research on peer education in India, and for research in relation to the optimal conditions for peer education to succeed in affecting KAB and other outcomes.


Introduction
Young people's sexual and reproductive health (SRH) is recognised as a crucial component for progress toward global development outcomes related to education, poverty reduction and gender equality, amongst others. 1,2 Given that young people constitute nearly one-fourth of the world's total population, a focus on this age group is both imperative and inevitable, particularly for India, the country with the largest share of adolescents in the world. 3 Peer education is not a new programmatic intervention for SRH. The simplicity and commonsensical nature of its rationale-that young people can more easily reach their peers with education and can discuss sensitive issues with them more easily than adults can-may be behind its prolific use in SRH programming. To place this India-focused systematic review in the context of the wider literature, we appraised the global literature, identifying reviews on the effectiveness of interventions aimed at preventing SRH problems and the behaviours amongst adolescents and young people that contribute to them. Despite the use of peer education globally, the evidence of its contribution to bringing about 129 Methods Search strategy Following standard systematic review methodology, the research team developed a protocol to comprehensively collect and analyse evidence related to the research questions. 38 As a first step, an expert advisory group was convened to help define key terms for the research (Box 1). [39][40][41] Members of the group included individuals with experience in research and programme implementation on young people's SRH in India and those with existing relationships with SRH non-governmental organisations (NGOs).
The search strategy aimed to identify studies and evaluations of initiatives in India that included a component of SRH peer education for young people. Relevant peer-reviewed articles and grey literature (hereinafter referred to collectively as "publications") were identified using three methods: PubMed and POPLINE database searches; bibliographic reviews; and targeted outreach to organisations. PubMed searches were conducted using the medical subject heading (MeSH) terms "sexual and reproductive health and rights", "peer education program", and "young people". The POPLINE search was done using the main topics and subtopics of this review, along with the key search terms (Box 2). The bibliographies of select articles were then reviewed to identify further publications. The list of relevant organisations to target with outreach was developed in consultation with the expert advisory group and included both youth-and adult-led national and international NGOs and donor agencies.

Inclusion criteria
The research team included publications only if they adhered to all of the following criteria: were studies and evaluations of interventions that took place in India; were published on or after 1 January 2000 and on or before 31 December 2016; the research was initiated on or after 1 January 2000; the intervention included a stand-alone or integrated peer education component focusing on the promotion of young people's SRH; the target group was young people aged 10-24; measurements on changes in knowledge, attitudes, and/or behaviours were reported; were published in English.

Exclusion criteria
The research team excluded publications that were: secondary analyses of existing data sets for the purpose of presenting integrative outcomes from different research studies or programmes; discussions of literature included in contributions to theory building or critique; summaries of the literature for the purpose of information or commentary; editorial discussions that argue the case for a field of research or course of actions

Data analysis
In order to facilitate the data analysis, the research team developed a logic model (Figure 1) which, in turn, formed the basis for the review tables (Appendix A). We used the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for reporting findings. 38 The tabled information includes: geographical location of the study or evaluation; year of completion; name of implementing organisation; objectives of the study or evaluation; implementation (intervention package, target group, and human resources); results (outputs and outcomes); and limitations. Data entered in the review tables (Appendix A) were discussed with all authors to reach a consensus on characteristics and main findings of each publications.
Consistencies and divergences of findings across publications, methodological limitations of existing research, and knowledge and evidence gaps were identified as part of the review and synthesis. However, given the dearth of publications that fit the inclusion criteria and were accessible to the research team, the decision was made not to assess and exclude publications on the basis of quality, as it would have further limited the evidence base. The preliminary findings of the review were discussed and refined in consultation with the expert advisory group.

Findings
Using the above-mentioned search strategy, the team identified 1545 publications, including 38 from the grey literature ( Figure 2). As a first step, the titles of all publications were screened by two authors, resulting in the exclusion of 1183 that did not meet the inclusion criteria; another 90 duplicates were also removed. As a second step, the abstracts of the remaining 272 publications were screened by the same two authors and categorised into three groups: (1) those that met the inclusion criteria (Y); (2) those for which it was unclear whether or not they met the inclusion criteria (M); and (3) those that did not meet the inclusion criteria (N). Any difference of opinion between the authors was resolved through discussion and consultation. As a third step, the 75 falling into categories Y and M were retrieved and reviewed in full by the two authors, as a result of which 62 were excluded for the following reasons: full text not available (n = 12) or not provided by the concerned organisation (n = 2); research initiated before the year 2000 (n = 6); no peer education based intervention or programme (n = 32); not research studies or evaluation reports (n = 9); or not meeting the age criteria (n = 1). Of the 13 publications in the final list, 9 are peer-  (Table 1). As our inclusion criteria include interventions initiated in the year 2000, it is likely that the publications included in this final list are skewed away from the first few years of the review period. Characteristics and main findings of these publications (labelled with letters A-M) 42-54 are found in Appendix A.
The work described in the publications (hereinafter referred to as "initiatives") was geographically distributed across India: two initiatives each in Jharkhand, Uttar Pradesh, and West Bengal and one each in Bihar, Chandigarh, Goa, and Maharashtra. Two studies reported on initiatives in multiple (two) states-Uttar Pradesh and Delhi National Capital Region (NCR) and Maharashtra and Uttar Pradesh, respectively. One study was a pan-India evaluation. Five initiatives were published before 2008, while eight were published between 2008 and 2016.

Figure 2. Literature search process and results
Non-governmental organisations (NGOs) carried out 10 of the 13 initiatives. Amongst those, six (A, D-F, H, M) were carried out by indigenous NGOs, one (C) by the Indian chapter of an international NGO, two (I, K) as collaborations between international and indigenous NGOs, and one (G) as a collaboration between the international and Indian chapters of an international NGO. Two initiatives were carried out by academic institutions (B, L), whilst the remaining initiative (J) was carried out by indigenous NGOs in partnership with an academic institution.
The included initiatives fell into three categories: quasi-experimental evaluations (n = 8), descriptive studies (n = 4), and a randomised controlled trial (n = 1) (Supplementary Box S1). The most commonly utilised methodologies were cross-sectional and longitudinal analyses. In six of the eight quasi-experimental evaluations, baseline, and endline analyses comparing intervention and control groups were conducted (A-C, G, J, K); the remaining two utilised such comparisons without a control group (E, M). Most quasi-experimental evaluations utilised quantitative measures (A-C, E, G, J, M), although one (K) utilised mixed-methods. The descriptive studies employed quantitative (n = 1) (D), qualitative (n = 1) (H), and mixed-method (n = 2) approaches (F, L). Qualitative studies used indepth interviews and focus group discussions with beneficiaries and/or key stakeholders such as frontline health workers, programme implementers, government functionaries, family members and community members. All the initiatives had clearly defined objectives. Nine of the 13 initiatives assessed changes in knowledge, attitudes and perceptions regarding SRH (A-G, J-K), whilst five of them assessed changes in knowledge or utilisation of SRH services (D-F, L-M). Seven assessed changes in attitudes such as gender-equitable attitudes; in perceptions such as emotional health, wellbeing, and improvements in self-confidence and leadership skills; and/or in behavioural outcomes relating to condom and contraception usage, self-reported violence, and substance use (tobacco, cigarettes, or alcohol) (A, G, I, K-M).

Implementation
Across the 13 studies, the implementation of peer education interventions varied widely. The following variables affecting implementation were considered by this review, including: (1) the SRH content of the information provided by peer educators; (2) the wider initiative within which peer education was included; (3) the modes of delivery; (4) the target population groups; and (5) the human resources used to implement the project. These variables are considered in turn below.
Firstly, whilst the exact content of the SRH information provided by peer educators was difficult to determine, the analysis indicates varying degrees of comprehensiveness. This variation in content and delivery of the initiatives and the changes in knowledge and attitudes towards SRH are not comparable. For most initiatives, it is apparent that peer educators provided general reproductive health information, though this was not defined clearly or consistently. Sexual and reproductive health topics common to many of the initiatives were: menstruation, puberty, contraception, sexually transmitted infections (STIs), including HIV, and pregnancy. Less commonly, the peer educators provided information on birth spacing, laws relating to child marriage and/or abortion, relationships, violence, sexuality, and gender. In most initiatives, peer education expanded beyond SRH to include other public health and development topics too. The most common additional topic covered was nutrition, whilst livelihoods, savings formation, substance use, sports, and adolescent health (general) were addressed by a few initiatives.
Secondly, more often than not, peer education was one amongst several interventions aimed at achieving programmatic objectives related to young people's knowledge, attitudes, and behaviours. Out of the 13 initiatives included in this review, two reported the use of peer education as a stand-alone intervention, whilst 11 reported it as one intervention amongst two or more. Each multi-component programme used a combination of interventions in addition to peer education. Some of the additional components were directed at frontline workers, including teacher training (n = 1) and capacity-building for health workers (n = 2), whilst those directed at adolescents included: delivery of educational sessions in schools by teachers or public health nurses (n = 2); livelihoods and/or vocational training (n = 4); savings formation (n = 2); communication skills training (n = 1); community outreach and sensitisation (n = 3); service delivery (n = 1); and sports coaching (n = 1).
Thirdly, between the initiatives, there was great variety in the settings, materials, and delivery modes. The majority were delivered in out-ofschool settings in places close to where young people live or congregate, such as community centres, anganwadi centres (type of rural child care centre), and homes of peer educators who work or live in slums. In two initiatives, peer educators were operating in school settings. Whilst most initiatives did not elaborate on the content or format of the materials available for peer educators, one publication mentions the use of a flip book with relevant case studies, whilst others mention training curricula or modules. In relation to delivery modes, in nine initiatives peer educators gave group informational sessions, rather than speaking to young people one-on-one, which was the modality reported in the four remaining publications.
Fourthly, whilst all the initiatives used peer education to reach young people, specific cohorts were targeted through each. The most common group targeted were adolescent girls in the 10-19 age bracket, or a subset thereof. Only two initiatives targeted young men specifically, and one targeted married couples. Most of the initiatives addressed young people younger than 20 years, although four included young people older than this and, in one case, up to 29 years of age. The target groups included a mixture of in-school and outof-school young people, as well as urban and rural residents. Several of the studies made reference to targeting poor, low-income or slum areas.
Lastly, in addition to peer educators, in multicomponent initiatives other cadres of workers were involved in delivering information or complementary interventions. Some initiatives built upon existing parts of the health, community development or education systems in India (e.g. community health workers, anganwadi workers, SABLA Scheme workers, teachers, child development officers) for implementation, whilst others drew upon staff members within non-governmental agencies. Implementing agencies also drew upon their own staff members, in addition to consultants, researchers, and local NGOs, for delivery.

Coverage and quality
Coverage of these interventions was assessed based on the number of people within the target population reached by the peer educators. In 11 initiatives, peer educators reached out to young people who were a part of the intervention, whereas the remaining two initiatives had no information on coverage (C, H). Amongst the 11 initiatives that mentioned coverage, four did not specify the denominator population (D, E, J, M). The scale of these initiatives varied considerably, with the number of young people reached by peer educators ranging from 84 to 4,811,264.
None of the initiatives reported on the quality of the content or delivery of peer education. Five initiatives did conduct process monitoring (A, E, F, H, L). In one of these initiatives, on-site supervision was done along with weekly review meetings to assess intervention delivery quality (A), whereas two further initiatives developed a monitoring mechanism involving multiple stakeholders to ensure effective implementation (F, L).

Changes in knowledge
Whilst 11 publications-including both multi-component and stand-alone peer education initiatives-reported increases in knowledge, just nine reported increases in SRH knowledge. These increases in SRH knowledge related to pubertal changes, menstrual hygiene, reproductive tract infections, STIs, and HIV; the existence of SRH services, including those for adolescents; and SRH practices such as contraceptive use (A-G, J, M). An initiative implemented by the Centre for Catalysing Change (C3) that carried out peer education for married couples in Jharkhand (M) reported significant increases in knowledge between baseline and endline surveys in relation to a variety of different topics, including knowledge of family planning methods (contraceptive pills: 20% to 91%; condoms: 39% to 97%); awareness of pregnancy detection kits (28% to 86%) and their use (20% to 56%); awareness of complications in pregnancy and childbirth often leading to maternal death as a consequence of early pregnancy (wives: 67% to 87%; husbands: 74% to 96%); and awareness of the benefits provided by the Government of India in case of institutional delivery (e.g. free transport to and from the health facility: wives 21% to 100% and husbands 36% to 97%). The Yuva Mitr initiative, implemented by indigenous NGO Sangath, demonstrated that young people reached by peer educators had higher levels of knowledge of and more favourable attitudes toward SRH [OR = 1.55, 95% CI: 1.06-2.28 (rural community) and OR = 1.46, 95% CI: 1.09-1.97 (urban community)] in comparison to young people reached by teachers (A).
One of the two stand-alone peer education initiatives reported change in SRH knowledge (J). This initiative assessed changes in HIV and AIDS knowledge and found that young people who received the intervention had higher knowledge scores (p ≤ 0.001). Additionally, young girls scored significantly higher on HIV and AIDS knowledge in comparison to young boys (p < 0.05).

Changes in attitudes
Only four of the 13 initiatives measured changes in SRH attitudes or beliefs (A, J, K, M). Among these, two were stand-alone (J, K) and two were multicomponent (A, M) initiatives. The STEP initiative (J) reported that young people reached by peer educators had significant increases in positive attitudes toward consistent condom use (p < 0.001) and positive beliefs towards people living with HIV (p < 0.001). The Yaari-Dosti initiative, which targeted young men aged 15-29, also reported more positive attitudes towards people living with HIV (p < 0.05) (K). Favourable attitudes were reported by the C3 married couple initiative, which reported changes amongst both young women (46% to 93%) and their husbands (51% to 92%) in relation to attitudes toward visiting a health facility for symptoms of reproductive tract infections (M).
Overall, the two stand-alone (J, K) and one multicomponent (A) initiatives reported statistically significant positive changes in attitudes among young people who received the interventions. One other multicomponent intervention (M) reported positive changes in attitudes; however, the initiative did not provide information on whether those changes were statistically significant.

Changes in behaviours
Seven of the 13 initiatives (A, F-I, K, M) reported changes in behavioural outcomes; however, only four of these initiatives reported changes in SRHrelated behaviours-one stand-alone peer education initiative (K) and three multicomponent initiatives (A, F, M). The outcomes reported by the initiatives included increases in reporting sexual health problems or menstrual problems for young women (A, F, K); help seeking from health care providers (A, M); and visiting adolescent-friendly health services for SRH (M). The Yaari-Dosti initiative reported several other behavioural changes, including improvements in communication with one's partner on condoms, sex, STIs, and/or HIV (p < 0.05); increased condom use (p < 0.05); and positive trends on the Gender-Equitable Men scale scores associated with a decrease in HIV/STI risk behaviours among the young men reached by peer educators (K). Amongst these initiatives, only the stand-alone peer education intervention reported statistically significant changes in behavioural outcomes among young people (K). None of the three multicomponent initiatives reported statistically significant changes in behaviours (A, F, M).

Other changes
In addition to changes in SRH knowledge, attitudes, and behaviours, some initiatives reported knowledge, attitudinal, and behavioural changes in relation to other areas, including gender-based violence, child marriage, livelihood, and savings formation, nutrition, substance use, community sensitisation, and advocacy.

Knowledge
Six of the 13 initiatives reported changes in knowledge on non-SRH-related issues such as nutrition, substance use, emotional health, and gender equity (A, E, F, H, I, L). Four of these initiatives reported increases in knowledge about nutrition, anaemia and/or intake of iron-rich foods and folic acid tablets for young women (E, F, H, L). For example, one initiative reported young people reached by the National Adolescent Health Programme (Rashtriya Kishor Swasthya Karyakram) in one of the districts had increased knowledge of iron-rich foods (97% vs. 76%); were more likely to have heard of anaemia (89% vs. 48%); received information on nutrition (79% vs. 24%) and were aware of their own weight (75% vs. 62%) compared to those not reached by the national programme (F).
Three of these six initiatives reported increased awareness of the right to education, life skills education, legal age of marriage, and/or various legal and other options for women who experience marital violence (E, F, I). One initiative reported increased knowledge between baseline and endline surveys of the legal age of marriage for girls (30% to 96.5%) and boys (26% to 77%) (E). Another reported higher levels of awareness among young people on their right to education, equal rights between boys and girls and available child protection services (F).

Attitudes
Other than those noted above, the most common attitudinal change affected by the initiatives was in relation to gender equality; three of the 13 initiatives-including one stand-alone peer education initiative (K)-reported statistically significant changes towards egalitarian gender role attitudes and, at the same time, less support for inequitable norms (C, I, K). The Do Kadam Barabari Ke initiative (I), for example, reported that young men reached by peer educators expressed more egalitarian attitudes and notions of masculinity (p = 0.04), rejected men's or boys' right to exercise controlling behaviours over women or girls (p = 0.003), and rejected men's or boys' right to perpetrate violence on a woman or girl (p = 0.002). Moreover, the young men believed their peers would respect them for demonstrating non-traditional behaviours in at least three of the following four situations: respected by friends if a boy talks about his problems with his friends or peers; helps his mother do her housework; walks away from a fight; and refuses to physically abuse his wife even if she disobeys him (p = 0.04) (I).

Behaviours
Four of the 13 initiatives reported changes in non-SRH behaviours (A, C, G, L), all of which were multicomponent initiatives. Three of these initiatives reported increases in autonomy amongst young women, which was demonstrated by improvements in vocational skills and livelihood activities, work aspirations, physical mobility within the community and/or communication skills (C, G, L). One initiative reported a decrease in the perpetration of physical violence among young people reached by the intervention (A).

Discussion
This paper sets out to answer a set of interrelated research questions regarding the use and effectiveness of peer education in achieving sexual and reproductive health knowledge, attitudinal, and behavioural outcomes in India. Although the quantity and quality of the evidence are limiting, this review has been able to highlight important trends and define a framework for future research.
In relation to the first three additional research questions, this review found that the way in which peer education has been utilised varies greatly in terms of content, delivery, and context in India.
There is no standardised model of peer education, and the majority of initiatives combine it with other interventions such as health service delivery, sports coaching or vocational training for young people. The next two additional research questions on coverage and quality were difficult to assess given the dearth of data. Whilst numbers of young people reached through peer education were available for 11 publications-and noteworthy in several-four were missing denominators. Further, the quality of peer education was not assessed systematically in any of the initiatives.
In relation to the changes affected by the initiatives, success varied in terms of impact on SRH knowledge, attitudinal, and behavioural outcomes. In relation to SRH knowledge, nine of the 13 initiatives reported increases, with four of these reporting statistically significant results (A, B, G, J). Of the nine, eight were multi-component initiatives (A-G, M), and one was a stand-alone peer education initiative (J). Changes in SRH attitudes were reported by just four initiatives; two of these were multi-component (A, M) and two were stand-alone (J, K). The two stand-alone (J, K) initiatives and one multicomponent (A) initiative reported statistically significant attitudinal change. Lastly, SRH behavioural outcomes were reported by four initiatives (A, F, K, M), one of which was a stand-alone peer education intervention (K). Only the stand-alone peer education intervention reported statistically significant changes in behavioural outcomes amongst young people (K). Changes in non-SRH knowledge, attitudes, and behaviours were also reported in many publications, and notably so in relation to knowledge of nutrition and changes in gender-equitable attitudes. Overall, changes in the desired direction in relation to knowledge, attitudes, and behaviours occurred in some multicomponent and standalone interventions, but not in others.
To place the findings of our India review in perspective, we utilised our global review of reviews (Table 2). These reviews were published between 2001 and 2014 4-13 and had been cited in two state-of-the-art reviews. 14,15 They included published reports of research studies and evaluations carried out in high-, 16-27 middle-and low-income countries. 28-37 Twenty-two initiatives-10 of which were from low-and middle-income countries-provided information on the effect of peer education interventions when delivered as stand-alone interventions. Changes in knowledge, attitudes, and behaviour as a result of stand-alone peer education are mixed (Table 3). Of those initiatives reporting changes, positive results in knowledge were seen in nine of 15 initiatives (60%); in relation to attitudes, positive change was seen in six of 11 initiatives (54.5%); and in relation to behaviour, in six of the 14 initiatives (37.5%). In other words, the global review illustrates that peer education has been shown to be more effective in improving knowledge and attitudes than in promoting healthier behaviours in some initiatives, but not in others, a finding that is consistent with the India review. In the India review, whilst peer education was part of a number of multi-component initiatives in which positive changes were reported, it was also part of initiatives in which such changes were not reported. However, it is worth noting that peer-educationonly initiatives from India did report statistically significant results in relation to knowledge (J), attitudes (J, K), and behaviours (J, K).
Our review of Indian peer-education initiatives did not directly address the optimal conditions for the success of peer education. On the other hand, three other systematic reviews examined what it takes to ensure that peer education programs are effective-Tolli et al.  n/a n/a n/a Gao 35 + n/a n/a Kinsler 36 n/a + + Ozcebe 37 + n/a n/a Abbreviations: +, positive change; -, no change or no statistically significant change; /, mixed impact; n/a, not researched/reported on the optimal conditions for success for peer education is needed to provide solid evidence for designing effective programs in India and across the globe. Another pertinent research question emerging from both India and global reviews is whether the fields of global health and human rights are measuring the "right" things in relation to peer education. To date, evaluations and research of peer education have judged its effectiveness primarily on changes in knowledge, attitudes, behaviours, and, in some cases, health outcomes. Whilst these measurements are not without value, it is important to further explore the potential of peer education to contribute to a range of desirable health and rights outcomes, including young people's awareness of their rights to access information and services; legitimation of dialogue on previously-taboo SRH issues; young people's awareness of where and how to seek help and their confidence in doing so; improvement in communication between peers, as well as between parents and young people; and enhancement of social networks.

Conclusion
Peer education has been employed in India and around the world in a variety of ways to bring about changes in the SRH knowledge, attitudes and behaviours of adolescents and young people. While the published literature on this in the Indian context is uneven in quality, there are clear indications that it has contributed to improvements in these areas in some-but not all-initiatives. Now is not the moment to give up on peer education, but, rather, to better understand the role it could play within public health and human rights initiatives. Taking the next step forward in programming for adolescents and young people in India and globally will require dialogue regarding which outcomes peer education programmes could reasonably be expected to contribute to and the conditions under which they can be achieved.

Acknowledgments
Venkatraman Chandra-Mouli conceived the paper. Suneeta Krishnan, Mariam Siddiqui and Ishu Kataria prepared the first draft. Venkatraman Chandra-Mouli provided feedback; Mariam Siddiqui and Ishu Kataria worked with him to prepare the second draft. Suneeta Krishnan dropped out of the process. Venkatraman Chandra-Mouli then worked with Mariam Siddiqui, Ishu Kataria and Katherine Watson to prepare the final draft. All authors reviewed and approved the final draft.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
The preparation of this review was funded by WHO's Department of Reproductive Health and Research/ Human Reproduction Programme with funds provided by the David and Lucile Packard Foundation.

Supplementary material
Supplementary material for this article can be accessed at https://doi.org/10.1080/26410397. 2020.1741494

Table A1. Characteristics and main findings of research studies and evaluation reports
Location: This is the state/territory in India in which the study or evaluation was conducted.
Year: This is the year that the study or evaluation was completed. Organisation name and type: In this column, the name of the implementing and supporting organisations are included alongside a description of the type of organisation (e.g. indigenous NGO, international NGO, academic institution). Objectives: The objectives are copied directly from the studies themselves, without making changes to the wording.
Design: This column provides information on the type of research study or evaluation used, giving an indication of the authors' methodology. Implementation: This column provides information on the inputs and process of the study or evaluation. The 'process' cell provides a description of the content, delivery and context relevant to the study.
Results: This column is divided into outputs (coverage, quality) and outcomes (knowledge, attitudes, practices). Coverage relates to the # of people within the target population reached. Quality relates to assessments done of the peer education (content or delivery). Where available, findings related to all 3 outcomes areas (and any additional ones) are presented with relevant statistics. Limitations: The limitations are taken directly from the studies and are, thus, the limitations and gaps identified by the authors themselves. Limitations relate both to the design of study and the project implementation.

ID (ref)
Location teacher-student relationships; detection and management of common problems faced by youth in school settings; and counselling skills.
In the urban community of Margao, four wards were randomly selected as the intervention community, and the remaining six were the comparison community. In the rural community, the largest village, Barcem, was randomly chosen as the intervention community and the remaining three were the comparison community. The three peer educators delivered the intervention with support from the Community Advisory Board (CAB), which is comprised of key people such as village council leaders in the rural community, and with support from trained teachers in the urban community. The duration of the intervention was 12 months. Effectiveness was assessed through a survey at baseline and a follow-up survey 18 months later. Outcomes were measured using a structured interview questionnaire with all eligible youth.

Process
The reproductive health training sessions were conducted using a set of five specially designed flipbooks in Hindi that related to the experiences of a 12-year-old girl. The flipbooks covered the following topics: physiological and behavioural changes during puberty; menstruation; pregnancy and birth; age at marriage and birth spacing; and family planning, including husbands' roles. The AGGs were responsible for forming groups of peers from their communities and for conducting reproductive health sessions, which were held at their own residences.
Each flipbook was completed in 1-2 hours, depending on the girls' participation. In addition to reproductive health information,

Outputs
Coverage: Information on coverage was not mentioned.
Quality assessment: No results of quality assessment were reported. Outcomes Increase in adolescent girls' knowledge of reproductive health between baseline and follow-up surveys, including: . being able to correctly name one or more contraceptive methods (89% to 97%), . being able to name an STI (67% to 94%), . being able to correctly answer a question about duration of pregnancy (76% to 100%), and knowing sexual contact was required to become pregnant (44% to 98%). . Out of school: Peer educators reached out to 10,000 adolescents and young people across 200 villages in 2 districts; no information on the denominator was provided . In school: Peer educators reached out to 3,824 students directly who, in turn, reached out to another 123,407 indirectly across the 2 districts; no information on the denominator was provided.
Quality assessment: During the implementation CINI team members conducted process documentation, but no results were included in the report. Over the period of a year, peer leaders conducted interactive sessions, trainings and role plays as well as shared information, education and communication materials to impart knowledge about SRH adolescents in their respective localities. Each peer leader was assigned 10 adolescents and were given tracking sheets to monitor 'risky' behaviour, health practices and problems. A mix of qualitative (focus group discussions, in-depth interviews) and quantitative research (close-ended questionnaire) was used for impact assessment. The impact assessment was conducted 10 months after the implementation of the intervention.
. More than 5,585 cases referred to the Adolescent Friendly Health Clinics by peer leaders and master trainers to access counselling and condoms . Improved SRH awareness and practices among adolescents . Improvement in SRH awareness and practices, namely related to onset of menstruation; menstrual hygiene; prevention SRH related ailments; maintaining personal hygiene and eating nutritious food; and significant increase in in use of sanitary napkins . Increased reporting of SRH-related issues by adolescents, including higher reporting of menstrual problems from adolescent girls Trained peer educators conducted the STEP program over 6 weeks (single one-hour session per week for six consecutive weeks) in participating schools. Two classes in each school participated, and the school administrator randomly assigned the classes to intervention and control arms. Students in the intervention group were exposed to the STEP curriculum, while those in the control arm received no curriculum. The baseline survey was completed by 1,846 students (946 intervention and 900 control), and the endline survey was completed by 1,733 (882 intervention and 859 control). The duration between the baseline survey and endline survey was 6 weeks. Communication with partners on condoms, sex, STIs, and/or HIV significantly improved in the intervention sites. Improvements among the intervention participants in discussing key reproductive and sexual health issues (condom use, sexual relationships, STIs, and HIV/AIDS) with a female partner in the last three months (p <0.05).
There was a significant increase in condom use at last sex with all partner types in the intervention areas (p <0.05). Men in the intervention arms were 1.9 times more likely to have used condoms at last sex in Mumbai (p <0.001) and 2.8 times more likely to have used them in Gorakhpur (p <0.001) than those in the comparison arms in each setting. Report of sexual health problems during the previous three months decreased significantly in the intervention sites from baseline to follow-up (p <0.05). There was a positive trend toward improvements in GEM Scale scores being associated with decreases in HIV/STI risk behaviours (not significant). Young men in the intervention sites reported more positive attitudes toward person living with HIV (p <0.05).
relied on selfreports of participants.
from these communities that projected an alternative form of masculinity. The effectiveness of the intervention was assessed through a survey at baseline and follow-up survey approximately 6 months later. The nutrition component of the scheme was delivered by AWWs, who also supported the peer monitors (sakhis) and peer leaders (sahelis) to deliver the life skills and vocational trainings in places where adolescent girls receive information. Adolescent girls also made social connections with their peers; built confidence and morale; and received support for envisioning their futures through the scheme. The evaluation relied on a mix of quantitative and qualitative methods. It was designed to be conducted in 12 states distributed across the five regions (at least 2 from each) of the country over a two-year period. The selection of states was based on

Inputs
Intervention: Information on reproductive health practices such as family planning and accessing reproductive health services. Target population: Married adolescent couplesgirls (10-19 years) and their husbands (14-25 years) residing in Ramgarh district.
Human resources: Project personnel from C3 team and Nav Bharat Jagrity Kendra, 50 trained peer educators.

Process
The intervention was designed to increase knowledge and awareness of age of marriage, reproductive health practices, delaying first pregnancy, use of family planning methods, linkages with service providers, and access and availability of reproductive health services in the health facilities. A total of 3,038 meetings (2 meetings/fortnight/village/month) were conducted during the period with married adolescent couples in 50 target villages. The peer educators gave the scheduled sessions among the married adolescent couples with support from health facilitators, who are functionaries of the Department of Health and Department of Women and Child Development. The group meetings were organised and held separately for the wives and the husbands due to their availability. The effectiveness of the intervention was assessed through a survey at baseline and an endline survey 12 months later.