Evaluating the effectiveness of the health educator intervention on health beliefs and attitudes of female Palestinian adolescents: Applying the Solomon Four-Group Design

Health and well being of the young people has been advocated by health planners in Palestine to become one of the main components of community health care. The national health information system such as vital statistics (PCBS) provides valuable information, but data on aspects of health relevant to young people are not easily available. Female adolescent health is a new area of concern in Palestine and most of the Palestinian adolescents' health studies have been concerned with the assessment of their health needs and problems. Some recent studies have assessed the adolescents' reproductive and sexual health needs. Very few studies indicated that health education programmes were developed and implemented based on those needs and problems but no one study has evaluated the effectiveness of the health educator role in those programmes. The diversity and lack of standards for health education programmes and for those who implement them may have an impact on the quality of health education/promotion services delivered to meet the changing health needs of society (WHO, 1998). To achieve a quality in health services offered, it largely depends on the people who deliver these services. Therefore; evaluation for the effectiveness of the health educator is one aspect for improving the quality of these services and thus the health status of the individuals and/or the communities. This experimental study is designed to evaluate the role of the health educator intervention in affecting change in the health beliefs and attitudes of Palestinian female adolescents aged 14- 17 years in four female public schools in the West Bank.. To answer the research questions of the study and to achieve its purpose and objectives, two theoretical frameworks were utilized: first, adolescence developmental approaches; the physiological, cognitive, psychological and social development. Second, the Stimulus-Organism-Response Model (S-O-R); (1) the stimulus element reflects the health educator intervention, (2) the organism element reflects the female adolescent health beliefs, values, knowledge and attitudes, and (3) the response element reflects the influence of health educator on the female adolescents' health beliefs and attitudes as measured at post test. The two frameworks were the base for the questionnaire construction and the base for implementing and evaluating the effectiveness of the health educator intervention. The following three experimental steps were followed to have the study completed:

1. An assessment of Palestinian female adolescents' health beliefs and attitudes toward their physiological, psychological and social development as the pre-intervention phase of the study. This assessment was conducted among 246 female students from 9th-II th grades in two public (governmental) female schools. It was based on quantitative type of data, a self-administered questionnaire that included socio-demographic variables and 92 checklist items, and qualitative type of data with two subjective questions. The questionnaire was constructed and developed by the investigator; its content validity was established through revision of the questionnaires by experts, and its reliability was measured by Cronbach's Coefficient alpha test. The findings of the pre-intervention data revealed that the Palestinian female adolescents' needs and concerns were associated with their biological, psychological and social development. The adolescents' general lack of knowledge regarding their sexual and reproductive health was evident in the quantitative as well as qualitative data, the feeling of low self esteem, poor self confidence, and the feeling of gender inequalities were of particular concerns. Based on those needs and concerns, a health education intervention programme was developed aiming at assisting them to have more information and knowledge regarding their sexual and reproductive health, and to increase their awareness regarding their psychological and social well-being.
2. The second experimental step of the study was the implementation of health education intervention programme to the experimental groups. The health education intervention programme was developed by the investigator based on the findings of pre-intervention data and implemented by an external heath educator with the presence of the investigator. The health educator has utilized the educational and community development models, as a guide for her role to implement different educational methods and strategies in order to help the adolescent students achieve the goals of the educational sessions assigned aiming at affecting change in their health beliefs and attitudes toward a healthy life style.
3. The third step of the study was a post-intervention data obtained for variables reflecting the psychological and social health beliefs and attitudes from experimental and control groups to evaluate the effectiveness of the health educator intervention provided to experimental groups under study. The study has employed an experimental research methodology; the Solomon-Four group design. This design has allowed for each of the four schools under study to be assigned to different condition; two were the experimental groups and two were the control groups, and each group was assigned as; CD The first experimental group has received pre-intervention assessment (pre-test), health educator intervention and post test, Q) the first control group has received pre-intervention assessment and post test, @ the second experimental group has received the health educator intervention only and post test, @ the second control group, was not assigned to intervention nor to pre-intervention assessment, but received the post test only. Statistical analyses were performed using the Statistical Package for Social Science (SPSS) version 10. Descriptive statistics were used to analyze the socio-demographic variables. The ttest for significance of means was the statistical analysis technique utilized to compare for differences between two group means or two means of one group at two levels; Q) at pre-test to compare for equality of mean groups prior to intervention, and (£> at post test multiple comparison for the mean differences between subjects in the four different groups was made to indicate for the effects of the pre-test, the health educator intervention: and for the pre-test intervention-interaction on 8 dimensions of the adolescents' psychological and social beliefs and attitudes for all groups. The major findings of the study at the post test data included the followings:
4. The findings showed a significant difference in the mean scores of the female adolescents' psychological health beliefs and attitudes dimension as a result of; the pre-test, the intervention, and the pre-test-intervention interaction. There was a significant difference for those who received the pre-test when compared with those who did not, but this difference was less than those who received the intervention. The difference for those who received the pre-test and intervention was stronger than those who received the pre-test or vii intervention .alone. This means that an interaction between pre-test and intervention gives stronger effects on adolescents' psychological health beliefs and attitudes.
5. The findings showed neither the pre-test nor the intervention or the pre-test intervention-interaction implied any effectiveness for the adolescents' social health beliefs and attitudes dimension which included the family, school and society sub dimensions. This is expected since these students do not live in a vacuum, and such programmes have to target their environment especially their family and school systems. The study design was helpful in assessing the adolescents' health beliefs and attitudes and identifying their needs and concerns; also it was helpful in developing culturally appropriate interventions according to those needs. Therefore, emphasis on the needs and concerns of the adolescents to be assessed prior to any intervention is of importance and highly recommended to have effective outcomes for any planned educational programmes. Furthermore; the design was helpful in identifying that direct health education instruction can be effective on female adolescent psychological/emotional well-being but not on their social well-being. This effectiveness was recognized by the significant difference in the mean scores of the experimental groups compared to control groups. The effectiveness of health education on the adolescents' health beliefs and attitudes was estimated immediately after the intervention; however, a further follow up study is required to estimate if this acquired effectiveness is maintained and sustained in those adolescents. Research studies emphasizes that while it may be relatively easy to influence attitudes and behaviour short-term, it can be very difficult for people to sustain behaviour change over the longer term (Pill, 1990). Therefore; continuity of such programmes and involvement of interdisciplinary approaches particularly for the psychosocial aspect of the female adolescents' development is required to have an effective and successful intervention programmes.