Validation of School-Based Health Education on Knowledge and Attitude of Female Students towards Female Genital Mutilation

Abstract: Background: Over the years, the governments conducted multiple interventions to address female genital mutilation. However, this inhumane practice continues because of several cultural and educational factors. Therefore, this study aimed to develop and validate school-based health education program for female students to raise their knowledge and change their attitude towards female genital mutilation. Methods: Quasi-experimental study was conducted to validate health education program by using a stepwise approach as the following: the content validity was assessed by academic experts (n = 15) using the suitability assessment of materials (SAM) tool; face validity was assessed by adolescent students (n=40) using a self-administered three-point Likert scale; and a pre-and post-intervention assessment of knowledge and attitude among adolescent students (n = 200) was done to evaluate the construct validity. Results: The content validity ratios were ranked above 60% by the experts. The face validity results also revealed excellent validity indices varying from 75 to 100 %. Additionally, there were statistically significant improvements in the mean knowledge and attitude scores (P< 0.001) post-intervention with huge effect sizes (d =6.38, and d =3.54 respectively). Conclusion: the validation process helps in assessing the relevance of health education program for greater acceptance and responsiveness by adolescent students and for ensuring more program implementation fidelity.


Introduction
Globally, World Health Organization (WHO), 2023, estimated nearly 200 million women and girls had undergone female genital mutilation (FGM). This practice is common in developing countries and traditionally conservative cultures, with the highest estimated prevalence in sub-Saharan Africa, Asia, and the Middle East.
As declared by Omar 2022, the rate of FGM in Egypt is still high. As, it has a long history in the nation, dating back to the Pharaonic era.
According to the 2015 Egypt Demographic and Health Survey (EDHS), nearly 92% of Egyptian adult women had been circumcised. Moreover, based on reported mothers' intentions, it is anticipated that more than 50% of girls from birth to adolescence will be circumcised in the future Hence, the validation process was adapted in this study to provide a framework through which a representation of the potential public health impact of the educational program for adolescent students towards female genital mutilation could be easily developed and presented.

Aim of the study:
The study was conducted using a stepwise approach to achieve two objectives: (1) To develop health education program for adolescents' female students to raise their knowledge and change their attitude towards female genital mutilation; (2) To validate the health education program towards female genital mutilation using a framework.

Research Hypotheses:
To achieve the study's aim, the following research hypotheses were developed: H1: The post mean students' knowledge towards female genital mutilation is expected to be improved after the implementation of the health education program.
H2: The post mean students' attitude towards female genital mutilation is expected to be improved after the implementation of the health education program.
H3: The health education program is expected to be validated after implementation of the validation process steps.

Materials and Methods:
Design: Quasi-experimental study using a stepwise approach (The key approach of the intervention was a health education program mediated by researchers using various assisted tools). Booklet, and printed media were used as assisted tools to deliver the HE program in the randomly selected preparatory and secondary schools.

Setting:
The study was conducted at eight randomly selected preparatory and secondary schools from El Mansoura and Bani-Sweif districts.

Subjects and sampling technique:
There were two target groups used for the development and validation of the HE program: experts in the fields of gynecological and community health nursing, in addition to education experts. As well as the end-beneficiaries group were adolescent female students (≥ 13 years old) who accepted to participate in the study.

For selecting end-beneficiaries:
A multi-stage stratified random sampling technique was used to select the female adolescent students throughout two stages. During the first stage, stratified sampling was employed by dividing each district into two strata. East and west strata; then each of them was also divided into two strata, preparatory and secondary school strata; then four schools (two preparatory and the other two secondary) were selected from each district, totaling eight schools. During the second stage, one class was chosen randomly from each school, and then a simple sample of students was randomly selected from each of the eight randomly selected classes.

For selecting experts:
A judgmental technique was used to select the study experts (gynecological and community health nursing, in addition to experts in education) who had a PHD and experience of more than 10 years in their specialty.

Data collection methods:
Data collection was accomplished by hiring three self-constructed tools, and one adapted scale that were translated into simple Arabic to collect the necessary data for this study.

Ethical considerations:
The study was approved by the research ethics committee of the faculty of Nursing, Mansoura University. Verbal informed consent was also obtained from the participating students for answering the study tools after being informed about their right to withdraw from the study at any time without giving a reason.

Study procedure:
The actual fieldwork for the study was conducted over a six-month period, from the first of September 2022 to the end of February 2023. The study was carried out through two phases, as shown in the schematic diagram (1).

Needs analysis:
Prior to the development of the HE program and its supporting material and tools, needs assessment, and a situational analysis were conducted using Tools I &II to get an overview of the students' knowledge and attitudes towards FGM and to determine the purpose of developing the HE program. printed materials (brochures, factsheets, guides, etc.), were analyzed to provide the key findings of the health messages to be delivered to the students.
Then, the planning of the HE program was done, including the design of the assisted material and tools. The 1 st draft of the assisted material (booklet) and tools was arranged with consideration of a suitable Arabic language, appropriate illustrations, and an attractive layout to ensure readability, understanding, and culturally relevance.

Diagram(1): Steps followed in developing and validating the HE program
The validation of the HE program:           Recommendation about the desired behavior is simple and satisfactory 0.93

Comprehensiveness of the delivered information 0.98
There is no unnecessary information 1.00

Literacy demand
Language is conversational and, written in the active voice 0.95

Instructions model specific behavior 0.95
Material is reader-friendly 0.98 Majority of the vocabulary is composed of common words 0.75

Illustrations
Illustrations are simple, appropriate and present an easily understandable outline 0.93 They are related to the text (express the desired purpose) 0.93 Lists and graphs are self-explanatory 0.85

Learning Stimulation and Motivation
Material enables the student to undertake the desired actions 0.75 Using different and interactive teaching methods (Interactive lecture ) 0.95

Presence of assisted material and tools
Providing appropriate guiding booklet aligned with the HE program content 0.98 Providing appropriate assisted tools as (Brochures, Knowledge, attitude tests) 0.98

Cultural appropriateness
It is integrated to the local culture 0.93 Images and examples present culture in positive ways.       So, the governments should enact deterrent laws that eradicate such inhuman practices.

Conclusion:
We validated health education program for their content and relevance. The evaluation process of the program included academic experts and endbeneficiaries (adolescent students). The HE program and its assisted material are relevant and can be considered as valid education materials for adolescent students in similar sittings in order to bring about changes in their knowledge and attitude towards FGM. This paper also highlights the importance of the validation process as a part of HE program implementation fidelity.

Recommendations:
Generalizability of the FGM health education program to similar sittings and population would be possible. Additionally, we recommend replication of the validation process in other future research, especially in the nursing areas, to ensure more implementation fidelity.
Funding: Self-funded, without any external source