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Measuring the Effectiveness of Sex Education at Nepalese Secondary School- Outcomes From a Randomised Controlled Trial (RCT) 29 February 2012 Dev R Acharya,

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Presentation on theme: "Measuring the Effectiveness of Sex Education at Nepalese Secondary School- Outcomes From a Randomised Controlled Trial (RCT) 29 February 2012 Dev R Acharya,"— Presentation transcript:

1 Measuring the Effectiveness of Sex Education at Nepalese Secondary School- Outcomes From a Randomised Controlled Trial (RCT) 29 February 2012 Dev R Acharya, PhD student School of Education and Lifelong Learning Aberystwyth University

2 First… about me Education: BA, Mathematics (1998) and MA, Anthropology (2003) from Tribhuvan University in Nepal In search of higher degree, came to UK and completed MSc in Health Services and Public Health Research degree from Aberdeen University (2006). Career development: Worked for Behaviour Change Intervention (BCI) programme on HIV/AIDS/STI control & prevention among young people in central Nepal 1996-2005.

3 Motivation for PhD: My MSc dissertation was to look at the parental and pupil involvement in developing sex and relationship education curricula in Scottish secondary school. I also worked at Epidemiology Group, University of Aberdeen March 2008-August 2009. The study was to investigate the musculoskeletal pain among peoples in Aberdeen and Manchester- a Randomised Controlled Trial (RCT) with factorial design ( http://archinte.ama- http://archinte.ama- So, the combination of Nepal work experience and research as well as work-based knowledge from Aberdeen University led me to do an innovative research among young people in Nepal. … about me

4 Young people are more likely to be sexually active before marriage than their parents generation in Nepal. Limited routine studies, research, and Non-Government Organisation (NGO) reports suggest that a significant proportion of Nepals young people are at risk of HIV, that they engage in high-risk behaviour, and have high adolescent fertility. Sexual health education in school is regarded as an effective way to increase young peoples understanding of unintended pregnancies, abortion, infertility, cancer, and STIs including HIV. 4 Rationale of the Study

5 Pupils are taught basic sex education at higher secondary level using the textbook Health, Population and Environment. Teaching sexual health is often very poor and this is directly associated with teachers embarrassment, lack of knowledge, poor teaching techniques and with a poor theoretical underpinning. In Nepal, there is a need for evidence-based research preferably a randomised controlled trial (RCT) to examine the impact of sex education on students knowledge, attitudes and behaviours as outlined by the Government of Nepal/Ministry of Education. 5 Rationale of the Study…

6 This research is based on three psycho-social behaviour change theories;. Social Cognitive Theory (Bandura, 1986): It puts emphasis on a concept of self-regulation which proposes that by visualising self-generated consequences, people can regulate their own behaviour. Social Inoculation Theory (McGuire, 1968): It strengthens peoples existing attitudes and beliefs, and builds resistance to future risks. It is vital that a motivation for resistance is imposed upon these existing ideas and ability to cognitively build defences to potential risks that may take place after the inoculation. 6 Philosophical Assumptions

7 Theory of diffusion of innovations (Rogers, 1995): This theory describes behaviour change as a process by which an innovation is communicated through certain channels over time. 7 Philosophical Assumptions...

8 Does a theory-based sex education programme led by health facilitators delivered in secondary schools improve the sexual health knowledge and understanding of young people compared to conventional teaching? 8 Main Research Question

9 What are the sources of sexual health information of young people ? What proportion of knowledge and understanding young people have towards sexual health? What are the sexual health norms and beliefs of young people? Which teaching methods have been used to deliver the sexual health session? Which kind of teaching methods and material have high impact on improving young peoples sexual health? 9 Sub-Questions

10 Hypothesis (H 1 ) = Sex education programme delivered by health facilitators (experiment group) is more likely to promote young peoples sexual health knowledge and understanding compared to programme delivered by conventional teachers (control group). Null hypothesis (H 0 ) = There is no significant difference in the post-intervention achievement of control group and experiment group in promoting young peoples sexual health knowledge and understanding. 10 Hypotheses to be Tested

11 Randomised Controlled Trials (RCTs) are the most rigorous way of determining whether a cause-effect relationship exists between intervention and outcome and for assessing the cost effectiveness of the intervention. This is an open, clustered and single-arm RCT with outcome evaluation. The study is carried out in four government secondary schools in Hetauda Makwanpur in central Nepal. 11 Research Design

12 Schools were identified, reviewed and finalised using flash report published by Ministry of Education and District Education Office in Hetauda. The researcher contacted the school head teachers in order to explain the purpose of the study and asked for permission for their participation. 12 Research Design...

13 A baseline survey was carried out before the intervention. Schools were randomised into two groups, each having one experimental school and one control school. Health facilitators led the experimental schools and the conventional teachers led control schools. In the classroom setting health facilitators delivered sex education programme to grade-IX pupils following governments existing sexual health curricula. Final evaluation was carried out after eight weeks of the baseline survey. 13 Trial Endpoints

14 Trial Endpoints... 14 Randomisation of schools/Baseline questionnaires Intervention arm (Programme led by health facilitators) Control arm (Programme led by conventional teachers) Pupils from grade-IX Compare results Final evaluation of the survey

15 15 Questionnaire Piloting Aim: To evaluate the psychometric properties of a questionnaire developed to measure sexual health knowledge and understanding of young people in secondary school, Nepal. Objective: To conduct a translational validity of the questionnaire e.g. content validity, face validity and construct validity, To conduct a reliability test of the questionnaire e.g. Internal consistency and test re-test reliability, and To develop a final questionnaire

16 16 Questionnaire Piloting... Piloted 3 Schools in Hetauda Makwanpur

17 17 Questionnaire Piloting... Validity Content Validity:9 sexual health experts. Face Validity: 24 young people from grade ten. Construct Validity & Internal Consistency :210 students from grade nine. Reliability (ICR) Test-retest Reliability: 25 young people from grade ten.

18 A draft sexual health knowledge and understanding questionnaire Validating procedure Translational validity: Content validity, Face validity Construct validity (Factor analysis: Kaiser-Meyer-Olkin (KMO) sampling adequacy, communalities of the item, Factor loading, varimax and scree plot) Final sexual health knowledge and understanding questionnaire Reliability procedure Reliability: Internal consistency (Chronbach alpha) Test-retest reliability (Continuous data/Pearson correlation coefficient; non- continuous data/Wilcoxon non-parametrical test) Questionnaire Piloting Flow Chart...

19 Instruction before the questionnaire distribution Questionnaire Piloting...

20 Questionnaire Piloting... Questionnaire Piloting... PROCEDURE FOR REMOVING ITEMS Summary of the questionnaire validating process Step-1 CVI Check Sexual health experts Total item distributed=65 Items not meeting requirement =8 (removed) Remained items=57 Step-2 Plausibility Check Class 9 school students Item distributed =38 Items not meeting requirement =3 (removed) Remained items=35 Step-3 Overall Reliability Total item remained =35 Items not meeting requirement =6 (removed) Remained items=29 Step-4 Correlation and Significance Total item remained =29 Items not meeting requirement =5 (removed) Remained items=24

21 Questionnaire Piloting... Questionnaire Piloting... PROCEDURE FOR REMOVING ITEMS Step-5 Communalities Check (with eigenvalues 1) Total item remained =24 Items not meeting requirement =3 (removed) Remained items=21 Step-6 Communalities Check (with 4 factors) Total item remained =21 Items not meeting requirement =3 (removed) Remained items=18 Step-7 Overall Reliability Check Total item remained =18 All items met requirement =0 (removed) Remained items=18 Step-8 Reliability Check for Each Factor Total item remained =18 Each item met requirement =0 (removed) Remained items=18

22 This study employed mixed method data collection. Data is recorded on the paper questionnaires and entered into an SPSS (19.0) database. The qualitative data will be transcribed and the written copy will be entered into an NVIVO (8.0) database. Prior to the data collection, a self-completion questionnaires was developed and pilot tested in consultation with the pupils and sexual health experts in Nepal. 22 Main Study Data Collection

23 A baseline questionnaire survey was carried out as a pre- intervention. The questionnaires included background information, sources of sexual health information, sexual health awareness level, level of knowledge and understanding, sexual health norms and beliefs and sex education at school. The principal researcher explained the purpose of the questionnaire, reassured pupils about the confidential nature of their responses and answered any queries. 10 Focus Group Discussions (FGDs) were carried out with single-sex group of pupils both in control and experimental schools. 23 Main Study Data Collection...

24 The aim of the FGD is to gain an insight into young peoples perception and evaluation of sex education in school. 22 Key Informant Interviews (KIIs) were carried out among school health teachers and head teachers in the randomly selected schools. Parents, community leaders, NGO members, faith group leaders and educational authority personals were also approached through KII. 24 Main Study Data Collection...

25 Parents were informed by letter of the research and the intervention programme and were given the opportunity to withdraw their children from the study. Pupils from grade-IX were also have the right to omit or withdraw responses to questions they do not wish to answer. Signed consent were also sought from health facilitators. It is assured that the information collected would solely be used for the purposes of this research and would be remained confidential. Ethical permission were obtained from Aberystwyth University Research Committee and Nepal Health Research Council (NHRC). 25 Ethical Issues

26 26 Basic Analysis Baseline_followup FrequencyPercent baseline42152.1 follow_up38747.9 Total808100.0 Type_school FrequencyPercent control47258.4 intervention33641.6 Total808100.0 Gender FrequencyPercent male38247.3 female42652.7 Total808100.0

27 27 Basic Analysis... Age FrequencyPercent 1432740.5 1521927.1 1618322.6 17546.7 18253.1 Total808100.0 Caste FrequencyPercent brahman/chhetri38447.5 magar/gurung/rai/limbu9812.1 newar8810.9 tamang12916.0 madhesi435.3 others668.2 Total808100.0

28 Frequency tables will be presented to report chi-square statistical result from the onset to determine the relationship between independent and outcome variables (A=Abstinence, B=Be faithful to sex partner and C=Correct and consistent condom use). The schools are the unit of randomisation, and data is collected from individual students. So, a multilevel statistical analysis will be used to account for the intra- class correlation. 28 Further Analysis

29 A multivariate analysis will be employed to explain the major contributors to differences in outcome variables in each stratum. Qualitative data will be analysed using thematic analysis. In the discussion, mixed method analysis will be employed as a means of triangulating the data. To comprehend and improve the quality of reporting and the results of the RCT, a Consolidated Standards of Reporting Trials (CONSORT) statement will be used. 29 Further Analysis...

30 Two book review published Global Politics of Health: Davies, Sara (2010). Polity Press: Cambridge. Promoting Health and Wellbeing through Schools: Peter Aggleton, Catherine Dennison and Ian Warwick (2010). Routledge: Oxon. Two abstracts presented Developing a Questionnaire to Measure Sexual Health Wellbeing in Nepalese Secondary Schools. Royal Society of Public Health (RSPH) Conference, London 8-9 Sep 2011. The Involvement of Parents and Pupils in a Sexual Health Education (SHE) Programme in Nepalese Secondary Schools. Global Health Conference, Montreal,Canada 13-15 Nov 2011. Accomplishment

31 Journal article published (co-authored) Regmi PR, van Teijlingen ER, Simkhada P, Acharya DR (2010). Dating and Sex Among Emerging Adults in Nepal. Journal of Adolescent Research, 1-26. Regmi PR, Simkhada P, van Teijlingen ER, Acharya DR (2010). Barriers to Sexual Health Services for Young People in Nepal. Journal of Health Population and Nutrition; 28(6):619-627. Journal article submitted Acharya DR, Thomas M, Cann R (2011). Developing and Validating a Questionnaire to Measure Sexual Health Knowledge and Understanding (SHQ) in Nepalese Secondary School: A Psychometric Process. Health Education Research, Oxford University Press. Completion of Questionnaire Pilot Study, (Nov. 2010- Feb. 2011) Main Study Completed, (May 2011- Sep 2011) Accomplishment…

32 A thorough literature review and update of methodology based on 2010 CONSORT statement ( ). Data entry and checking completed, analysis is to be done. Thematic analysis to be done for qualitative data (FGD and KII). Data triangulation in the discussion. Activities To Be Accomplished Membership British Educational Research Association (BERA)-2010 Royal Society of Public Health (RSPH)-2010

33 Resource person, Mr. Yuva Raj Dahal from DEO facilitating the session Some Photos

34 Bal Jyoti secondary school (a typical Nepali school) acts as an intervention site Some Photos…

35 Health facilitators developing a session plan Some Photos…

36 Pupils are reading consent form before participating in the research. Some Photos…

37 Thank You! Any question please?

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