Discussing sexual and reproductive health can be awkward for most young people, but in India, there are almost no discussions at all. Young girls are expected to remain "pure" until marriage. Parents and community members discourage conversations with young people about menstruation, sex, pregnancy, and family planning. As a result, young people in India have limited access to sexual and reproductive health information and services, which makes them vulnerable to multiple health conditions with lifelong consequences: unintended pregnancy, sexually transmitted infections, maternal mortality, mental distress, and more. Girls carry a disproportionate amount of these burdens and lag behind boys in education, income, and overall health due to gender-based discrimination.

Kissa Kahani, which translates to "anecdotes and stories," is a uniquely designed, evidence-based intervention that provides information about sexual and reproductive health to Indian adolescents through storytelling, multimedia, and innovative research. Created by the Center for Interdisciplinary Inquiry and Innovation in Sexual and Reproductive Health (Ci3) at the University of Chicago in partnership with Indian design and curriculum experts and community organizations, Kissa Kahani educates adolescents ages 12 to 14 about sexual and reproductive health in schools across India. It encourages young people to discuss topics related to sexual and reproductive health, and is a distinctive approach for three main reasons:

1. Kissa Kahani shifts how sexual and reproductive health information is delivered to Indian adolescents. Combining the power of traditional curricula with animated stories, graphic novels, and games, Kissa Kahani teaches youth about menstruation, family planning, and sexual harassment. It also emphasizes the value of education and financial autonomy for Indian girls, empowering adolescents to develop skills to help them navigate and complete school, improving their long-term economic vitality.

2. Kissa Kahani addresses the unmet sexual and reproductive health needs of Indian adolescents. Early adolescence is a crucial time to lay the foundation for healthy and fulfilling sexual and reproductive lives, but few interventions are designed for young people under the age of 14. Using contextual inquiry and participatory methods, young people shared their stories, concerns, and hopes about sexual and reproductive healthcare, their hopes and aspirations, informing the design of a relevant and accessible format. Inspired by these stories, and guided by the Positive Youth Development framework, Ci3 used iterative prototyping to create an accessible format for adolescents to learn about menstruation, menstrual hygiene practices, family planning, and sexual harassment prevention. Kissa Kahani tools and curriculum were tested with more than 150 young people and 50 educators in multiple Indian government schools and in the community, and refined based on this input.

3. Kissa Kahani is designed to scale. Over the next 12 months, Kissa Kahani will be implemented in nearly 100 government schools in India, educating more than 3,000 adolescents. Using a randomized control trial method, Ci3 researchers will evaluate the intervention's effects on young people's knowledge, attitudes, and behaviors pertaining to sexual and reproductive health topics and gender norms. Future plans include disseminating Kissa Kahani to all young people enrolled in government schools with support from the Indian government.

Context

More than 125 million Indian adolescents are between ages 10-14, representing nearly 13% of the country's population. During adolescence, young people experience puberty and sexual maturation, but in India, they are forbidden from having conversations about sexual and reproductive health with anyone. Adolescents don't receive emotional and physical support from families or community members to help them navigate these changes. Additionally, adolescents lack access to medically accurate information, menstrual supplies, and health services, and often rely on information obtained from informal sources like pornography and friends which can be inaccurate.

Despite these challenges, Indian adolescents explore their sexuality. Half of young Indian women are sexually active by age 18, and almost one in five are sexually active by age 15. Few health resources are available to support these sexually active young people, and India has among the highest rates of adolescent pregnancy globally.

Adolescence is also a time of major social changes in India with the introduction of gender norms at home, in schools, and in the community. Family members can force girls to drop out of school to get married. Child marriage is a crime under Indian law. Yet, nearly 27% of Indian women are married before age 18 and 7% are married before age 15.

Schools are ideal places to provide sexual and reproductive health information to younger adolescents, but there is a lack of evidence-based sexual and reproductive health programs in India for this age group.

In 2014, the Indian government launched Rashtriya Kishor Swasthya Karyakram (RKSK), a health policy designed to help adolescents achieve their fullest potential. RKSK provides sexual and reproductive health information and services to younger adolescents in schools.

Ci3 collaborated with 314 Indian young people and 25 community-based organizations to design a unique intervention that supports the goals of RKSK and raises awareness about sexual and reproductive health among younger Indian adolescents.

Formative research

In 2016, Ci3 recruited young people in India through local health services organizations. Ci3 spent two years conducting formative research using traditional and non-traditional research methods including digital storytelling, games, body mapping, and human-centered design. Young people were encouraged to speak freely about their experiences and share stories about gender and sexual and reproductive health issues.

"Like I am doing higher studies, so my uncle, aunty and my neighbours say that you are educating your daughter so much, it will be difficult to find a good match for her. She is a girl so why are you educating her so much, in the end she has to do household chores. Don't educate her so much, she is a girl, how will you arrange so much dowry for her wedding." (Young woman, age 19)

Intervention development

In 2018, Ci3 collaborated with local Indian curriculum experts, StratComm Consulting, and design experts, Ramya Ramakrishnan Design, to respond to three themes that resonated the most with young people, including:

• Menstruation and menstrual hygiene practices,

• Increasing public safety of girls, and

• Knowledge about sexual and reproductive health and family planning.

Combining insights from the formative research with behavior change theories including the Information, Motivation, and Behavioral Skills (IMB) model; the Socio-Ecological framework; and the Positive Youth Development framework, Ci3 determined that Kissa Kahani must:

1. Educate younger adolescents in new, dynamic ways;

2. Provide clear, relatable, age-appropriate content; and

3. Address issues young people face as individuals, at school, in the community, and through policies affecting their lives.

To satisfy these criteria, we adopted a transmedia approach that relies on fictional elements, systematically dispersed across multiple delivery channels to engage adolescents.

Kissa Kahani features a world of characters in contexts that mirror the lives of younger adolescents. An overarching story weaves through different media — digital animated stories, games, and graphic novels — creating an immersive world inviting young people to step in. Each media component plays a unique, targeted role delivering tailored messages that help to convert knowledge to action.

Drawing on insights from the formative research, Ci3 made two key decisions about Kissa Kahani's curriculum structure and content. First, recognizing the need for facilitator-led engagements allowing younger adolescents to ask questions and facilitate comprehension, we built the curriculum in a traditional teacher-led format. Second, younger adolescents often lack sexual and reproductive health knowledge. We designed an age-appropriate curriculum, avoiding the use of medical jargon and incorporating terms familiar to adolescents.

Building the transmedia world

Creating an immersive experience that crosses various media required developing a compelling visual atmosphere for characters and contexts within the stories. Drawing on the interviews conducted with young people, we created characters who are relatable to younger adolescents. The characters attend a familiar school , wear recognizable uniforms, and face similar challenges in their homes and communities. Characters have diverse physical characteristics: tall and short, both fair and dark-skinned, etc. They lead normal lives, and use conversational language.

Young Kissa Kahani characters face issues of gender discrimination, societal pressures, and lack of parental support, but they move with confidence, seeking out help and information, advocating for themselves, and identifying solutions to problems. They are not afraid to ask questions to their parents and teachers. Above all, they seek accurate information.

Characters appear in different roles, connecting to core intervention themes — menstruation; menstrual hygiene practices; increasing public safety of girls; and knowledge about sexual and reproductive health and family planning.

Animated digital stories

During the formative research, young people recorded their personal stories about gender and sexual and reproductive health. To protect their privacy and provide clear messaging, these stories were recreated using animation, keeping the original narration intact. Because the stories are based on real-life experiences, young people quickly connect with them. The stories invoke empathy in their minds that accentuates their willingness to adopt desired health behaviors.

Games

Kissa Kahani includes three games that address each of the intervention themes.The games give younger adolescents a welcome break from their textbooks, allowing them to apply and practice what they learn from traditional educational methods in a playful, relaxed setting.

The games also take into consideration the unique setting of Indian classrooms in government schools, allowing for participation by the entire class whether it be 15 or 50 young people, and ensuring playability in various settings.

Graphic novels

Connecting to Kissa Kahani intervention themes, the graphic novels follow a cast of characters who face everyday problems and navigate solving them. After gathering information from trusted adults, characters display positive attitudes and aspirational behaviors, inspiring young adolescents to do the same. Each Kissa Kahani participant receives a graphic novel to use in class and take home to share with their families.

Recognizing the lack of Indian adolescents' familiarity with graphic novels, the stories were created to layer information and be not too simple, or too complex, ensuring a consistent level of understanding for every reader. The novels feature activities that encourage readers to obtain information about health center policies, increasing health access and building advocacy skills.

Iterative prototype testing

Kissa Kahani was tested with adolescents and educators during the development process to evaluate its effectiveness. The project team conducted five rounds of prototype testing in Indian government schools to evaluate curriculum flow and structure; adolescents' comprehension of content; and youth's overall comfort with using new media. Iterative making and testing was conducted to ensure that each intervention aspect succeeded in the actual implementation context.

Results showed that adolescents related to all intervention components, especially the games and graphic novels. Several adolescents referenced the importance of providing such information to adolescents their age.

Ci3 also gained crucial insights instrumental in improving the intervention. Key observations included:

1. Simplify game mechanics and game content.

2. Inform teachers of the importance of educating younger adolescents about their bodies.

3. Reduce the number of background images in animated digital stories.

Building on these insights, the project team redesigned two games with simpler gameplay and content, developed a module to educate teachers, and reduced background imagery in the animated digital stories. The final round of testing showed that young people were fully engaged in the intervention and understood all parts of it. Adolescents could answer questions at the end of testing and clearly communicate important messages from the intervention.

Testing and scaling

During the next year, Kissa Kahani will be implemented and tested in 100 government schools with support from the Uttar Pradesh state government. More than 3,000 adolescents, ages 12 - 14, will receive the Kissa Kahani intervention in a randomized control experiment, the gold standard for testing. Ci3 is working with a premier Indian data collection agency to deliver the intervention and study its effectiveness on the following outcome variables at baseline, end line, and six months after completion:

• Knowledge about puberty and menstruation; family planning; and sexually transmitted infections

• Attitudes towards gender norms

• School attendance

Testing data will inform next steps to enhance intervention effectiveness and its ease of implementation in India. Once this work is completed, Kissa Kahani will be implemented in other states to maximize its impact.