Intervention program
The health education program we developed aimed to improve education for the prevention of cervical cancer, to reduce the risk of sexual transmitted infections (STIs), and to improve HL among female undergraduate students aged 20 and older. The program was developed with reference to previous studies using skills training for condom use [16,17] to improve HL education by using jargon-free communication, pictures to clarify concepts, and confirmation of participants’ comprehension via the “show-me” or “teach-back” method [18] based on feedback from female nurses and undergraduate students. The program consisted of a group lecture and a demonstration to provide knowledge on the following: (i) use of a basal body temperature thermometer and a vaginal discharge model to understand one’s own menstrual cycle; (ii) gynecological disease cases (e.g., general STIs, and cervical cancer) to learn about recent trends in and the prevention of gynecological diseases; and (iii) using one’s own smartphone to access health resources and worksheets regarding gynecological examinations and consultations. The teaching materials used in the program were created using Microsoft PowerPoint 2013 (Redmond, WA, USA). A literature review regarding HL and women’s health suggested that readability, layout, and design were key components in developing effective printed materials [19]. We previously conducted a program development study, and all participants indicated high levels of satisfaction and understanding of the material, an appropriate level of difficulty of the curriculum, and had improved HL and knowledge of women’s health after completing the program [15]. We sent e-mails (e.g., information about the menstrual cycle, gynecological diseases and women’s health resources) to the participants’ smartphone once a month for 3 months after the group lecture. The contents of the program are shown in Table 1. A researcher conducted the group lecture and demonstrations after providing an explanation of the study purpose and methods to the participants.
Study Design
In the present study, a quasi-experimental study with comparison groups was used.
Participants and setting
Participants for the intervention group and control group were recruited from one private university in Kyoto, Japan. Participants were recruited from three faculties designated by the university cooperating in the study to avoid cross contamination of information between groups. The intervention group participants were recruited from the faculties of economics and psychology and the control group participants were recruited from the faculty of bio-environment. A poster was placed in each of the three faculties requesting student participation. The inclusion criteria for both groups were: (ⅰ) female Japanese undergraduate students, (ⅱ) aged 20 years or older. The sample size for each group was set at ≥13 people based on the difference in HL scale scores in our previous study [15]. The study was conducted between March and October 2015. The start of the program was scheduled to coincide with the participating students’ course registration and health checkup.
Evaluations and variables
We conducted an anonymous self-administered questionnaire survey and managed the data using concatenate numbers. Assessments of each group were conducted before (baseline) and 6 months (follow up) after the program was implemented. The study variables were basic attributes and HL variables. Basic attributes consisted of age, gynecological history, sex education history, level of concern for one’s own body, and cervical cancer screening history. HL variables consisted of HL scale score, confidence in explaining one’s own body to a medical practitioner (Y/N), cervical cancer screening behavior (Y/N). Test of knowledge for women’s health was used to measure knowledge of women’s health. The participant’s cervical cancer screening behavior indicated whether they had undergone that screening within 6 months after the program (Y/N). HL scale for Japanese women in their 20s and 30s organized into four subscales (Cronbach’s a, 0.75–0.83) was used to obtain HL scale score (score range, 21-84) [20], with reference to a previous study on the development of an HL scale for Japanese [21]. Questions to test knowledge of women’s health (score range, 0-20) were developed with reference to previous studies on women’s health [17,22,23]. Our study design did not randomly assign participants to the two groups, so we conducted intergroup pair matching using the variables of concern for one’s own body (Y/N) and HL scale score at baseline. The evaluation protocol is shown in Figure 1.
Statistical analysis
The data were analyzed using SPSS, version 23.0 for Windows (SPSS Inc, Chicago, IL, USA). Statistical significance was set at P<.05. Analysis of the results consisted of calculating basic statistics and intergroup comparisons of HL variables, knowledge of women’s health, and cervical cancer screening behavior at follow-up using the Mann-Whitney U test and Fisher’s exact test or the chi-square test.
Ethical considerations
All participants were informed of the study aims and methods and assured that their participation was voluntary and that every effort would be made to protect their privacy. Written informed consent was obtained from all participants. We provided all participants with pamphlets on women’s health after follow-up.