الفهرس 
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Abstract
Evaluation of health education initiatives serves a multitude of functions and stakeholders; from assessing the effectiveness of an isolated intervention, to redesigning national public health policies and justifying national health expenditures. Systematic approach to evaluation of health education interventions refers to analyzing the core elements of any intervention in terms of input, process, output, and context. Consumers of the health education services are a major stakeholder who should be engaged in service evaluation. Consumer satisfaction has become an increasingly important indicator for measuring the quality of different health services, including health education.
Aim of the study:
The current study evaluated the current status of health education services provided by Department of Health Education and Information (DHEI) in Alexandria Directorate of Health through the following:
1- Assessing the human and non-human inputs of the provided services.
2- Evaluating some of the health education process components
3- Investigating the output of health education services
4- Identifying facilitating and hindering factors affecting the quality of health education services.
Broad strategic recommendations were proposed to enhance the quality of the health education services aided by the findings of the study.
Target population and Study sample:
To achieve this aim, a cross-sectional study was performed on the entire DHEI staff amounting to 180 staff members, with a response rate of 82% (148 respondents), and a sample of 400 consumers attending the health education sessions at randomly selected target settings by using simple random sampling based on hypothetical assumption that 50% of the consumers are satisfied with the provided health education service. The study also targeted periodic documents issued over one year in the Central Department and 3 randomly selected regional Departments.
Technical design:
A number of tools were structured and used for data collection in the current study;
• An assessment sheet for human and non-human resources was partly filled by interviewing Department managers, and partly by observation of the Departments’ offices.
• A self-administered questionnaire was used to collect data from the DHEI staff on; (a) their personal characteristics; (b) qualifications; (c) experience; (d) knowledge about health education; (e) attitude towards health education; (f) practice of health educator responsibilities; (g) evaluation of the provided services; and (h) different factors influencing the service provision.
• An interview questionnaire was used to assess consumers’ (a) personal data; (b) health literacy; (c) sources of health information; and (d) satisfaction with the DHEI health education service.
• Observation sheets were designed to check the performance of the DHEI staff during activity delivery, the features and suitability of the used setting, as well as a document review sheet to extract data on the recorded activities of the Department.
The main findings of the study can be summarized in the following points:
a) Human and non-human inputs of Alexandria DHEI:
- The studied sample of Alexandria DHEI staff comprised 148 respondents, 93.9% of which were females. Ranging from 25 to 60 years, almost half of the sample were aged above 50 years. The mean of working experience years at the DHEI was 8.18±5.67 years with one-third of the sample having an experience of 5 to 10 years.
- Medicine university graduates represented 20.3% of the sample, while graduates of non-medical faculties represented 24.3%. Nursing degree holders comprised of 24.3% who finished nursing secondary schools and 12.2% who graduated from the faculty of nursing. About 17.6% of the sample carried out postgraduate studies, mostly in the field nursing.
- Thirty-five percent of the DHEI staff held the job of nurse or head nurse at their workplace. Health educators working exclusively for the DHEI formed 27%. Health education physicians represented 14.9% of the staff, and an additional 5.4% were physicians holding management positions in the DHEI.
- The majority of the DHEI staff (72.3%) had a fair knowledge level about basic areas of health education with an overall mean score of 66.48 ± 10.66. The poorest area of knowledge was the area of behavioral determinants and modification with a mean score of 39.86 ± 10.36. Physicians showed significantly higher knowledge than non-physicians across all areas of health education basics.
- Physicians’ knowledge level about advanced areas of health education was mostly fair (73.3%) with a mean score of 77.14 ± 9.56. Ninety percent showed high knowledge level about advocacy for health education, while two thirds of them had poor knowledge about subordinates’ training, development and evaluation.
- Basic knowledge was significantly correlated positively with age, qualifications, postgraduate studies, and number of received professional trainings. However, multiple regression proved that only age and qualifications had a significant positive direct effect on the overall knowledge score (β= 0.289 and β= 0.295 respectively).
- The DHEI staff had an overall neutral attitude towards health education on individual, community and professional level with an overall attitude score of 51.13± 4.48. Qualification had a significant direct negative effect on attitude (β= -0.509) where physicians significantly showed lower attitude scores compared to non-physicians.
- Eighty-three percent of the DHEI staff evaluated the inputs of the health education service as fair, with a mean evaluation score of 62.38 ± 7.58. Human and managerial inputs received better ranking by the DHEI staff than non-human inputs including educational materials, AVAs, rewards, incentives and budget.
b) Health education processes:
- The majority of the DHEI staff reported a fair practice level of basic health educator responsibilities with a mean percent score of 66.35± 12.76. The least practiced competencies among the basic responsibility areas was scientific research competencies where 98.6% of the staff showed poor practice level in this area (mean= 31.33± 9.48), while acting as a resource in health education and public health was the most highly practiced responsibility (69.6%), having a mean percent score of 86.09± 11.56.
- Significant positive correlations existed between basic practice reported by the DHEI staff and basic knowledge, qualification, postgraduate studies, number of professional trainings, and age. Another significant correlation exists negatively between overall attitude and reported basic practices of the staff.
- Basic knowledge proved to have a significant direct positive effect on basic practice scores with a regression coefficient of 0.487 (P=0.000). Conversely, attitude showed a significant negative direct effect on basic practice at a coefficient of -0.245 (P=0.002).
- Physicians reported a significantly higher practice level across all areas of basic responsibilities and overall, except for acting as a resource person. Non-physicians obtained a mean score 87.08 ± 11.05 which was significantly higher than that of physicians (82.22± 12.90) regarding this responsibility area.
- The majority of the DHEI physicians and managers (63.4%) had a poor practice level of advanced health educator responsibilities with an overall mean score of 61.44± 16.11. Human and non-human resource management obtained the least mean percent score (54.33 ± 20.16), opposed to planning of health education programs which obtained a mean percent score of 75.21± 19.03; which is the highest among other advanced health educator responsibilities.
- Working experience at the DHEI proved by regression to be the only variable having a significant positive effect on the practice of advanced health educator responsibilities by physicians and managers with a beta coefficient of 0.449 (P= 0.42).
- The overall level of observed performance of the majority (61.5%) of a subsample of the DHEI staff was acceptable with a mean score of 72.01 ± 9.06. The best observed area of practice was the professional attitude shown by the activity providers towards the audience and the health education practice, with a mean observation score of 95.51 ± 4.72. Managing the educational content of the activity obtained the least observation score of 51.92 ± 7.69.
- The majority of the DHEI staff (83.8%) evaluated the health education processes as having a good standard with a mean percent score of 79.88 ± 8.33. The skills and competencies of the activity providers as well as the management’s monitoring and supervisory practices received the highest mean scores among other components of the health education processes evaluated by the DHEI staff.
c) The health education service output:
- Less than one third of the DHEI staff (31.8%) evaluated the service output as of poor standard, while the rest evaluated the output standard as fair. The mean score obtained by the service output as evaluated by the staff was 54.05 ± 10.03. The provided service in general received the highest mean score while governmental support and stakeholder interest received the least evaluation scores.
- Alexandria DHEI served an average of 70102 consumers per month in the period from April 2014 to March 2015. During this period, the DHEI provided a monthly average of 7092 activities, 5788 of which were lectures or seminars.
- Mother and child health topics were the most addressed topics during this period (30.7%) followed by infections and hygiene, chronic diseases, smoking and addiction, and adolescent health.
d) Consumers’ satisfaction with the provided health education services:
- The studied consumers’ sample was composed of 400 consumers, with a mean age of 45.17±13.36 and a female majority of 69.25%. Thirty-one percent of the sample were unskilled manual workers, followed by 29.75% who had no job. The majority of the sample finished either preparatory or secondary education (27.25% and 25% respectively) as their highest educational level. The socioeconomic class of 71.8% of the sample was low with a socioeconomic percent score ranging from 22.62 to 54.76.
- The majority of the consumers’ sample (69.5%) had a fair health literacy level, with a mean percent score of 71.45 ± 8.04. The most cited source of health information was physicians selected by 89.8% of the sample, while nurses were chosen by 30% of the sample. Health education sessions were selected as an information source by 58.8% of the sample.
- Over half of the studied sample (50.3%) had received 2 to 4 similar health education sessions, and 80.7% affirmed that these sessions had helped to raise their health knowledge. However, only 8% recognized that the DHEI existed and is the actual provider of these sessions.
- A great majority of the consumers’ sample (90.2%) were highly satisfied with the provided health education services. The overall mean percent score of consumers’ satisfaction was 76.68 ± 6.63.
- The behavior and skills of the health education providers received the highest satisfaction mean score from consumers (87.31 ± 7.74) while the quality of the provided educational materials received the lowest mean score (51.44 ± 16.27), with 80.5% of consumers showing fair satisfaction level regarding this aspect. About 81.8% showed high satisfaction with the provided service in general with a mean score of 82.35 ± 13.72.
e) Factors affecting the quality of the health education service provided by the DHEI:
- Professional development and training were perceived by 97.58 of the DHEI staff as the facilitating for the provision of high quality services, while the available non-human resources were perceived as the most hindering factors by 69.25% with a mean score of 21.52 ± 19.36.
- The DHEI staff stated a number of factors as difficulties to their job performance mainly associated with the work burden, audience psychological and socioeconomic factors, shortage of resources, settings’ inadequacy, remoteness, or poor coordination.
- The DHEI staff ranked training and professional development of the staff as the first priority for improving the quality of the provided service with a mean score of 8.13, followed by public advocacy for health education and public promotion for the provided services (7.28 and 6.66 respectively).
- The DHEI staff made a number of suggestions to raise the quality of the provided health education services primarily concerning financial and material support, upgrading the recruitment and selection procedures of health education staff, providing appropriate transport facilities for remote settings and improving the coordination between the Department and the target settings.
Based on the findings of the present study, the following recommendations were suggested:
a) Recommendations for the Department of Health Education and Information:
A line of strategies, under the acronym TASQIF©, has been designed and proposed to improve the quality of the provided health education services:-
• The first strategy in TASQIF involves teaching the health educators to enhance their knowledge about health education and different health matters.
• TASQIF lists authorizing audience as in empowering them by raising their health literacy, promoting community action and heightening Department responsiveness to audience needs and expectations.
• The third strategy operates through scaling up the attitude of the health education staff towards health education through encouragement, rewarding, advocacy and promotion for the Department services.
• Quality Control is the fourth strategic line aiming at developing Health Education Service Quality Standards concerning the service providers’ competencies and performance, the organizational culture, and monitoring procedures and indicators.
• Investing in the Health education staff Physicians by offering referral, clinical coaching and health education consulting services was proposed by TASQIF to add more value to the provided health education service and make extra benefit from the presence of physicians among the staff, while concurrently boosting the physicians’ attitude towards their role among the health education staff.
• The sixth TASQIF strategic recommendation postulates that improving the communication channels between the heads of different target settings and the Health Education Department managers shall facilitate the job of the health education staff at these settings.
b) Recommendations for the health sector:
Formal integration of health education into different routine healthcare services was recommended, which will also necessitate training of all the healthcare workers on different health education skills. Increasing the share of the private health sector in the provision of health education services offers great potential for the quality of the provided health education services on national levels. The DHEI staff can have key roles in the provision of health education services at different health organizations.
c) Recommendations for the community:
Mass and social media can be used to advocate for the importance of health education in cooperation with the DHEI. Non-health and private corporate sectors can have marked roles in the health education and promotion of different population segments.