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The evaluation of the effectiveness of health education interventions in clinical practice: a continuing methodological challenge: Aim. This paper examines the methodological issues arising from an evaluation of the effectiveness of a health education project undertaken to increase Hong Kong Chinese women's knowledge of the prevention of cervical cancer and the uptake of screening.
Background. The significance of health promotion to the prevention of diseases currently affecting contemporary society has become increasingly recognized. Within the context of health promotion health education continues to provide an important preventive strategy. Indeed the leading causes of mortality such as coronary heart disease and cancer lend themselves well to health education interventions. However the evaluation of the effectiveness of health education remains complex and raises some important methodological issues.
Design. The project used a health education intervention as the major preventive strategy and employed multiple methods of evaluation to assess its effectiveness. Outcome evaluation consisted of a confidential questionnaire administered at two points in time to measure changes in health-related behaviour and knowledge. It also included the collection of data from service providers to assess changes in the uptake of cervical cancer screening. Process evaluation involved the use of focus groups with randomly selected groups of women who had participated in the health education intervention and a diary kept by the project nurse.
Findings. Methodological issues identified in the evaluation of the project included the extent to which changes in health-related knowledge and behaviour could be attributed to the intervention, the sensitivity of outcome measures and challenges in developing methods of process evaluation appropriate to the target population.
Conclusions. The findings highlight the complexity of designing effective evaluation strategies for health education and the need to consider these issues in the development of both process and outcome evaluation.
The contribution of health promotion to the prevention of contemporary diseases affecting society has become increasingly recognized. The targets for health set by organizations such as the World Health Organization (WHO) and the Department of Health (DOH) in the United Kingdom (UK) provide examples of the perceived significance of health promotion to the prevention of the major causes of mortality and morbidity (Buck et al. 1997). In addition, the complexity of the causation of many diseases such as coronary heart disease has highlighted the continuing need for health promotion interventions to draw on the combined strategies of health protection, prevention and education (Downie et al. 1996).
Despite the significance of combined strategies of health promotion to successful programme outcomes, health education interventions continue to play an important role in the prevention of disease. This is particularly so in diseases such as coronary heart disease and some types of cancer where changes in individual risk factors remain an essential component of prevention. Health education has focused traditionally on changing the knowledge, attitudes and behaviours of individuals and communities in preventing the onset of disease (Tones 1997). More recent interpretations have highlighted the importance of health education in raising awareness of those with potential power of the effects of social and environmental factors on health, as well as creating self empowerment amongst individuals to promote their health (Tones & Tilford 1994). Indeed, the need for the goals of health education to extend beyond the traditional focus of health knowledge, attitudes and behaviour to changes in capacity, social support and control over decisionmaking highlight the increasing complexity of evaluating the outcome of health education (Israel et al. 1995).
The literature, however, suggests that even the traditional approach to health education demonstrates the complexity of evaluating the outcome of health education interventions. The difficulty created by the time lag between the intervention and outcomes of that intervention has been consistently acknowledged. Authors suggest that the outcome of interventions in the 1990s will not be evident until well into 21st century (Buck et al. 1997). Attempts to overcome the difficulties of the long-term nature of evaluation in health education have led to the development of a range of indicators to assess the outcomes of interventions (Tones & Tilford 1994). Indeed frequently traditional epidemiological outcomes of changes in mortality and morbidity are inappropriate for evaluation and intermediate or indirect indicators are required. Nutbeam (1998) argues the need to select indicators that are sufficiently sensitive to reflect the effects of the intervention. The difficulty in determining appropriate indicators to measure the success of the intervention also highlights the need for pertinent definitions of the anticipated outcomes of the intervention. Macdonald et al. (1996) argue that inappropriate outcome indicators have contributed to the complexity of evaluation.
The significance of appropriate outcome measures has also been highlighted in the critique of the over reliance on the knowledge, attitude and beliefs paradigm as a valid model of behaviour change (Buck et al. 1997). Buck et al. (1997) go onto argue that this paradigm assumes implicitly that individuals will change their behaviour in response to the acquisition of knowledge about the health consequences of their actions facilitated by their changing attitude. Much critique has been made of this paradigm which implies that information and personal responsibility is all that is needed to change behaviour. Indeed there is clear evidence indicating that socio-economic status, poor educational attainment, environmental factors and levels of self-esteem influence individuals' potential to change their health behaviour (Freudenberg et al. 1995). Indeed the rather simplistic view of the contribution of the knowledge, attitudes and beliefs paradigm to behaviour change has limited the development of appropriate outcomes thereby contributing to the difficulties involved in the evaluation of interventions.
A particular issue in evaluation is that of determining attribution in health education. The difficulties of using evaluation strategies such as randomised controlled trials (RCTs) has been well documented. The complexity of delivery of the intervention and problems of contamination between control and intervention groups particularly contribute to this difficulty (Nutbeam 1998, Webb 1999). The multifactorial nature of health education interventions has contributed to the complexity of attribution. Factors include communities' and individuals' perceptions of the value of different health needs, and the participation and partnership of communities and individuals (Allison & Rootman 1996, Macdonald et al. 1996). In addition, the development and delivery of the intervention which include the personal values and norms of the health educator have been identified (Van der Weijden et al. 1998). The multifactorial nature of health education raises issues about appropriate strategies for evaluation.
There has been considerable debate about the relationship between process and outcome measures in the evaluation of health education and health promotion (Sanson-Fisher et al. 1996). Although debate continues about the different contribution of process evaluation in assessing how the programme works, and outcome evaluation in assessing whether it changes health behaviours, there is clear consensus about the requirement for a comprehensive evaluation strategy (Israel et al. 1995, WHO 1998). Indeed it is argued that effective strategies should involve process evaluation, outcome evaluation and context evaluation. It is also acknowledged, however, that frequently it is only possible to use one or two of these strategies (Israel et al. 1995). Evidence such as this highlights once more not only the complexity of evaluation strategies but also possible methodological issues that arise in the evaluation of interventions. A project using a health education intervention to increase Hong Kong Chinese women's knowledge about the prevention of cervical cancer and available screening programmes provides an illustration of some of the methodological issues that arose during the evaluation of the project.
Cervical cancer remains a significant cause of mortality and morbidity in women's health despite the efficacy of the screening procedure for the disease (Herbert 1997). Indeed cervical cancer is one of the few cancers for which there is a `consensus-approved' screening test not only for early diagnosis but more importantly for prevention of the disease (Marcus & Crane 1998). Despite the effectiveness of cervical screening, cancer of the cervix remains the seventh cause of mortality amongst Hong Kong Chinese women with a mortality rate of 4·3 per 100 000 women in 1996 (Hong Kong Cancer Registry 1999). In order to prevent these avoidable deaths women need to attend regularly for cervical screening. A number of extrinsic and intrinsic factors have been shown to influence women's attendance pattern for Papanicolaou (Pap) smears (McKiernan et al. 1996). Intrinsic factors include women's knowledge, belief and attitudes about cervical cancer and screening procedures. Knowledge levels about both the disease and screening procedures have been shown to be particularly significant to women's uptake of screening services in a range of cultural and socio-economic groups (Fylan 1998).
The aim of the health promotion project was to assess the feasibility of using a community outreach programme run by a registered nurse to increase women's knowledge and understanding about the prevention of cervical cancer and to increase the uptake of screening services. The objectives of the project were to:
The programme was targeted at community groups located in a particular area of Hong Kong where the census data suggested there were higher numbers of women from lower socio-economic groups as this has been identified as a risk factor associated with cervical cancer (Marcus & Crane 1998). In addition, the demographic data also indicated higher numbers of potentially sexually active women, which is the major risk factor for developing cervical cancer (Marcus & Crane 1998). The project consisted of four preventive strategies. The first consisted of a needs assessment to ascertain women's knowledge and information needs about cervical cancer and screening procedures. Ten focus groups involving 94 participants were undertaken, with the number of women in each group ranging from 5 to 13. The second strategy involved the development of a community outreach programme, which involved networking with a range of community groups and providers of government and nongovernment cervical screening services.
The third strategy consisted of a health education intervention for women attending the identified community groups. The analysis of the data obtained from the needs assessment was used to develop the focus and content of the health education intervention. Women's lack of knowledge about screening procedures as well as the risk factors associated with cervical cancer was clearly demonstrated. In addition, their lack of perceived susceptibility was a particularly important finding. The analysis also identified barriers associated with the screening procedures including the stigma associated with the disease. These findings were therefore used to develop the health education programme using the Health Belief Model as a guiding framework. The health education intervention consisted of a 2-hour programme providing information about cervical cancer, associated risk factors and methods of prevention. The programme included group discussion, the use of a video developed for the project as well as the opportunity for women to see the instruments used during the screening procedure. The group discussion was considered a particularly important part of the session to facilitate women's exchange of views about cervical cancer and screening.
During the project contact was made with 40 groups and 34 of these groups participated in the programme with the number of women in each health education session ranging from 7 to 44. An important component of the formal health education session was to encourage women attending the groups to discuss the prevention of cervical cancer with their friends and relatives, thereby providing an informal method of health education. Informal health education has been described as particularly effective in strengthening the capacity of communities to respond to learning (Jeffs & Smith 1999). Indeed it was anticipated that the increased knowledge and understanding gained by women in the formal health education group would facilitate their discussion amongst friends and relatives by giving them confidence to talk about a stigmatized topic. The final strategy involved the direct mailing of information about cervical cancer and screening procedures to identified housing estates within the target area to reinforce the information provided in the formal and informal sessions. This paper focuses on the evaluation strategies used to assess the effectiveness of the health education intervention.
In an attempt to provide a comprehensive evaluation of the effectiveness of the programme both outcome and process evaluation strategies were used. Because of the long-term nature of changes in morbidity and mortality data outcome evaluation focused on assessing effectiveness of the programme in achieving changes in health-related knowledge and behaviour (Israel et al. 1995). Two strategies were used to assess this outcome. The first consisted of a confidential questionnaire administered at two points in time to women attending the health education session. The second consisted of an analysis of records maintained by service providers to measure any changes in attendance rates from 4 weeks prior to commencement of the programme to 6 weeks after the termination of the health promotion project (Yancey & Walden 1994).
Process evaluation was used to explicate the contribution of the health education intervention to any changes in women's health-related behaviour and knowledge and consisted of two methods of data collection. The first involved the use of focus groups with women who had participated in the programme to identify the strengths and weaknesses of programme implementation. Eight focus groups were organized with attendance at the groups ranging from none to 12 participants. The second method involved the project nurse completing a journal of her activities throughout the implementation and management of the project. It was anticipated that this would allow an assessment of the processes involved in the implementation, and identify activities particularly significant to the outcome of the programme.
The process and outcome strategies identified above were used to provide a comprehensive evaluation of the intervention. The use of these strategies, however, also highlights some important methodological issues for consideration by practitioners when assessing the effectiveness of a health education intervention.
Outcome evaluation consisted of the use of confidential coded questionnaires administered to women prior to the health education session and again at a follow-up telephone interview to assess any changes in health-related knowledge or behaviour. The data demonstrated a significant level of difference (P <>
The development of the questionnaire for the baseline assessment of knowledge and screening behaviours provides a further illustration of the methodological issues generated by the use of the questionnaire. Obviously the development of any questionnaire is determined to some extent by a range of assumptions about the nature of establishing knowledge and what is valid knowledge (Hepworth 1997). Although a panel of experts had assessed the content validity of the questionnaire and the questionnaire had been piloted, neither the amount of time required by women to complete the questionnaire, nor the help required in completing the questionnaire had been anticipated or demonstrated in the pilot study. This was a particular problem with the groups of older women as many of them had low levels of literacy. These women, who were a very important target audience because of their level of risk (Quinn et al. 1999), completed the questionnaires in small groups. Although other studies have used this method of evaluation (Neuhauser et al. 1998), difficulties were experienced in this project in managing the analysis of data obtained in this way. This was particularly so during the analysis of changes in health-related knowledge and behaviour to determine the effectiveness of the intervention.
Another methodological difficulty was highlighted in the use of the follow-up questionnaire to assess changes in health-related behaviour undertaken by a telephone survey approximately 6 weeks after the health education intervention. It was anticipated that this was an appropriate time to measure any changes in knowledge as well as providing women with sufficient time to attend for cervical screening, if they were going to do so. A total of 96 (42%) of women, however, continued to state their intention of attending for screening. This finding raises questions about the use of self-report intended behaviour as a method of evaluating the effectiveness of the intervention. In addition, although women had been given information about a free screening programme with an appointment system, some factors women identified as limiting their attendance, such as cost and accessibility, remained essentially unchanged after the health education intervention highlighting the complexity of evaluating such interventions. Although, once again, the open-ended questions in the questionnaire had attempted to address this issue, generally the qualitative data provided limited descriptions as many women appeared reluctant to expand their replies to the open-ended questions. Indeed it is interesting that despite women agreeing to participate in the follow-up interview by giving their telephone number in the baseline questionnaire, when contacted by the interviewer women appeared reluctant initially to complete the telephone questionnaire. Informal follow-up indicated that women were anxious about issues of confidentiality because the project nurse who had carried out the health education session was not used to conduct the telephone interview.
The second strategy employed during outcome evaluation consisted of an analysis of service providers' records. The use of service providers' records of women's attendance for screening before and after the intervention was considered an important objective method of assessing changes in health behaviour. In Hong Kong, however, there is no population-based computerized screening programme such as that provided in the UK and a range of practitioners provide screening services. This approach to screening made it impossible to access all service providers' records in the target area, particularly as many were private general practitioners (GPs). A decision was therefore made to focus on two main providers who had clinics in the target area which were the Family Planning Association (FPA) and the Department of Health (DOH). Evidence indicating that the FPA was one of the main providers of cervical screening supported this decision (Twinn et al. 1999).
Both organizations agreed to provide monthly attendance figures of women attending for cervical screening during the lifetime of the project. In addition, the FPA also recorded the source of referral for those women attending for their first Pap smear. The DOH, however, was only able to provide the total number of Pap smears taken within the region in which the project had taken place. This total included a number of clinics that were unlikely to be accessed by women participating in the project.
Although Table 1 demonstrates that both organizations reported an increase in the number of women attending for screening, attendance rates fluctuated particularly at the FPA clinics. In part this fluctuation may reflect the timing of the health education talks which were held mainly during the months of June–September 1998. The results presented in Table 1 also demonstrate the difficulties of attributing change directly to the health education intervention as the number of women citing the mass media as their source of referral for screening also increased. Indeed the methodological issues arising from the use of this strategy as a method of evaluating the effectiveness of the intervention, demonstrates that this method is only appropriate when all records can be directly accessed during the evaluation process.
| [Help with image viewing] [Email Jumpstart To Image] | Table 1 Statistical returns from the DOH and the FPA |
The significance of process evaluation in establishing the outcome of health education interventions has become increasingly recognized (Milburn et al. 1995, Nutbeam 1998, WHO 1998). Indeed it is now recognized that qualitative methods of data collection are essential to the evaluation process. This is particularly so in terms of providing an understanding of the processes involved and contributing to an evidence-base for health education (Milburn et al. 1995, Learmouth & Cheung 1999). Israel et al. (1995) highlight two issues significant to process evaluation, which are particularly relevant to this project. The first of these is the issue of coverage including the extent to which the programme reached the target population and the extent to which participants were exposed to activities. The second was the nature of the relationship between the health educator and participants. This issue was significant as the extent to which any planned change is successful will depend in part on the effectiveness of the relationship that has developed between the educator and participants.
Two methods of process evaluation were used in this study providing the opportunity to explore and investigate these issues. The first issue, that of the coverage of the programme, was addressed in part by the journal kept by the project nurse. This provided descriptions of her contact and networking with different community groups and the development and implementation of the health education programme. Although networking was successfully undertaken in terms of making contact with community groups, many of these groups were run by nongovernment organizations supported by government funding from the Department of Social Welfare. Generally these groups targeted more motivated women rather than those who were the most difficult to access. Indeed 219 (34%) of women attending the programme already had a Pap smear. It is important to note, however, the data demonstrated that although these women had previously had a Pap smear, they knew very little about the prevention of, or risk factors associated with, cervical cancer. Evidence such as this indicates the effectiveness of the project in targeting women with little knowledge about cervical cancer or screening.
Another important methodological issue relating to the use of the journal data was the possible reliability and validity of the self-report data. The project nurse recording the data was the only nurse involved in the study, which allowed no anonymity of the data. She was also employed by the project which raises issues about the extent to which she was willing candidly to share her frustrations and difficulties in working with the project, particularly in the process of networking and accessing hard to reach women. In addition, all the journal entries were made in English for the ease of analysis which raises questions about the extent to which the data reflect the accurate feelings of the project nurse for whom Cantonese was her first language. Although unique to this project, these issues in the author's view provide an illustration of more general issues related the use of journals as a method of process evaluation and perhaps highlight the importance of supplementing journal data with observations (Sheridan-Leos 1995). Indeed, although observation was not used systematically in this study, those sessions where video recording was used demonstrated the participation and enjoyment of women in the health education sessions. Importantly it also demonstrated the nature of the interaction between the women and the health educator. This was particularly significant to the success of the intervention, as she was young and single. Within the Chinese culture age and marital status remain influential to the effectiveness of relationships between women and health professionals (Chao 1995).
Focus groups provided the major method of data collection in evaluating the interaction between the health educator and participants, particularly the implications of the dynamics influencing the effectiveness of the intervention. Focus groups have been used extensively in the evaluation of health education programmes. Because of the synergy created by the group process which contributes to the depth of data focus groups are considered particularly useful in exploring experiences and modifying interventions (Packer et al. 1994, Straw & Smith 1995). The data obtained from those seven focus groups which were held, demonstrated the effectiveness of the relationship between the project nurse and participants with women referring to the project nurse with obvious warmth. Generally women were very positive about the strategies and content used in the programme, with the data identifying few strategies in the intervention that needed modifying. This is illustrated by comments such as
… I didn't know anything about it before even though I had gone for screening. The talk let me know what it was all about. In the past when I was asked if I had gone for screening I didn't know what to say because I didn't know what it was. The talk made me understand … Listen more and know more. Good.
It should be acknowledged, however, this finding may result from the lack of opportunity of many of these women in experiencing alternative methods of learning and group participation. Indeed one woman commented;
I think …What things do I want to add to it? Because my knowledge in this aspect is really very little…actually I can't answer this question.
Another possible explanation may relate to women's reluctance to criticize and comment on the health education intervention provided by the project nurse to a person who was seen as her direct employer. Indeed, generally, evidence suggests that older Chinese women are reluctant to criticize the care provided by professionals (Holroyd et al. 1998).
Another important issue to consider within the context of process evaluation in this project was the effectiveness of the focus groups as a method of evaluation. Although focus groups have been successfully used with similar populations of Hong Kong women (Twinn 1998), the depth of data obtained in the project was not as rich as earlier studies. In part this may have been accounted for by the size of the focus groups which were generally rather small consisting of three or four women, and this may have given little opportunity for the social interaction and group processes required to generate depth of data. Indeed attendance was a problem at the focus groups despite women stating they were willing to attend and being reminded about the date and time of the group. This is an interesting observation as attendance had not been a problem when using focus groups with similar populations (Twinn 1998). A further explanation may also be that women felt that they could contribute little to the discussion, particularly the older women who had minimal exposure to education. The depth of data may also have been influenced by the choice of moderator, who as previously described, was seen in a position of authority, which may have contributed to women's reluctance to share their ideas and experiences (Yelland & Gifford 1995).
The final methodological issue to emerge from the evaluation of the health education intervention also relates to process evaluation and raises questions about the management of data obtained from informal methods of evaluation. During the project the researchers were sent photos and letters of thanks demonstrating women's appreciation of the talks and the knowledge they gained about their health and the prevention of cervical cancer. In addition, as completion of the project, several requests were received from other community groups asking for similar health education sessions. Although obviously important to the evaluation of the project, the management of these data perhaps adds to the complexity of evaluating the outcome of health education interventions.
The evaluation of the effectiveness of the health education intervention used in this project raises a range of methodological issues which, in the author's view, should be considered by practitioners when developing and undertaking both process and outcome evaluation. Although some of these issues are specific to the cultural context and the nature of the project, others have implications for health education interventions in a range of settings. Issues such as the sensitivity of the outcome measures, the problems of determining attribution of change in behaviour to the intervention, and developing process evaluation strategies appropriate to the target group provide an illustration of the complexity of the process of evaluation. The complexity of assessing the effectiveness of interventions also highlights the importance of using both outcome and process measures supporting recent recommendations by organizations such as the WHO. In addition, the issues identified above highlight other important factors for consideration in the evaluation process such as the necessity of using complementary methods of data collection as well as different approaches to evaluation such as that of cost effectiveness. This appears to be particularly important if a truly comprehensive evaluation is to be achieved. Issues such as these highlight the continuing methodological challenges facing practitioners in assessing the effectiveness of health education which is an essential component of clinical practice.
The author would like to acknowledge the support of the Health Care and Promotion Fund Hong Kong in funding the study. The opinions, however, expressed in the paper remain those of the author.
1Allison K. & Rootman I. (1996) Scientific rigor and community participation in health promotion research: are they compatible? Health Promotion International 11, 333–340. [Context Link]
2Buck D., Godfrey C. & Morgan A. (1997) The contribution of health promotion to meeting health targets: question of measurement, attribution and responsibility. Health Promotion International 12, 239–251. [Context Link]
3Chao Y.M. (1995) Nursing's values from a Confucian perspective. International Nursing Review 42, 147–149. Bibliographic Links [Context Link]
4Downie R., Tannahill C. & Tannahill A. (1996) Health Promotion Models and Values, 2nd edn. Oxford University Press, Oxford. [Context Link]
5Fylan F. (1998) Screening for cervical cancer: a review of women's attitudes, knowledge and behaviour. British Journal of General Practice 48, 1509–1514. Bibliographic Links [Context Link]
6Learmouth A. & Cheung P. (1999) Evidence-based health promotion: the contribution of qualitative social research methods. International Journal of Health Promotion & Education 37, 11–15. [Context Link]
7Freudenberg N., Eng E., Faly B., Rogers T. & Wallerstain N. (1995) Strengthening individual and community capacity to prevent disease and promote health: in search of relevant theories and principles. Health Education Quarterly 22, 290–306. Bibliographic Links [Context Link]
8Hepworth J. (1997) Evaluation in health outcomes research: linking theories methodologies and practice in health promotion. Health Promotion International 12, 233–238. [Context Link]
9Herbert A. (1997) Is cervical screening working? A cytopathologist's view from the United Kingdom. Human Pathology 28, 120–126. Bibliographic Links [Context Link]
10Holroyd E., Cheung Y.K., Cheung S.W., Luk F.S. & Wong W.W. (1998) A Chinese cultural perspective on nursing care behaviours in an acute care setting. Journal of Advanced Nursing 28, 1289–1294. [Context Link]
11Hong Kong Cancer Registry (1999) Cancer Incidence and Mortality in Hong Kong 1995–1996. Hong Kong Hospital Authority, Hong Kong. [Context Link]
12Israel B.A., Cummings M.B., Heaney C.A., Perales D.P., Simons-Morton B.G. & Zimmerman M.A. (1995) Evaluation of health education programs: current assessment and future directions. Health Education Quarterly 22, 364–389. Bibliographic Links [Context Link]
13Jeffs T. & Smith M.K. (1999) Informal education and health promotion. In Evidence-Based Health Promotion (Perkins E., Simnett I. & Wright L. eds), John Wiley & Sons, Chichester. [Context Link]
14Macdonald G., Veen C. & Tones K. (1996) Evidence for success in health promotion: suggestions for improvement. Health Education Research 11, 367–376. Bibliographic Links [Context Link]
15Marcus A.C. & Crane L.A. (1998) A review of cervical cancer screening intervention research: implications for public health programs and future research. Preventive Medicine 27, 13–31. Bibliographic Links [Context Link]
16McKiernan M., Campbell H., McDonald S. & Douglas F. (1996) Promoting attendance for cervical screening: the health visitor's role. Health Visitor 69, 454–456. [Context Link]
17Milburn K., Fraser E., Secker J. & Pavis S. (1995) Combining methods in health promotion research: some considerations about appropriate use. Health Education Journal 54, 347–356. [Context Link]
18Neuhauser L., Schwab M., Syme S.L. & Bieber M. (1998) Community participation in health promotion: evaluation of the California Wellness Guide. Health Promotion International 13, 211–222. [Context Link]
19Nutbeam D. (1998) Evaluating health promotion-progress, problem and solutions. Health Promotion International 13, 27–44. Bibliographic Links [Context Link]
20Packer T., Race K.E.H. & Hotch D.F. (1994) Focus groups: a tool for consumer-based program evaluation in rehabilitation agency settings. Journal of Rehabilitation July/August/September, 30–33. [Context Link]
21Quinn M., Babb P., Jones J. & Allen E. (1999) Effect of screening on incidence and mortality from cancer of the cervix in England: evaluation based on routinely collected statistics. British Medical Journal 318, 904–908. Bibliographic Links [Context Link]
22Sanson-Fisher R., Redman S., Hancock L., Halpin S., Clarke P., Schofield M., Burton R., Hensley M., Gibberd R., Reid A., Walsh R., Girgis A., Burton L., McClin Tock A., Carter R., Donner A. & Green S. (1996) Developing methodologies for evaluating community-wide health promotion. Health Promotion International 11, 227–236. Bibliographic Links [Context Link]
23Sheridan-Leos N. (1995) Women's health loteria: a new cervical cancer education tool for Hispanic females. Oncology Nurses Forum 22, 697–700. Bibliographic Links [Context Link]
24Straw R.B. & Smith M.W. (1995) Potential uses of focus groups in program evaluation studies. Qualitative Health Research 5, 421–427. [Context Link]
25Tones K. (1997) Health education, behaviour change and the public health. In Oxford Textbook of Public Health, 3rd edn (Detels R., Holland W., McEwen J. & Omenn G. eds), Oxford Medical Publications, New York, pp. 783–814. [Context Link]
26Tones K. & Tilford S. (1994) Health Education: Effectiveness, Efficiency and Equity. Chapman & Hall, London. [Context Link]
27Twinn S. (1998) An analysis of the effectiveness of focus groups as a method of qualitative data collection with Chinese populations in nursing research. Journal of Advanced Nursing 28, 654–661. Ovid Full Text Bibliographic Links [Context Link]
28Twinn S., Holroyd E. & Shui A. (1999) An Investigation of the Extent to which Current Service Provision for the Screening of Cervical Cancer Meets the Needs of Hong Kong Women. Unpublished Research Report, The Department of Nursing, The Chinese University of Hong Kong, Hong Kong. [Context Link]
29Van der Weijden T., Knottnerus J.A., Ament A.H.A. & Stoffers H.E.J.H. (1998) Economic evaluation of cholesterol-related intervention in general practice. An appraisal of the evidence. Journal of Epidemiology Community Health 52, 586–594. [Context Link]
30Webb D. (1999) Current approaches to gathering evidence. In Evidenced-Based Health Promotion (Perkins E., Simnett I. & Wright L. eds), John Wiley & Sons, Chicester. [Context Link]
31WHO European Working Group (1998) Health Promotion Evaluation: Recommendations to Policy-Makers. WHO Regional Office for Europe, Copenhagen. [Context Link]
32Yancey A. & Walden L. (1994) Stimulating Cancer Screening among Latins and African-American Women. Journal of Cancer Education 9, 46–53. Bibliographic Links [Context Link]
33Yelland J. & Gifford S.M. (1995) Problems of focus group methods in cross-cultural research: a case study of beliefs about sudden infant death syndrome. Australian Journal of Public Health 19, 257–262. Bibliographic Links [Context Link]
Keywords: cervical cancer; health education; evaluation strategies; outcome evaluation; process evaluation; Hong Kong Chinese women
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