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
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.
… about me
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.amaassn.org/cgi/content/abstract/archinternmed.2011.555v1).
 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.
Rationale of the Study
 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 Nepal’s 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 people’s understanding
of unintended pregnancies, abortion, infertility, cancer,
and STIs including HIV.
4
Rationale of the Study…
 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 teacher’s 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
Philosophical Assumptions
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...
 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
Main Research Question
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
Sub-Questions
 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
Hypotheses to be Tested
 Hypothesis
(H1) = Sex education programme delivered
by health facilitators (experiment group) is more likely to
promote young people’s sexual health knowledge and
understanding compared to programme delivered by
conventional teachers (control group).
 Null
hypothesis (H0) = There is no significant difference
in the post-intervention achievement of control group
and experiment group in promoting young people’s
sexual health knowledge and understanding.
10
Research Design
 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...
 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
Trial Endpoints
 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
government’s existing sexual health curricula.
 Final evaluation was carried out after eight weeks of the
baseline survey.
13
Trial Endpoints...
Randomisation of
schools/Baseline
questionnaires
Intervention arm
Control arm
(Programme led by
health facilitators)
(Programme led by
conventional teachers)
Pupils from grade-IX
Final evaluation of the survey
Compare results
14
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
15
Questionnaire Piloting...
Piloted 3 Schools in Hetauda Makwanpur
16
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.
17
Questionnaire Piloting Flow Chart...
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)
Reliability procedure
Reliability:
Internal consistency (Chronbach alpha)
Test-retest reliability (Continuous data/Pearson correlation coefficient; non- continuous
data/Wilcoxon non-parametrical test)
Final sexual health knowledge and understanding
questionnaire
Questionnaire Piloting...
Instruction before the questionnaire distribution
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
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
Main Study Data Collection
 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...
A
baseline questionnaire survey was carried out as a preintervention. 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...
 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
Ethical Issues
 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
Basic Analysis
Baseline_followup
baseline
follow_up
Total
Type_school
control
intervention
Total
Gender
male
female
Total
Frequency
421
387
Percent
52.1
47.9
808
100.0
Frequency
472
336
808
Percent
58.4
41.6
100.0
Frequency
382
426
808
Percent
47.3
52.7
100.0
26
Basic Analysis...
Age
Frequency
327
219
183
54
25
808
Percent
40.5
27.1
22.6
6.7
3.1
100.0
brahman/chhetri
Frequency
384
Percent
47.5
magar/gurung/rai/limbu
newar
tamang
madhesi
others
Total
98
88
129
43
66
808
12.1
10.9
16.0
5.3
8.2
100.0
14
15
16
17
18
Total
Caste
27
Further Analysis
 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 intraclass correlation.
28
Further Analysis...
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
Accomplishment
Two book review published
 Global Politics of Health: Davies, Sara (2010). Polity Press:
Cambridge. http://www.socresonline.org.uk/16/1/reviews/3.html
 Promoting Health and Wellbeing through Schools: Peter Aggleton,
Catherine Dennison and Ian Warwick (2010). Routledge: Oxon.
http://rsh.sagepub.com/content/131/5/240.2.citation
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…
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)
Membership

British Educational Research Association (BERA)-2010
 Royal Society of Public Health (RSPH)-2010
Activities To Be Accomplished

A thorough literature review and update of methodology
based
on
2010
CONSORT
statement
(http://www.consort-statement.org/).
 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.
Some Photos
Resource person, Mr.
Yuva Raj Dahal from
DEO
facilitating
the
session
Some Photos…
Bal Jyoti secondary
school
(a typical
Nepali school) acts as
an intervention site
Some Photos…
Health
facilitators
developing
a
session plan
Some Photos…
Pupils are reading
consent form before
participating
in the
research.
Thank You!
Any question please?