Gender and Content influence Second-Level Students’ Expectations of Health Education Seminars provided in a Health Promoting Hospital Setting
Cecily C Kelleher, David Kelly, Oran Finnegan, Mary Kerley, Kirsten Doherty, Irene Gilroy, Greg Conlon, Patricia Fitzpatrick, Leslie Daly
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About the Authors:
Department of Preventive Medicine and Health Promotion, St Vincent’s University Hospital
UCD School of Public Health, Physiotherapy and Population Science
Dundalk Institute of Technology
ABSTRACT
Purpose Our objective was to evaluate health education seminars off ered to school transition year students (aged 15-16 years) within the hospital catchment area by means of analysis of self-completed student evaluations of seminars from 2009 to 2013. Internationally, detailed evaluations of such seminars are not widely reported.
Method The seminars aimed to increase students’ knowledge about their health and well being and to enable behaviour change. Male and female students attended one or more of five hour-long seminars; Smoking, Minding Your Mind (MYM), Healthy Eating, Active Living (HEAL), Cancer Awareness and Alcohol - a Different Approach. Student opinions were recorded via Likert Scale on a structured form. Responses were dichotomised into those who found the seminars strongly met students’ expectations and those who did not. Logistic Regression analysis taking into account gender, seminar type and other relevant variables was used to fi nd predictors of expectation.
Results There were in all 925 respondents. Factors predictive of strongly met expectations were strongly fi nding the seminar interesting, OR 5.11, 95% CI (3.43-7.61), balanced OR 2.49, 95% CI (1.62-3.80) and understandable, OR 2.47, 95% CI (1.53-4.01). These OR were all highly signifi cantly increased p < 0.001. There was also evidence of a signifi cant interaction (p = 0.039) between gender and type of seminar. Conclusion The importance of gender is demonstrated in this analysis. As with other health promotion activities, more targeted student health seminars could enhance engagement.
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Introduction
Partnerships between schools and health care providers offer an opportunity to contribute to school pupils’ health education. The settings-based approach to health promotion, as promoted by the World Health Organisation, is highly contextual in that it capitalises on the infrastructure, expertise and resources available to achieve positive outcomes for individuals (1). The Health Promoting School Model together with Healthy Cities and Healthy Workplace Settings for health promotion is the basis for the now established International Network of Health Promoting Hospitals and Health Services (HPH Network) and proposes a health-proofed spiral curriculum content, in that key concepts are revisited at different age points, with different subject areas and with increasingly complex content. Although it is well understood by health educators that one-off talks are not effective in themselves, they can improve knowledge, and contribute to a wider personal skills development strategy, as well as acting as a cue to action in relation to behavioural modifi cation and change (2;3).
The HPH Network too can make an educational contribution on health matters to the wider community by providing topic-specifi c and informative materials to adults and young people in its catchment area. Although collaborative seminars between the health sector and school communities are a commonly used educational technique for improving students’ knowledge on health promotion topics (4-8) and undoubtedly a signifi - cant grey area, literature is likely to exist in many countries. However, relatively few systematic evaluations of satisfaction have been published to date, including whether such seminars meet the expectations of students, an important educational outcome if the learning objectives are to be capitalised upon. For instance Bandura’s social cognitive model for health promotion identifi es a number of components infl uencing health behaviour including self-effi cacy, socio-structural factors and outcome expectations (9). The consideration of met expectation may infl uence quality of life assessments as from treatment pathways as well as experience (10).
Such school programmes can be resource-intensive, however, and arguably be at the expense or opportunity cost of other, possibly more effi cacious interventions. Accordingly, evidence-based evaluations, which assess impact, process and outcome from the intervention, are important. Examples from the literature are various, dating from early efforts to reach young people on AIDS prevention (5;11), sun protection (2;12) and fruit and vegetable promotions (13), alcohol (14;15) and exercise programmes (16) and specifi c medical interventions around medication consumption (17), or organ donation cards (18;19). St Vincent’s University Hospital is a large general teaching hospital in Dublin. The hospital’s Department of Preventive Medicine and Health Promotion was one of the fi rst established in the world in the nineteen seventies and has a long history of health education and health promotion activities in cardiovascular disease prevention in particular. It has received a gold level award from (ENSH European Network for Smokefree Healthcare Services) Global Network for Tobaccofree Healthcare Services for becoming the fi rst campus to ban smoking outright in 2009 (20;21).
The department has offered structured one-hour health education seminars for both male and female transition year students from second-level schools in the surrounding area since 2000 (See Participants below). The purpose of these seminars is to act as a support that helps reinforce what the students have learned in Social, Personal and Health Education (SPHE) modules as part of the National school curriculum (22;23), or possibly other mainstream subjects such as Home Economics, Science or other relevant topics in their so-called Transition year curriculum (24). The aim of the programme is to develop the students’ skills and knowledge in relation to their health, personal lives and social development. Our objective in this analysis was to assess whether the content or topic of the seminars met student expectations and whether this was infl uenced by gender, content and type of seminar offered or by students’ opinions of the seminar. This is an evaluation of the fi ndings of the selfadministered surveys completed by each student for the seminars attended from 2009 to 2013.
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Methods
Participants
Transition year is an optional year offered by schools in the Republic of Ireland between the junior and leaving certifi cate cycles (aged on average 15-16 years). The Transition year offers a fl exible, personal skills development curriculum for students, with the aim of helping them integrate into the working and social environment when they leave school. Transition year students are targeted for this hospital seminar programme, as they tend to have fl exible timetables with no end-ofyear examinations. Each school plans its own unique Transition year programme, which also includes core academic subjects. Students may choose other fl exible modular subjects, some of which can cover areas in mental, physical and emotional health. Currently the Social, Personal & Health Education Program (SPHE) provides Irish secondary school students with one class period per week, throughout the 3 years of the junior cycle.
Procedure
The hospital seminars we provided were interactive, delivered by topic specifi c clinical experts and offered the opportunity for students to ask questions and receive advice from health professionals, who were experts in their relevant fi eld. The health seminars all took place in the hospital. Each one lasted approximately one hour and consisted of an oral presentation, along with power point presentations and discussions. Facilitators were drawn from disciplines across the hospital; Medicine Specialties, Nursing, Physiotherapy and the Health Promotion staff themselves. The topics covered and the year offered are summarised in Table 1.
At the end of each seminar, students were asked to complete an evaluation form rating the seminar they had just attended. Students answered a series of mainly closed questions in Likert scale format where 1 represented strongly disagree, 2 represented disagree, 3 represented undecided, 4 represented agree and 5 represented strongly agree. We asked whether the seminar met the students’ expectations, whether they found the seminar interesting, how they found the balance between information and activity and whether they understood the information given. Other questions used a yes/no/don’t know answering system which covered length of programme, whether they had learned the information in school already, or learned anything new and were interested in attending another seminar. Students were also asked which part of the seminar they had liked the most, least liked and if they had any suggestions on improvements.
Data Analysis
Data from the student evaluation forms were analysed using S.P.S.S. (Statistical Package for the Social Sciences). All questions on the evaluation forms were tested for signifi cance at the 0.05 level of probability, employing the chi square test of independence to compare differences in range of response between male and female student respondents. For the multivariable logistic regression analysis, we selected strongly agreed that the seminar met expectations as the outcome measure and dichotomised the variable appropriately. The initial logistic model included ender, type of seminar and all the other rating measures from the evaluation form as co-variates. Likert scale variables were dichotomised into ‘Strongly agree’ versus the rest. The second and fi nal model included those variables that met a signifi cant level of p < 0.05. A signifi cant (p = 0.039) interaction between gender and type of seminar was also found and included in the model.
Results
In all, 925 students attended seventeen seminars from a range of local schools in the South Dublin area and each completed the individual evaluation forms. Though response rate was not systematically recorded, all students were expected to complete the forms, collected by one of the health promotion team. Based on booking information, an average class size of around 72 per seminar and the average number of forms collected was 54, we estimated a response rate of approximately 73%. Overall the seminars were evaluated positively by the students with Smoking and Cancer Awareness performing particularly well. The Minding Your Mind (MYM) seminar had a less positive response. All individual survey questions were evaluated positively for all students with understood information given, learned anything new, interested in attending another seminar and length of programme performing particularly well. The findings from the univariate analysis are summarised in Table 2, giving the strongly agree and strongly disagree categories for both male and female respondents. There were apparent gender differences between the individual seminars. The Healthy Eating Active Living seminars tended to be more popular with males, while Minding Your Mind, Smoking and Cancer Awareness tended to be more popular with females.
Predictors of a seminar strongly meeting expectations were examined. In the fi nal logistic regression model (Table 3) the four signifi cant predictors were the type of seminar, whether students found the seminar interesting, whether they found the balance between information and activity was good and whether they understood the information that was given. All four of these factors were associated with strongly met expectations for the seminar. A signifi cant (p = 0.039) interaction between gender and type of seminar was also found. The odds ratios for each type of seminar according to gender are presented in Figure 1, with the cancer awareness seminar for males as the reference category. The Minding Your Mind seminar least met male expectations.
Discussion
This was a systematic evaluation of an ongoing health education seminar series showing that content, topic area and gender were all important factors in meeting students’ expectations. The study has strengths in that there were high and consistent levels of student evaluation and numbers were suffi cient to examine different aspects of the content of the seminars. For the fi nal logistic regres-
sion model, we took a stringent cut-off point of strongly meeting expectation, as such programmes are likely to meet expectation to some degree, which proved to be the case with most students. A higher-level cut-off helps to discriminate opinions more clearly.
As might be expected, in that model, if the topic was rated as novel, interesting or informative, it was more likely to meet expectation. If content was already covered in the school curriculum it was less likely to be highly rated. The seminar with the lowest score for learning anything new, in both males and females, was for instance Healthy Eating and Active Living, suggesting that the students had covered this information in school programmes such as S.P.H.E. or Home Economics or more widely from media and other sources. The Minding your Mind seminar was least popular, particularly for males, which may relate to the fact that both males and females scored it lowest on balance between information and activity. The gender effect was also consistent, both in differences between males and females generally and in relation to specifi c seminars. Female students showed a greater interest in attending future seminars when compared to male students.
Sex differences in how students receive health information are well documented internationally and should be addressed in planning. The Hamilton Board of Education in Canada carried out 70 minute AIDS seminars for senior grades in 10 secondary schools in 1990 and reported on the fi ndings of student surveys to ascertain how useful students found the seminar and also found a gender effect, with greater interest amongst girls (5).
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The gendered nature of education is particularly relevant for sex education (25-27). Previous studies in Ireland have shown that girls perceived breastfeeding as more challenging than boys because they would actually have to initiate the practice, whereas boys could be supportive without commitment themselves (28). Similarly fashion conscious girls were more likely to be smokers, the converse with boys (29). In a schools lifeskills programme, girls were more likely to engage effectively with the programme than boys (15). These gender effects persist into adulthood and in other settings (30;31). Men appear to favour more factbased than skills development programmes in primary care (32). Planners of health education and promotion programmes should routinely proof their content for this effect, to ensure the content is relevant and focused to the target audience, whilst avoiding the introduction of bias and preconception about different gender expectations and maintaining gender equity considerations.
Limitations
It is problematic that the exact response rate is unknown, though we estimate that around three-quarters of the students attending any given seminar did complete and hand up the evaluation form. Another possible limitation is that the students might have been infl uenced by the classroom effect when they were completing their evaluation forms; discussions could have occurred between the students during the completion of the evaluation form. Individual students may have had an effect on their fellow students’ opinions and this could have led to non-independent responses from the students. Such clustering is a common consideration, however the study did show a wide spread of opinion, both within and between groups. We performed a number of tests at univariate level and as in most similar type analyses there was no correction for multiplicity. We could arguably have considered a correction such as that of Bonferroni. Use of such a method can be over conservative, however and it is up to the reader to interpret our fi ndings as given. On the other hand, the main outcome we set for the regression model was strongly agreeing to meet expectation, which is quite stringent and we wished to retain power to consider several variables in the model.
Another limitation of the study is that it was observational in design without pre-seminar data on knowledge, attitudes or beliefs and was not randomised in design. Nevertheless it does give important insight into delivery of a hospital-based programme for schools on which there is little published literature. In health promotion there is much discussion as to whether random allocation to an intervention is feasible though in general for logistic reasons, especially in a setting such as a hospital, this would be diffi cult to mount. For instance school groups could be randomly allocated to topic seminars, stratifi ed by gender with a priori powered outcome measures. In the real-time setting a topic list is offered to schools, and they have the option to choose, introducing some self-selection into the analysis.
Conclusions
In conclusion, differences emerged according to gender and type of seminar in this evaluation in common with other health promotion activities. Whilst a majority of students rated the seminars positively, more targeted student health seminars could enhance engagement at the strongly agree level. The school presents an important opportunity to provide effective topic-based health education in partnership with health professionals. We have shown in this study that content and gender infl uence expectations, which is of international interest to those working in developing such programmes. This could include proofi ng the content for gender specifi c issues, rather than simply opting to deliver the seminars separately.
Funding
The schools pay a small concession towards the running costs of the seminars. There was no formal funding of the evaluation. As this is completely anonymous data collected for routine service evaluation it is regarded as an audit rather than research and does not require formal approval by the hospital’s research ethics committee.
Author contribution
Planning, implementation, analysis and write up of seminars: All authors.
contributed to the planning, implementation, analysis and write up of the seminars.
Maina draft of manuscript: CK, PF
Responsible for planning, delivering and evaluating the seminars: IG, GC, KD
Statistic: DK, OF, MK under the supervision of IG, KD, LD.
Analysis, data interpretation, write-up of the fi ndings, and approved the paper: All
Competing Interest
None declared.
References
(1) Kelleher CC. Evaluating health promotion in four key settings. In: Quality, Evidence and Eff ectiveness in Health Promotion. Striving for Certainties. (Eds) Davies JK and Mac Donald G. Routledge. London. 1999.
(2) Geller AC, Rutsch L, Kenausis K, et al. Can an hour or two of sun protection education keep the sunburn away? Evaluation of the Environmental Protection Agency’s Sunwise School Program. Environ Health 2003; 2:13.
(3) Olm-Shipman C, Reed V, Christian JG. Teaching children about health, part 11: the eff ect of an academic-community partnership on medical students’ communication skills. Educ Health (Abingdon) 2003; 16:339-47
(4) Kelleher CC, Fallon UB, McCarthy E et al. Feasibility of a lifestyle cardio-vascular intervenÆŸ on programme for 8-15 year olds in Irish general practice: results of the Galway Health Project. Health Promo Int. 1999; 14:221-9.
(5) Scott F, Chambers LW, Underwood J, et al. AIDS seminars for senior grades in secondary schools. Can J Public Health 1990; 81:290-4.
(6) Michael S, DiƩ us P, Epstein J. Family and Community Involvement in schools: results from the School Health Policies and Programs Study 2006. J Sch Health 2007; 77:567-87.
(7) Brener ND, Weist M, Adelman H, et al. Mental Health and Social Services: Results from the School Health Policies and Programs Study 2006. J Sch Health 2007; 77:486-99.
(8) Crickmore Farrior K, Keehner Engelke M, Shoup C et al. A community pediatric prevenÆŸ on partnership: linking schools, providers and Tertiary Care services. J Sch Health 2000; 70:79-83. (9) Bandura A. Health Promotion by Social Cognitive Means. Health Educ Behav 2004; 31:143-60.
(10) Carr AJ, Gibson B, Robinson PG. Is quality of life determined by expectations or experience? BMJ 2001; 322:1240
(11) Brown LK, Fritz GK. AIDS education in the schools: a literature review as a guide for curriculum planning. Clin Pediatr (Phila) 1988; 27:311-6
(12) Buller DB, Reynolds KD, Yaroch A et al. Eff ects of the Sunny Days, Healthy Ways curriculum on students in grades 6 to 8. Am J Prev Med 2006; 30:13-22.
(13) Keihner AJ, Meigs R, Sugerman S, et al. The Power Play! Campaign’s school idea & resource kits improve determinants of fruit and vegetable intake and physical activity among fourth- and fifth-grade children. J Nutr Educ Behav 2011; 43:122-9.