1 Background

‘Adolescence’ or ‘Teenage’, defined by the World Health Organization (WHO) is the time between 10 and 19 years of age represents critical transition from childhood to adulthood marked by greater structural, functional and psychological changes [1]. The appearance of health risk behaviors during this period has significant influence on physical, mental and emotional well-being both during this point of life and later [2]. About one third, of the global burden of adult disease is originated in adolescence and over 3000 deaths occurring daily are majorly due to Non Communicable Diseases (NCDs), intentional and unintentional injuries and other preventable causes [3].

The major NCD risk factors amid adolescents differ by gender and regions, nevertheless, many are usually associated with behaviors that are formed in childhood or adolescence like unhealthy diets, sedentary lifestyles and use of tobacco and alcohol [4]. Due to the increase in trends of overweight and obesity over the couple of decades, many countries, including India are perpetually facing the dangers of snowballing NCDs burden [5, 6]. Healthy behaviours and habits formed during childhood and adolescence often persist into adulthood and positively influence family and community health making them potential ambassadors of health & wellness [7, 8]. Life skills education offers an effective strategy to promote healthy behaviours and the World Health Organization recommended life skills framework aims at translating knowledge, attitudes to positive behaviours [9, 10]. The schools provide an easy access to involve this age group and implant healthy life style for health promotion thus, making school a perfect site for positive health promoting [11].

Despite understanding the significance of adolescent health challeneges, comprehensive, school based intervention programmes are limited. Most research studies conducted are fragmented and focus on single area like nutrition or physical activity. The currently running national programme of India, Rashtriya Kishore Swastha Karyakrama (RKSK), a health programme designed for holistic well-being of adolescents, emphasises on key areas like nutrition, smoking and alcohol use, sexual and mental health however, it does not focus on developing behaviours required to practice to attain a healthy lifestyle [12]. Thus there is a need to develop culturally sensitive age appropriate health promotion module that not only educates adolescents but also empowers them to adopt and sustain healthy behaviours. The present study was conducted with a primary aim to develop and validate an interactive awareness module for adolescents using life skills approach.

2 Materials and methods

The study was initiated after obtaining approval by the Institutional Ethical Committee of BLDE (Deemed to be) University (BLDE (DU)/IEC/602/2022-23). This study was conducted in three phases. Phase I: Needs assessment; Phase II: Development of adolescent health promotion module; Phase III: Validation of the module. The study has been carried out in accordance with the ethical guidelines. Written informed consent was obtained from the school principals and assent from the adolescents before initiation of the study.

2.1 Phase I: needs assessment

2.1.1 Study setting

Needs assessment was done through adolescent centered approach. A qualitative research design was adopted using Focused Group Discussions (FGD) to explore adolescents ‘opinions, ideas and perceptions about their health and wellbeing, content and design of the interventional module. The approach was chosen for its effectiveness in obtaining in depth insights through peer discussions. To capture socio cultural diversity in adolescent health perceptions, lifestyle practices so as to ensure that module is relevant across rural-urban backgrounds, four FGDs were conducted, two in rural and two in urban area, in a district of North Karnataka among Class 8 (aged 13–14 years) adolescent boys and girls, purposively selected to ensure appropriate mix of gender. Class 8th students were particularly selected as they represent early adolescence- a formative stage of attitudes and behavior development. The needs assessment was intentionally designed to be adolescent centric to prioritize adolescents opinion in the module content and delivery. Although, parents and school teachers are major stakeholders of adolescent health, they were not included in the formative phase to avoid adult driven perceptions of adolescent health. Their role in augmenting the implementation and sustainability of the intervention is acknowledged and will be explored in future phases of module evaluation.

2.1.2 Data collection

All the FGDs were conducted in a quiet room within school premises to ensure comfort and privacy. In each FGD, about 15 students participated and to promote open discussion, ground rules were established before initiating the discussion. FGDs followed a natural flow of conversation with semi-structured questions. The moderator asked certain open ended questions to encourage free discussion among participants and to ensure that discussion remains focused and on track. The questions asked were.

  • ➣ What topics do you want to learn in “healthy living”?

  • ➣ In your opinion, what kind of educational design will interest you?

  • ➣ In your opinion, what are the factors that cause you to be not interested educational materials?

The FGD protocol was reviewed by qualitative research experts’ panel. Each FGD was conducted till the “saturation point”, the point where in participants produce no or little new information, was reached. All FGDs lasted for 50–60 min and were all recorded using a MP3 player. The moderator took field notes along with the recordings to observe group dynamics and nonverbal prompts like facial expressions, voice tone and body language [13].

2.1.3 Data analysis

Audio recordings were verbatim transcribed and translated to English. Field notes were also incorporated into the transcripts. The authors went through the transcripts many times to acquaint with the data. Data management and coding were facilitated by NVivo Qualitative data software for systematic organization of data. Coded data was then collated into potential themes and sub themes. Each theme was clearly defined and named, with the focus on its content characteristics description, scope and contribution to the research question.

2.2 Phase II: development of adolescent health promotion module

The interventional module was developed depending on the themes as attained from FGDs with the adolescents and reinforced by the Social Cognitive Theory (SCT) [14], which emphasizes the dynamic relationship between personal, behavioral and environmental factors.

SCT is especially useful in adolescent intervention programmes because it recognizes that people learn in social context, focusses not on just knowledge but on building skills and confidence and emphasizes on sustained behavior change and not just awareness.

The development of the adolescent health promotion module followed a systemic and theory-informed process. Insights from FGDs identified the priority content areas and preferred modes of content delivery and were systematically integrated with expert inputs to ensure contextual relevance and scientific accuracy and aligned with evidence based age appropriate national recommendations as given by WHO, National Adolescent Health Programme [7, 12]. The finalized module consisted of four thematic units viz. Healthy diet; Physical activity; Avoidance of alcohol & tobacco; Holistic health. Each unit structured around a narrative framework featuring four central adolescent characters whose journey illustrated the challenges and paths to achieving good health. The story telling approach was employed to enhance relatability, promote engagement and facilitate behavior modelling among adolescent learners. The topics began with basic information and moved to specific information to make it more easily comprehensible.

Realistic, culturally sensitive, age appropriate examples, illustrations in simple layman languages were used to connect successfully with the readers. To reinforce learning and promote practical, each unit included interactive components such as reflective activities, games and quizzes. These activities were designed to foster critical engagement with the content and support retention of key messages.

Additionally, the module incorporated the ten core life skills identified World Health Organization (WHO) as essential for promoting positive behaviors: Critical thinking, Creative Thinking, Self-awareness, Empathy, Decision-making, Problem-solving, Effective Communication, Interpersonal relationships, Coping with Stress and Coping with Emotions [10]. These life skills were seamlessly embedded within the narrative and contextualized through the experiences of story’s characters, thereby enabling adolescents to internalize and apply them in their daily lives.

The contents of the module incorporated the Social Cognitive Theory (SCT) components. (A) Observational learning – To facilitate learning through modeled behavior which was structured around the four fictional characters; (B) Self efficacy – Activities were designed to enhance adolescents’ belief in their capacity to adopt healthy behaviors; (C) Reinforcement – Interactive components such as games, quizzes to provide immediate feedback and motivation; (D) Behavioral capability – Each unit introduces knowledge and life skills for behavior change; (E) Reciprocal Determinism – The module acknowledges the influence of environment and social contexts through the scenarios depicted in the story of adolescent characters. The final development of adolescent health promotion module involved the findings from need assessment and integration of Social Cognitive Theory of behavioral change and WHO Life skills framework (Fig. 1).

Fig. 1
figure 1

Conceptual framework guiding the development of adolescent health promotional module

Full size image

2.3 Phase III: validation of the module

The interventional module underwent a rigorous validation process by a panel of experts. A total of eight experts were selected, in alignment with the recommended range of 6 to 10 experts required for content validation [15]. Our panel of experts included two adolescent pediatricians, two nutritionists, an adolescent psychiatrist, a lifestyle physician, a life-skills professional and a health promotion expert. This interdisciplinary composition ensured a comprehensive evaluation based on their diverse professional perspectives.

The content validity was assesses independently using a structured content validation form adapted from the instrument developed by Lau et al. [16]. Experts evaluated each component of the module on two key dimensions- Scientific accuracy and content relevance. The face validity was judged in five aspects – clarity, comprehensiveness, engagement& motivation, illustrations and language appropriateness. Each item was rated on a 4 point Likert Scale; 1 for Not relevant/inappropriate, 2 for Somewhat Relevant/Appropriate, 3 for Relevant/Appropriate and 4 for Highly Relevant/Very Appropriate. The Content Validity Index (CVI) was calculated by dividing the number of experts who rated an item as 3 (Relevant/Appropriate) or 4 (Highly Relevant/Very Appropriate) by the total number of experts. A CVI of more than 0.83 was considered the threshold for content acceptance. Judgment on each item was made as follows: if the CVI was higher than 0.79, the item was considered appropriate; if the CVI was between 0.70 and 0.79, the item required modification; and if the CVI was less than 0.70, the item was removed.

For face validity, a face validity questionnaire, similar in structure to that used by the experts was administered. Participants were asked to rate the module in the five aspects and grade each component as Strongly Agree, Agree, Neutral, Disagree and Strongly Disagree. The Face validity Index of 0.8 was considered indicative of adequate acceptability among the target population [15].

3 Results

3.1 Phase I: needs assessment

A total of 58 adolescents, aged 13–15 years participated in the four FGDs conducted to assess the needs of the adolescents. The socio-demographic characteristics of the participants is described in Table 1. Most of the participants were of 14 years of age and the mean age was 13.8 (0.61) years (Table 1).

Table 1 Characteristics of participants n (%)
Full size table

The thematic analysis of the responses obtained from the discussions were categorized into two topics as the contents of the module and preferences regarding content delivery. The major themes in content of the module to adopt a healthy living were nutrition, physical activity and prevention of bad habits. The subthemes identified in nutrition were foods that were beneficial to the overall health, for good body image, understanding foods that improve concentration levels and effects of soft drinks and energy drinks. The physical activity theme included preferred type and duration of physical activity, its role in improving stamina and body image building. Prevention of bad habits recognized subthemes that included harmful consequences of tobacco and alcohol, anger management, stress and sleep issues.

The module designing and content delivery topic identified facilitators of interest as major theme which included easy language, simple to understand incorporating humor and relatable examples as subthemes. The barriers to engagement identified elements that were perceived as uninteresting were long duration sessions, content delivery similar to conventional school lessons, strict lesson plans without flexibility. The major themes and subthemes are depicted in Table 2.

Table 2 Themes and subthemes from focused group discussion
Full size table

Some of the participants replied in one word and they were not very useful. Boys were more concerned with foods and physical exercises for body building, to build strength and stamina. They were also interested in energy drinks and their effects to body. The girls were, on the other hand more inclined to know about foods that would make their skin more glowing, have long hair, physical exercises to reduce weight.

3.2 Phase II: development of adolescent health promotion module

The FGDs suggested topics for module content as nutrition, physical activity and avoidance of bad habits. The other category included preferences for module delivery. These insights were critical for developing a contextually relevant and adolescent friendly health education module for promoting health and wellbeing.

The module developed was based on the information obtained from the focused group discussions and in consistent with the recommendation guidelines by the National bodies for adolescent health promotion. The module had four chapters- (a) Superpower of Eating Right; (b) Superpower of Active Living; (c) Power of Choice; (d) Path to Holistic Health.

Every unit had a story about the four central characters (two boys and two girls), their journey through acquiring life skills to achieve health and information about the topics. At the end of the module, there was an interactive activity to create interest in the topic and for experiential learning. The details of the module, topics and learning objectives are given below (Table 3).

Table 3 Content details of the interventional module
Full size table

The manner in which the contents are presented can directly influence the degree to which the information is understood and remembered. The participants in FGD said,

Participant 1: Please insert pictures so that it becomes interesting;

Participant 2: Keep it short, don’t make it long like conventional textbook lessons.

Thus the information was concise, in simple language, appropriate to the local social and cultural context and presented as bullet points. The contents included pictures, illustrations, four central characters which explained the healthy behaviours to be followed (Fig. 2).

Fig. 2
figure 2

Glimpses of the intervention module

Full size image

3.3 Phase III: validation of the module

The module was validated for its accuracy, coverage, relevance, appropriateness, cultural relevance, age appropriateness, and feasibility for implementation and consistent with the existing theories. Each item was calculated for the Content validity Index (CVI) and all of them had CVI more than 0.80 considering to be appropriate for use. The average CVI was 0.95 making the entire module appropriate to use and deemed it to be valid. (Table 4) Every expert was asked to give overall suggestions for the module and based on their opinions minor changes were made to the module. However, no major changes were suggested.

Table 4 Content validity index for module by expert panel (n = 8)
Full size table

To obtain face validity of the module by experts, the face validity index (FVI) was calculated for the six aspects namelyQuery ID="Q2" Text="Table: Please specify the significance of the symbol [Bold] reflected inside Table [4] by providing a description in the form of a table footnote. Otherwise, kindly amend if deemed necessary." Resolved="yes" clarity, comprehensiveness, engagement, illustrations, language and overall quality. The value of 0.8 was considered as cut off for the acceptability and validity of the module. All the aspects had FVI of more than 0.8 and were considered valid for the implementation (Fig. 3)

Fig. 3
figure 3

Face validity by experts (n = 8)

Full size image

4 Discussion

The present study positively developed and validated an all-inclusive, school based health promotion module tailored for school going teenagers using life skill based participatory approach. The outcomes underline the prominence of including adolescents in designing health interventions and integrating life skills to promote behavioural change.

4.1 Adolescent centred needs assessment

The module was developed after the Focussed Group Discussions with the adolescents and conducting needs assessment. This phase revealed the importance of nutrition, physical activity and substance abuse for overall wellbeing. These findings align with earlier studies indicating the importance of health among adolescents [17,18,19]. The inclination for simple language, illustrations, relatable content, interactive activities like storytelling and games supports the evidence that participatory methods improve learning and retention paving way for increased awareness and behaviour change [20, 21].

4.2 Module designing

The incorporation of Social Cognitive Theory (SCT) was a main asset in the module’s design. SCT highlights reciprocal determinism, observational learning, and self-efficacy—all crucial for enabling sustainable behavior change among adolescents. This is in consistence on the prior evidence that SCT-based interventions certainly influence health outcomes and intervention usefulness [22, 23]. By inserting health messages within narratives involving relatable adolescent characters, the module promoted observational learning and behavior modeling.

The ten life skills recommended by WHO were effectively embedded into the narrative structure. This integrative approach is supported by global health literature, which emphasizes that interventions that blend cognitive, emotional, and behavioral components are more likely to succeed in achieving lasting behavior change [24, 25]. Moreover, embedding health behaviors within a life skills framework has been shown to improve both psychosocial outcomes and health behaviors in similar settings [26].

4.3 Module validation

The rigorous validation process included both content and face validity assessments by multidisciplinary experts and target end-users (adolescents). The average CVI score of 0.95 indicates high agreement between experts on the topics of the accuracy, relevance, and comprehensiveness of the module. These values are above the commonly accepted threshold of 0.83, suggesting that the content is not only scientifically sound but also contextually appropriate and implementable. Other studies that validated educational resources also used CVI to measure content validity signifying the prominence of validation for creation and implementation of educational materials [27, 28]. The course of developing health educational resources after review by panel of experts is an important phase to brand the module more effective and scientifically precise [29, 30]. Similarly, face validity, evaluated on criteria such as clarity, illustrations, engagement, and language, received favorable ratings from both expert reviewers and adolescents, with FVI values exceeding 0.8 for all aspects. This supports the module’s acceptability and its potential to engage adolescent learners meaningfully [31].

4.4 Strengths

The current module fills the gap by combining evidence-based content with adolescent-friendly delivery methods and contributes to the growing evidence on adolescent centred, life skills based health promotion. Adolescent centric, participatory design and rigorous validation process makes the module acceptable and scalable. Furthermore, while most school-based programs in India focus on isolated topics such as nutrition or menstruation, this module adopts a holistic, integrated approach, addressing physical, emotional, and social health domains.

4.5 Limitations

The study was conducted in a specific geographic region of North Karnataka, which may limit generalizability. Cultural and linguistic modifications may be needed before implementation in other regions. Additionally, while the module was validated for content and face validity, long-term impact on behaviour change was not assessed in this phase. Future studies should examine the effectiveness of the module through pre- and post-intervention assessments and longitudinal follow-ups.

5 Conclusion

The study highlights the effectiveness of combining adolescent-centered design with theoretical and evidence-based approaches to create a valid, engaging, and culturally sensitive health promotion module. This school-based intervention has the potential to empower adolescents with knowledge and life skills essential for leading a healthy and balanced life. Future research must focus on assessing the effectiveness of the module through implementation studies and may also be further strengthened by integration of teacher and parent engagement for its sustainability and real world impact.