This project focused on implementing a needs assessment to measure baseline knowledge of college females on fertility awareness and to see if there was an interest for a curriculum addressing fertility awareness. The sample consisted of one hundred and fifty-seven (N = 157) college females who were given a needs assessment on their knowledge of the menstrual cycle, self-efficacy in interpreting fertility biomarkers, and desire for educational opportunities in fertility awareness. Statistical analysis showed a small correlation between an increase in age and self-efficacy in fertility awareness and Hispanic/Latinos scored significantly higher than Black/African Americans on the self-efficacy scale. The results of the needs assessment also indicated a desire for an educational opportunity in fertility awareness. Four content experts validated the curriculum that was created from the needs assessment, using a 10-point Likert scale. Future research needs to focus on racial and ethnic discrepancies on knowledge of the menstrual cycle and health education programs need to focus on menstrual and fertility awareness education for adult women.
TABLE OF CONTENTS
Copyright Notice
Signature
Dedication
Acknowledgement
List of Tables
Abstract
CHAPTER I – INTRODUCTION
Statement of the problem
Purpose of the Project
Project Limitations
Hypotheses and Assumptions
Summary
Definition of Terms
CHAPTER II –LITERATURE REVIEW
History of Fertility Awareness
Overview of Menstrual Cycle
Social Cognitive Theory and Health Promotion
Self-Efficacy and Social Cognitive Theory
Summary
CHAPTER III – METHODOLOGY
Participants
Survey Development
Procedures
Statistical Analyses
Summary
CHAPTER IV – RESULTS
Descriptive Statistics
Knowledge of the menstrual cycle
Self-Efficacy
Hypotheses Testing
Summary
CHAPTER V DISCUSSION AND CONCLUSIONS
Discussion
Summary
CHAPTER VI CURRICULUM OVERVIEW
Format and Structure
Relationship Offerings
Activities
Time Allotment
Source Factors
Instructional Strategies
Limitations
Disclaimer
CHAPTER VII VALIDATION RECOMMENDATIONS
Validation Panel
Validation Instrument
Validation Results
CHAPTER VIII THESIS CONTRIBUTIONS TO HEALTH EDUCATION AND COMPLIANCE WITH HEALTH EDUCATION RESPONSIBILTIES AND COMPETENCIES
Responsibility I Assessing Individual and Community Needs for Health Education
Responsibility II Planning Effective Health Education Programs
Conclusions
REFERENCES
APPENDICES
Appendix A
Appendix B
Appendix C
Appendix D
Appendix E
Appendix F.
LIST OF TABLES
Table 1 Cervical Fluid Patterns
Table 2 Paired-Samples Correlation
Table 3 Paired-Samples T-test
Table 4 Frequencies Summary for Self-Efficacy Scale
Table 5 Mean Scores for Menstrual Score and Number of Children (dichotomous)
Table 6 Mean Scores for Menstrual Score and Number of Children (categorical)
Table 7 Mean Scores for Fertility Awareness Self-Efficacy and Number of Children (dichotomous)
Table 8 Mean Scores for Fertility Awareness Self-Efficacy and Number of Children (categorical)
Table 9 Mean Scores for Menstrual Score
Table 10 Mean Scores for “Body-Literacy
Table 11 Mean Scores for Total Self-Efficacy
Table 12 Hispanic/Latino Post-Hoc Self-Efficacy Mean
Table 13 Hispanic/Latino Post-Hoc “Body Literacy” Mean
Table 14 Correlations on Menstrual Score and Self-Efficacy
Table 15 Constructs Used for Curriculum Project
Table 16 Validation Summary
LIST OF FIGURES
Figure 1 Racial/Ethnic Breakdown
Figure 2 Marital Status
Figure 3 Question 9 “A few days before the egg leaves the ovary, cervical mucus becomes”
Figure 4 Question 11 “A woman’s basal body temperature is usually”
DEDICATION
To my loving parents Alfonso and Reyes Holguin and my older brother Alfonso, who have always been living examples of hard work and perseverance, and have always given me an abundance of support.
To Shawn and Rus, who were a great foundation of love and laughter as I worked on completing my Master Degree.
ACKNOWLEDGEMENTS
Fist I would like to acknowledge Dr. Kathleen Young and her constant support and oversight of this project of mine. Her encouragement took this thesis beyond the scope that I thought possible.
Dr. Lawrence Chu, for his support and mentoring over the statistical analyses portion of the project. He made what I thought would be an arduous and stressful portion of the thesis into something less intimidating and more insightful.
Dr. Gretta Madjzoob, for her encouragement plus her knowledge and expertise on curriculum content and design form day one of HSCI 531, to the culmination of this project.
Dr. Madison for going out of her way and providing input on the methodology of this project.
To my validation committee starting with Ms. Amy Reichbach who was always personified a library’s worth of information on women’s reproductive health issues. She was always a constant support in the EROS program and a great example of what a health educator should be.
To Toni Weschler, who although I do not know personally, gave valuable critiques and gave support for this project and my future professional endeavors.
Jeanette A. Cachan, who took time out of her immensely busy schedule to review my curriculum and send me additional information to add to the lesson plans.
Barbara Kass-Annese who is considered to be “the guru” of Fertility Awareness knowledge and education for her valuable knowledge.
Thank you all, for your invaluable support and expertise.
Abstract
A CURRICULUM TO INCREASE THE SELF-EFFICACY IN REPRODUCTIVE HEALTH OF COLLEGE FEMALES
By
Serena Holguín
Master of Public Health
This project focused on implementing a needs assessment to measure baseline knowledge of college females on fertility awareness and to see if there was an interest for a curriculum addressing fertility awareness. The sample consisted of one hundred and fifty-seven (N = 157) college females who were given a needs assessment on their knowledge of the menstrual cycle, self-efficacy in interpreting fertility biomarkers, and desire for educational opportunities in fertility awareness. Statistical analysis showed a small correlation between an increase in age and self-efficacy in fertility awareness and Hispanic/Latinos scored significantly higher than Black/African Americans on the self-efficacy scale. The results of the needs assessment also indicated a desire for an educational opportunity in fertility awareness. Four content experts validated the curriculum that was created from the needs assessment, using a 10-point Likert scale. Future research needs to focus on racial and ethnic discrepancies on knowledge of the menstrual cycle and health education programs need to focus on menstrual and fertility awareness education for adult women.
Chapter I Introduction
Fertility Awareness (FA) and Natural Family Planning (NFP) are knowledge-based methods of contraception that educate women on their biological fertility signs. When these biological markers are present a woman practicing FA may chose to use barrier methods of contraception during the fertile period and have unprotected intercourse when the fertility signs are no longer present. A woman who practices NFP would not use barrier methods of contraception or participate in alternative expressions of sexuality during the fertile period (Jennings, Arevalo, & Kowal, 2004, p. 317). FA and NFP utilize the same knowledge and technology to prevent or plan a pregnancy; the crucial difference is the adherence to abstinence during the fertile period by NFP users. Practitioners of NFP tend to do so for religious reasons; Humane Vitae was the papal encyclical of Pope Paul VI that forbids abortion, sterilization, alternative sexual practices, and all chemical and barrier methods of birth control (Yewchuk, 2006, p. 5). The philosophy of FA places no restrictions on the above mentioned behaviors in essence, FA could be considered the secular form of NFP.
However when you take the family planning aspect out, FA is still advantageous since learning fertility awareness goes beyond contraception. The acquisition of knowledge about the female reproductive cycle can give women the ability to plan a conception (when modern FA is used by couples of normal fertility for conception, about two thirds of women will become pregnant within one cycle of use, (Stanford, Lemaire, & Thurman, 1998), detect pregnancy (a postovulatory temperature rise sustained for 18 or more days is promising indicator that pregnancy is underway), detect impaired fertility, and detect a possible reproductive tract infections (Jennings et al., 2004, p. 320). Pyper (1997) states, “Fertility awareness is fundamental to understanding and making informed decisions about reproductive health and sexual health. If females have a better understanding of fertility awareness, they are in a stronger position to make informed decisions about how they wish to manage their reproductive and sexual health”. Vogelsong (n.d.) states the following benefits of fertility awareness:
- Identify what is healthy and normal for each individual throughout the life cycle;
- Identify signs and symptoms that may indicate a need to seek health care;
- Practice behaviors that have positive effects on their reproductive health;
- Develop communication and self-advocacy skills to help them deal effectively with partners and health care providers about their reproductive health;
- Skills developed through a fertility awareness approach can be tailored and targeted to children and adolescents to help young people understand their changing bodies and learn to protect their own reproductive health
A Canadian organization, Justisse, refers to this knowledge as “body literacy” (Justisse, 2002). The FA/NFP methods to determine the fertile period of a woman are summarized below:
- CALENDAR METHOD – A method where a woman record days of menses prospectively for 6 cycles. Earliest day of fertile period = day # in a cycle corresponding to shortest cycle length minus 18; Latest day of fertile period = day # in a cycle corresponding to longest cycle length minus 11 ( Institution of Reproductive Health, 2003 ).
- STANDARD DAYS METHOD – A method that is appropriate for women with menstrual cycles between 26 and 32 days long. To use the method, couples avoid unprotected intercourse on days 8 through 19 of the woman’s menstrual cycle. Many women who use the SDM also use a string of color-coded beads, called CycleBeads™, to track their fertile days ( Institution of Reproductive Health, 2003 ).
- CERVICAL MUCUS OVUALTION METHOD/BILLINGS METHOD – A method that is based on understanding and interpreting changing cervical secretions that are produced at the neck of the uterus (cervix). At the time of greatest fertility, these secretions become clear, stretchy, slippery and wet ( Institution of Reproductive Health, 2003 ).
- BASAL BODY TEMPERATURE METHOD – A method where fertility is determined by observing body temperature each morning before beginning any activity. The body temperature is lower before ovulation and rises slightly to about .2 degrees Celsius or .4 degrees Fahrenheit after ovulation ( Institution of Reproductive Health, 2003 ).
- POST-OVULATION METHOD –A method that permits unprotected intercourse only after signs of ovulation has subsided (Hatcher, Nelson, Zeiman, Darney, Creinin, Stosur, Cwiak, 2004).
- SYMPTOTHERMAL METHOD - A method where fertility is determined by observing changes in the cervical secretions, along with changes in the basal body temperature, and the position and feel of the opening of the cervix. Other fertility signs such as mid-cycle pain or bleeding may accompany ovulation ( Institution of Reproductive Health, 2003 ).
- LACTATION AMENORRHEA METHOD- A post-partum birth control method where a woman consistently breast feeds her infant for the first six months to delay ovulation (Kass-Annese & Danzer, 2003, pgs. 148-149).
The effectiveness of the above methods in comparison to other contraceptive methods is summarized in Appendix A.
Statement of the Problem
Dr. Carl Djerassi, considered to be the “father” of the oral contraceptive pill, concedes that women should be privy to education on their biological fertility occurrences. “Eventually, many a woman in our affluent society may conclude that the determination of when and whether she is ovulating should be a routine item of personal health information to which she is entitled as a matter of course,” (Djerassi, 1990). Djerassi goes on to say “many American women pass through the educational system learning deplorably little about the menstrual cycle,” (Djerassi, 1990). The results of an Australian study supports this where the researcher found 80% of the adolescent participants thought periods cleared the body of dirty blood, overestimated the amount of blood flow, and that the purpose of menstrual fluid was to” flush out” the egg every month (Moore, 1995).
Research into the content of sex education and menstruation curricula found a lack of understanding of menstruation and a negligent amount of information of fertility biomarkers is taught. Koff and Rierdan (1995), Rierdan et al. (1983), and Whisnant and Zegans (1975) found a lack of understanding of the physiology of menstruation, reproductive processes, and basic female anatomy. The research of Landry, Darroch, Singh, and Higgins (2003) from the Alan Guttmacher Institute revealed that despite the independent variables of geographic location in the United States (northeast, south, midwest, and west) nothing in terms of fertility awareness is addressed. The primary concentration was on sexual behavior, abstinence, STD facts and prevention, STD services, and methods for pregnancy prevention.
In a qualitative study Beausang and Razor (2000) found through a written narrative of 85 female participants, 74 had a negative view of their menstruation education and experience. Problems of menstruation education included perceptions of teacher discomfort discussing menstruation, and unclear instruction leading to misunderstandings. In this same theme Costos, Ackerman, and Paradis, (2002), measured the communication between mothers and daughters on menarche in a retrospective study. A majority of the participants stated they received a negative message from their mothers along the lines of a “grin and bear it” approach.
Lee (2002) analyzed narratives of female participants on their menstrual cycle changes. She found that women who experienced irregular periods and heavy flow found menstruation to be an inconvenience. Reilly and Kremer (1999) referred to this perception as disempowering because timing and symptoms are “perceived as uncontrollable.” However McPherson and Korfine (2004) found that females who had negative attitudes about their periods could better predict the onset of their next period. For the purposes of this project it could be construed that these women had better self-efficacy in the ability to predict their next period.
Lack of knowledge of fertility biomarkers is not only limited to lay persons. Stanford, Thurman, and Lemaire (1999), surveyed physicians on their knowledge and practices on FAM. When educating their patients on planning a conception; of those who were unaware of NFP/FAM instructors in their area only 31% recommended the observation of cervical mucus (compared to 48% who were aware of instructors), and 66% recommend basal body temperature (compared to 81% who were aware of instructors).
Purpose of the Project
This purpose of this study was to assess baseline knowledge of college women on fertility awareness and to see if there was a need and an interest for a curriculum to specifically address fertility awareness. Generally speaking fertility awareness curricula are created to teach women how to avoid or plan a conception. However the content can also be used to teach females more about the physiological changes that happen during the menstrual cycle, and how to interpret these changes. Some of the things that can be interpreted are when late menstruation will occur, whether or not a woman is experiencing a late period or early onset miscarriage, anovulatory cycles, whether or not a woman is experiencing abnormal pre-menstrual spotting, and early detection of pregnancy.
The following are the steps that were taken to complete this project.
1. Obtained approval of thesis topic by thesis committee
2. Developed the needs assessment survey
3. Obtained human subjects approval from CSUN Institutional Review Board; no pilot test was conducted.
4. Conducted needs assessment from a sample of the female student body of CSUN
5. Analyzed survey results, test hypotheses, report study results
6. Created curriculum
7. Curriculum validation by expert panel
Project Limitations
The following is a list of limitations and delimitations to the study
Limitations
- The needs assessment (Appendix B) survey sample was a convenience sample.
- Participants were recruited through professors that the researcher had a working relationship with.
- Survey instrument was not pilot tested
- The sample was not randomized therefore; each female student at CSUN did not have an equal chance of receiving the needs assessment survey.
Delimitations
- Survey respondents probably had not given much thought to the items mentioned in the self-efficacy scale and at that point in time and would have needed to form an opinion on their confidence level.
- Bad weather may have impeded some students from arriving to class on time
- Close proximity to Spring Break on one day of data collection may have contributed to a lower than normal student attendance
Hypotheses and Assumptions
The following hypotheses have been generated for this project:
An increase in age is associated with an increase in self-efficacy in Fertility Awareness.
An increase in age is associated with an increase in knowledge on the menstrual cycle.
Married women will have an increased knowledge on the menstrual cycle compared to single women.
Married women will have more self-efficacy in fertility awareness than single women.
Parous women will have an increase in self-efficacy in fertility awareness, than nulli-parous women.
Parous women will have an increase in knowledge on the menstrual cycle, than nulli-parous women.
White/Caucasian women will have an increase in knowledge on the menstrual cycle compared to non White/Caucasian women
White/Caucasian women will have more self-efficacy in fertility awareness than non White/Caucasian women.
Women with increased knowledge of the menstrual cycle will have more self-efficacy in fertility awareness than those with decreased knowledge of the menstrual cycle.
Summary
The literature review on the education of the menstrual cycle and fertility changes during the cycle falls short of educating women on the intricacies of their fertility making women “body illiterate.” A needs assessment was created using the components of Social Cognitive Theory (behavioral capabilities, self-efficacy, and outcome expectancies), to measure baseline knowledge of fertility awareness in college females. The following chapter will give a more in depth overview over the evolution of fertility awareness and a background on Social Cognitive Theory and self-efficacy.
Definition of Terms
BARRIER METHODS – Birth control methods that utilize a barrier to keep sperm from traveling through the cervix and into the uterus (Education Program Associates, pg. 6-1, 2004).
BASAL BODY TEMPERATURE METHOD – A method of FA where fertility is determined by observing body temperature each morning before beginning any activity. The body temperature is lower before ovulation and rises slightly to about .2 degrees Celsius or .4 degrees Fahrenheit after ovulation ( Institution of Reproductive Health, 2003 ).
BODY LITERACY - Is the self-knowledge gained by learning to observe and chart scientifically proven signs of fertility and infertility, together with other health and wellness observations. Body Literacy incorporates fertility awareness and more, including a broad base of knowledge from which women can make fully informed reproductive choices. Even more, Body Literacy respects your choice, by empowering you with the knowledge you need to make an informed choice about your sexual and reproductive health (Justisse, 2002).
CALENDAR METHOD – A FA method where a woman record days of menses prospectively for 6 cycles. Earliest day of fertile period = day # in a cycle corresponding to shortest cycle length minus 18; Latest day of fertile period = day # in a cycle corresponding to longest cycle length minus ( Institution of Reproductive Health, 2003 ).
CERVICAL MUCUS OVUALTION METHOD/BILLINGS METHOD – A method of FA that is based on understanding and interpreting changing cervical secretions that are produced at the neck of the uterus (cervix). At the time of greatest fertility, these secretions become clear, stretchy, slippery and wet ( Institution of Reproductive Health, 2003 ).
CONTRAINDICATIONS - A sign that someone should not continue with a particular medicine or treatment because it is or might be harmful. (Cambridge Dictionary, 2004).
COPPER-T IUD – An intrauterine device that contains copper causing an inhospitable environment for sperm to live in causing sperm to die. It is effective for up to ten years (Education Program Associates, pg. 6-229, 2004).
DEPO-PROVERA - A form of synthetic progesterone that is administered in shot form, once every three months to prevent pregnancy (Education Program Associates, p. 6-211, 2004).
ESTROGEN- Known as the “female hormone” that is produced by the ovaries and stimulates the release of luteinizing hormone from the pituitary gland and promotes proliferation of the endometrium of the uterus (King, p. 55, 1998).
FERTILE PERIOD - Days during a woman’s menstrual cycle when pregnancy is possible; The fertile window of the woman’s menstrual cycle consists of approximately 6 days—the 5 days before ovulation and the day of ovulation, with variable probabilities of pregnancy for each day (Arévalo, Jennings, & Sinai, 2002).
FERTILITY AWARENESS METHODS - A knowledge based birth control method that educates women on their biological fertility signs. When these biological markers are present a woman could choice to use barrier methods during her fertile period (Education Program Associates, pg. 6-23, 2004).
FOLLICLE STIMULATING HORMONE- A hormone that stimulates the development of a follicle in a woman’s ovary (King, p. 54, 1998).
INFERTILE PERIOD - Days during a woman’s menstrual cycle when pregnancy is not possible; i.e. pre and post ovulation (Kass-Annese & Danzer, pgs. 148-149, 2003).
LACTATION AMENORRHEA METHOD – A post-partum birth control method where a woman consistently breast feeds her infant for the first six months to delay ovulation (Kass-Annese & Danzer, pgs. 148-149, 2003).
LUTENIZING HORMONE- A hormone that triggers ovulation in women and stimulates the production of male hormones in men (King, p. 54, 1998).
MIRENA - An intrauterine device that releases a small amount of progestin over a period of five years (Education Program Associates, 6-231, 2004).
NULLIPAROUS- a female that has not borne offspring (Healthline, 2007).
NUVARING – A silicone ring containing a combination of synthetic estrogen and progesterone, that is worn vaginally and is worn for three weeks at a time to prevent pregnancy (Education Program Associates, pg. 6-174, 2004).
OGINA-KNAUS CALENDAR RHYTHM METHOD – A form of birth control that was utilized after the discovery that woman ovulates approximately 14 days before each menstrual period. Does not take into account the lifespan of sperm in a woman’s body, (Kass-Annese & Danzer, pg. 9, 2003).
ORTH-EVRA PATCH – A patch containing a combination of estrogen and
progesterone that releases hormones transdermaly to prevent pregnancy Education Program Associates, pg. 6-155, 2004).
PAROUS- A female who has produced offspring (Healthline, 2007).
PERFECT USER RATING - The percentage of women who become pregnant during their first year of use of a birth control when the method is used correctly and consistently each time (Hatcher, Nelson, Zeiman, Darney, Creinin, Stosur, Cwiak, 2004).
POST-OVULATION METHOD – NFP/FAM method that permits unprotected intercourse only after signs of ovulation has subsided (Hatcher, Nelson, Zeiman, Darney, Creinin, Stosur, Cwiak, 2004).
PROGESTERONE- A hormone that is produced in large amounts by the ovaries after ovulation. It prepares the endometrium of the uterus to nourish a fertilized egg (King, p. 53, 1998).
SPINNBARKEIT – As ovulation approaches, the rising level of estrogen causes glands in the cervix to produce wetter mucus and that can be stretched between two fingers and has the texture of raw egg white (Kass-Annese& Danzer, p. 43, 2003).
STANDARD DAYS METHOD – A method of FA that is appropriate for women with menstrual cycles between 26 and 32 days long. To use the method, couples avoid unprotected intercourse on days 8 through 19 of the woman’s menstrual cycle. Many women who use the SDM also use a string of color-coded beads, called CycleBeads™, to track their fertile days (Institute of Reproductive Health, 2003)
SYMPTOTHERMAL METHOD - A method of FA where fertility is determined by observing changes in the cervical secretions, along with changes in the basal body temperature, and the position and feel of the opening of the cervix. Other fertility signs such as mid-cycle pain or bleeding may accompany ovulation (Institute of Reproductive Health, 2003)
TYPICAL USER RATING - The percentage of women who become pregnant during the first year of use of birth control, when the method is used inconsistently and incorrectly (Hatcher, et. al, 2004).
Chapter II Literature Review
This project focused on implementing a needs assessment to measure baseline knowledge of college females on fertility awareness and to see if there was a need and an interest for a curriculum addressing fertility awareness. The needs assessment focused on two main components; the menstrual cycle and physiological changes during the menstrual cycle. The following chapter will review the evolution of fertility awareness, the menstrual cycle, and literature review and seminal work in Social Cognitive Theory.
History of Fertility Awareness
Over 150 years ago, Dr. Theodore Bischoff found eggs present in the uterus and fallopian tubes of a female dog while the dog was in estrus, or heat. Due to this discovery, Dr. Bischoff made the assumption that the human females must also have eggs present during their menstrual cycle. As a result of his findings, a natural birth control schedule was created. This method stated that to avoid pregnancy intercourse should be avoided during the menstrual period as well as five days before, and nine days after it (Kass-Annese & Danzer, 2003, p. 8). This method of birth control continued to be practiced until the 1930’s and needless to say countless women became pregnant (Kass-Annese & Danzer, 2003, p. 8).
In 1929 another discovery formed the basis of the Ogina-Knaus Calendar Rhythm Method named after the two discoverers Drs. Kyusaku Ogina and Herman Knaus (Kass-Annese & Danzer, 2003, p. 9). These two men, who worked independently of each other and lived on opposite sides of the globe, discovered that an egg is released from the ovary approximately 14 days before the menstrual period. This method does not take into account that women can ovulate earlier or later than usual, and therefore the absence of this fact from the calendar rhythm method contributed too many unplanned pregnancies for rhythm method users.
In between the discoveries of Drs. Bischoff, Ogina, and Knaus, other researchers discovered two important fertility signs that are pertinent to modern day NFP/FAM. In 1876 Dr. Marie Putnum Jacobi discovered that basal body temperature increases and decreases at certain times during the menstrual cycle and these changes follow a distinct pattern (Kass-Annese & Danzer, 2003, p. 9).
Other researchers in the 1800’s discovered the cervical mucus changed in amount and quality during the menstrual cycle. The researchers believed that a certain type of cervical mucus was needed to achieve pregnancy (Kass-Annese & Danzer, 2003, p. 9).
These findings lead to the Billings Ovulation Method that is used today in FAM. During the 1960’s an Australian team of physicians, Drs. John and Evelyn Billings, sought to develop a method of FAM that was more accurate than the rhythm method (Kass-Annese & Danzer, 2003, pgs. 9-10). Their research concerned cervical mucus and its changes throughout the menstrual cycle, they discovered that at the time of peak fertility cervical mucus has a thin watery consistency that can be stretched between fingers and has the appearance of raw egg white. The same of this type of mucus is spinnbarkite (Kass-Annese& Danzer, 2003, p. 43; summary of cervical mucus changes in Table 2). The billings ovulation method was created around this finding with women either abstaining from intercourse or using barrier methods at the time this mucus is noticed.
Table 1- Cervical Fluid Patterns
illustration not visible in this excerpt
Overview of the menstrual cycle
An understanding of the menstrual cycle is essential to understanding Fertility Awareness as well as how hormonal contraceptives work. The menstrual cycle can be broken down into four phases: the menstrual phase, follicular phase, ovulatory phase, and the luteal phase (Kass-Dazner, 2003, p. 25).
Day one of the menstrual cycle is the first day of menstrual bleeding. This phase of the menstrual cycle usually lasts anywhere form three to seven days. During this phase the endometrial lining is shed through the vagina if conception does not occur (Kass-Dazner, 2003, p. 25).
At around day eight of the cycle the follicular phase of the cycle begins. At this phase follicle stimulating hormone (FSH) is released from the pituitary gland causing about 15-20 eggs to mature in each ovary. Each of the eggs is encased in its own follicle which releases estrogen at this point in the cycle, the estrogen buildup is what causes the cervical mucus to become wetter until ovulation; a key fertility sign. This phase of the cycle lasts anywhere from eight days to two weeks, the length depending on how much of an estrogen threshold each woman’s body achieves. Once this high threshold is achieved luteinizing hormone (LH) is released causing the egg to burst from the follicle (Weschler, 2003, p. 46).
At this point in the cycle ovulation occurs, and the egg is released from the follicle onto the pelvic cavity. Here the fimbria (fingerlike projections in the fallopian tube) sweeps the egg into the adjoining tube. Following the release of the egg from the ovary the follicle in which it was encased, collapses on itself becoming the “corpus luteum”, which is Latin for “yellow body”. The corpus luteum starts releasing progesterone for approximately 12-16 days. Progesterone (which can be read as “pro gestation”) is a critical hormone it terms of fertility. It prevents other eggs from being released, it causes the uterine lining to thicken and sustain until the corpus luteum disintegrates, and it causes a rise in temperature. This rise in temperature is used in the basal-body temperature method in FAM. If a pregnancy does not occur, progesterone levels decrease signaling the uterus to shed the lining leading once again to the menstrual cycle (Weschler, 2003, p. 47). As a mnemonic device, (Weschler, 2003, p. 46) has the acronym FELPOP to remember the hormones involved in the menstrual cycle; F-follicle stimulating hormone, E- estrogen, L- lutenizing hormone, P- progesterone.
It is important to note that an egg is only capable of being fertilized up to 24 hours after ovulation. The reason menstruation does not begin immediately after the disintegration of the egg is a fertilized egg takes about a week to reach the uterus and burrow into the endometrial lining.
Social Cognitive Theory and Health Promotion
Ideally, health education programs would have an intended population with a high level of perceived self-efficacy and in turn have positive outcome expectancies on these behavioral changes. However, that is just the ideal and health campaigns need to change their emphasis from scaring people into better health habits to enabling them with self-management skills and self-beliefs needed to take charge of their health habits (Bandura, 2004).
Social Cognitive Theory provides the groundwork for doing this by specifying core determinants including knowledge of health risks and benefits of health behavioral changes, perceived self-efficacy, outcome expectancies, health goals, perceived facilitators, and impediments to the health changes individuals seek (Bandura, 2004).
However in Social Cognitive Theory in order to turn knowledge into action one must believe they produce desirable effects by their actions, their perceived self-efficacy (Bandura, 2004). Health behavior is also affected by the outcomes their behavioral changes may produce. These can include physical outcomes, social outcomes in terms of approval or disapproval from one’s social circle, and positive and negative self-evaluative outcomes. People have standards and regulate their behavior according to their standards of what gives them self-satisfaction and refrain from behaviors that breed self-dissatisfaction (Bandura, 2004). Personal goals provide further self-incentives and guides for health habits. “Short-term attainable goals help people succeed by guiding action in the here and know “(Bandura p.145, 2004).
Self-Efficacy and Social Cognitive Theories
Social Cognitive Theory assumes that there is interdependence among the characteristics of the person whose behavior is targeted for change, the attributes of the behavior itself, and the environment in which the behavior is to take place (Deeds, Hayden, Ramsey, Rice et al, 2000, p. 93). The theory specifies a core set of determinants, the mechanism through which they work, and the optimal ways of translating this knowledge into effective health practices. The core determinants include knowledge of health risks and benefits of health practices, perceived self-efficacy, outcome expectations about the expected cost and benefits for health habits, health goals, and perceived facilitators; the social and structural impediments to the change they seek (Bandura, 2004).
Perceived self-efficacy is concerned with people’s belief in their capabilities to produce given attainments (Bandura, 1997). Self-efficacy should be distinguished from other constructs such as self-esteem and locus of control. Self-esteem is a judgment of self worth, whereas self-efficacy is judgment of capability; locus of control is concerned with whether outcomes are controlled by one’s own actions or outside forces (Bandura, 2006).
Behavioral Capability is the knowledge and skill used to perform a given behavior (Baranowski, Perry, Parcel, 2002, p.169). In terms of health education programs, the learning content must contain more than health knowledge but skills on how to adapt the knowledge into a behavior.
Outcome expectancies are the values that a person places on a particular outcome (Baranowski, Perry, Parcel, 2002, p.169). In essence individuals will perform a health behavior that will maximize positive outcomes or minimize negative outcomes.
Summary
This purpose of this study was to assess baseline knowledge of college women on fertility awareness and to see if there was a need and an interest for a curriculum to specifically address fertility awareness. The results of the survey did show an interest in a curriculum anda six-lesson plan curriculum was created. Implementing the curriculum could potentially increase self-efficacy in reproductive health awareness. The following chapter will detail the methodology behind the survey creation and implementation.
Chapter III Methods
The following chapter covers the procedures that were conducted for the survey development, IRB approval, survey implementation, and planned statistical analyses. For survey implementation the survey needed to be created, human subjects approval from the CSUN Instructional Review Board (IRB) was needed, and permission for faculty to collect data from classrooms was required.
Participants One hundred and fifty-seven female participants (157) from the student body of California State University Northridge participated in a voluntary survey through the permission of their instructors. Fifty-six participants came from a Women and Health class and the remaining 101 came from a Marriage and Family Studies class. Survey implementation occurred after Institutional Review Board approval from the University (Appendix C). California State University Northridge (CSUN) is a public four-year university in the San Fernando Valley, a suburb of Los Angeles. The campus has approximately 33,000 students taking part in one of the 61 Bachelors or 42 Masters programs. The gender breakdown for this study is 60% female 40% male. The ethnic/racial breakdown is 32% Caucasian, 26% Latino, 12% Asian/Pacific Islander, 8% African American, and 16% classified as “other.” The average age is 25.2 for all students, 23.5 for the undergraduate population.
Survey Development The questionnaire on fertility awareness consisted of three parts. The first portion contained six demographic questions (date of birth, race/ethnicity, were you born in the US, language spoken at home, marital status, and number of children). The second part contained six multiple choice questions on fertility biomarkers (length of menstrual cycle, how many days after ovulation should menstruation occur, texture of cervical mucus around ovulation, position of cervix after ovulation, basal body temperature changes, cervical mucus texture after ovulation). The third portion measured perceived self-efficacy on a discrete self-efficacy scale from 0-100 as described by Bandura (2005). A reliability analysis was conducted and revealed a Cronbach alpha score of .792. Six questions asked the participant to measure their ability to interpret fertility bio-markers (“body literacy”) for early pregnancy detection, distinguishing between a late period and early miscarriage, knowing when a period will be late, knowing when a menstrual cycle was anovulatory, knowing when there is a vaginal infection, and distinguishing between normal and abnormal pre-menstrual spotting. Four questions asked to measure their ability to take their temperature first thing in the morning, noticing vaginal secretions and recording temperature and secretions on a chart. At the end of the questionnaire participants were asked if they were interested in an educational opportunity to learn more about what was covered in the survey and another question asking how such a class would affect their reproductive health practices (Appendix B).
A SMOG (Simple Measure of Gobbledygook) formula was used to score the readability of text (i.e. what education level is needed in order to understand a given amount of text) (McLaughlin, 1969). Using an online SMOG calculator, at http://www.harrymclaughlin.com/SMOG.htm, the score of the needs assessment is 9.5; which puts the education level needed between 9 and 10th grades.
Procedure Permission was asked from professors to enter their classroom and administer the surveys at the beginning of class. Participants were given an information sheet (Appendix D) describing the content of the survey, ensuring them anonymity, and informing them of their ability to back out of the survey without fear of penalty. The survey took approximately fifteen minutes to complete. After the survey, participants were thanked and given a list of resources if they wanted more information on the topic (Appendix E).
Statistical Analyses
Table 2- Proposed Statistical Analyses
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Summary
The data were not collected until human subjects approval was obtained in accordance with IRB regulations. Inclusion criteria consisted of female participants who had read the information sheet insuring them of their rights and the content of the survey. The researcher entered the classrooms a few minutes prior to the beginning of class in order to have the materials ready in order limit the amount of time taken away from classroom time to data collection. The following chapter will discuss the findings of the study.
Chapter IV Results
157 surveys were collected and the data were recorded in SPSS version 14.0 statistical software program (SPSS Inc., Chicago IL). Descriptive statistics were analyzed, the hypotheses were then tested, and other analyses were done to see if there were relationships among variables. The following chapter describes the statistical findings.
Descriptive Statistics
The mean age of the respondents was 22.5 with a median age of 21 years. The racial/ethnic breakdown was as follows: 36.9% White/Caucasian, 28% Hispanic/Latino, 14% Black/African-American, 12.1% Asian Pacific-Islander, and 8.9% classified themselves as “other” (Figure 1).
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Figure 1 Racial /Ethnic Breakdown
Of the 157 respondents 78.3% were born in the United States while nearly half of the respondents (48.4%) spoke a language other than English at home. A vast majority of the participants (80.9%) were single, while 8.9% of the respondents were either living with someone or married (Figure 2). A small percentage were divorced (1.9%) or separated (0.6%). 87.9% of the respondents did not have any children.
Figure 2 Marital Status
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Knowledge of the Menstrual Cycle
One point was given for each correct answer on questions 7-12 on the survey (Appendix B) measuring menstrual cycle/fertility knowledge for a maximum of 6 points total. The mean score for the sample was 2.5 with a SD of 1.66 and a median of 2.
Question seven asked the respondents about the length of the menstrual cycle. Forty-three percent of participants believed the menstrual cycle is only as long as the days of the menstrual period; that is 43% chose the answer that stated “Begins on the first day of menstrual bleeding and ends when bleeding stops.” Only 27.4% of respondents knew that the length of the menstrual cycle began on the first day of bleeding and ended the day before bleeding starts.
Of the six questions the ones with the largest discrepancy among answers were questions nine ten, and eleven. Question nine asked participants about the texture of cervical mucus around ovulation (Figure 3). Approximately 61.1% of participants knew that the texture was wet, slippery, and stretchy.
Figure 3
Question 9- A Few days before the egg leaves the ovary, cervical mucus becomes:
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However when asked in question twelve about the texture of cervical mucus after ovulation a plurality of the respondents (45.5%) did not know and 38.9% knew the texture changed to sticky and pasty. A correlation statistic and paired t-test was calculated for questions 9 and 12. Results showed that these two questions were slightly correlated, and the mean difference between the two questions were statistically significant (Tables 2 & 3).
Table 2-Paired Samples Correlation
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Table 3- Paired Samples T-Test
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The paired t-test and percentages revealed that there is a disconnection between recognizing pre-ovulatory and post-ovulatory cervical mucus. On question 11 on basal body temperature, 42.7% did not know how temperature shifted during the menstrual cycle (Figure 4). Only 28.7% knew that BBT rose after ovulation.
Figure 4 Question 11 A woman’s basal body temperature is usually:
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For question ten on the position of the cervix upon ovulation, 52.2% of respondents knew the cervix became high soft and open and 32.5% stated they did not know the answer.
Self-Efficacy Results
The self-efficacy scale consisted of ten questions measured by a discrete scale from 0-100, for a maximum total score of 1,000. The first six questions pertained to fertility awareness and “body literacy (for a possible sub-total of 600), and the second set of four questions (for a possible sub-total of 400) dealt with completing tasks necessary for fertility awareness (taking temperature, charting, etc.). The mean and median for the fertility awareness portion were 231.95 and 220 respectively (Table 4). For the tasks portion the mean and median were 191.46 and 200. For the total self-efficacy score the mean and median were 415.83 and 420.
Table 4- Frequencies Summary for Self-Efficacy Scale
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Hypotheses Testing
The first hypothesis was “An increase in age is associated with an increase in self-efficacy in Fertility Awareness.”. A Pearson’s correlation analysis was conducted and there was a small positive correlation r = .183 (p< 0.05) where the older a participant was the higher the self-efficacy of “body literacy”. 95% confidence intervals for the correlation coefficient were calculated with a lower bound of 0.024 and an upper bound of 0.333. Confidence intervals revealed that the null hypothesis would be rejected 95% of the time, yet the range confirmed a relatively weak correlation. A correlation with age and the tasks portion on self-efficacy and total self-efficacy score was also conducted with no statistical significance found (r = .096).
For the hypothesis “An increase in age is associated with an increase in knowledge on the menstrual cycle”, the correlation was computed with no statistical significance (r = -152).
The next two hypotheses were “Married women will have more self-efficacy in fertility awareness than single women” and “Married women will have an increase in knowledge on the menstrual cycle, than single women”. Frequencies showed a small number of participants were married (n = 13). A recoding of the variable of marital status was done combining married, divorced, separated, and cohabitating (n = 30). T-tests were calculated for both hypotheses (“Married women will have more self-efficacy in fertility awareness than single women” and “Married women will have an increase in knowledge on the menstrual cycle, than single women”) and no statistical significance was found.
The next set of hypotheses were “Parous women will have more self-efficacy in fertility awareness than nulli-parous women” and “Parous women will have an increase in knowledge on the menstrual cycle compared to nulli-parous women”. Again a small sample of participants had children (n = 19). Two recodes were done for this variable: a dichotomous variable (had children or did not have children) and an ordinal variable where the responses were no children, one child, and two or more children. A T-test (via compare means) and a One-way ANOVA was calculated and no statistical significance was found (Tables 5 - 8)
Table 5 – Mean scores for Menstrual Score and Number of Children (dichotomous)
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Table 6 – Mean scores for Menstrual Score and Number of Children (categorical)
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Table 7 – Mean Scores for Fertility Awareness Self-Efficacy and Number of Children (dichotomous)
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Table 8 – Mean Scores Fertility Awareness Self-Efficacy and Number of Children (recoded categorical)
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The two other hypotheses were that White/Caucasian women will have an increase in knowledge on the menstrual cycle than other women and White/Caucasian women will have more self-efficacy in fertility awareness than other women. A one-way ANOVA of race/ethnicity and menstrual score was computed and no statistical significance was found. (Table 9).
Table 9– Mean Scores for “Menstrual Score”
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p > .05, F = .966
A one-way ANOVA with the variable of race/ethnicity and the variables of the “Body Literacy” score and total self-efficacy score was calculated with the results in Tables 10 and 11 below.
Table 10- Mean scores for “Body Literacy” Self-Efficacy
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Table 11- Mean scores for Total Self-Efficacy
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p< .01, F = 3.784
Bonferroni and Scheffe post-hoc tests revealed the mean differences to be significant between Hispanic/Latinos and Black/African Americans. (p < .05 for both) (Tables 12 &13). These tables reveal that African Americans scored significantly lower than Hispanic/Latinos.
Table 12- Hispanic/Latino Post-Hoc Self-Efficacy Mean
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* p < 0.05
Table 13-Hispanic/Latino Post-Hoc “Body-Literacy” Mean
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* p < 0.05
The last hypothesis was “Women with increased knowledge of the menstrual cycle will have more self-efficacy in fertility awareness than those with decreased knowledge of the menstrual cycle. Correlations were calculated with the variables of “menstrual score” and the self-efficacy scores (“body literacy” subtotal, “completing tasks subtotal, and total self-efficacy score). Results revealed a correlation between the menstrual score and total self-efficacy score, and menstrual score and completing tasks subtotal score (Table 14).
Table 14- Correlations on Menstrual Score and Self-Efficacy
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* p < .05
Summary
Two hypotheses that were supported were ”an increase in age is associated with an increase in self-efficacy in fertility awareness”and “Women with increased knowledge of the menstrual cycle will have more self-efficacy than those with decreased knowledge.” The first hypotheses was significant with a slight positive correlation where the older a participant was the higher the score on “body literacy” self-efficacy. The second hypotheses was not supported with the variable of “body literacy” subtotal. However, when the variables of self-efficacy total and completing task subtotal were analyzed a slight correlation was found.
The mean perceived self-efficacy totals (body literacy, tasks, and total self-efficacy) were all below 50% of the highest possible score. There were racial/ethnic differences in self-efficacy scores but not among White/Caucasian participants as hypothesized but between Hispanic/Latinos and African/Americans, where Hispanic/Latinos scored significantly higher on perceived self-efficacy than African-Americans.
In terms of a desire to receive a curriculum on fertility awareness, a majority of participants stated that they wanted an educational opportunity to learn about fertility awareness and felt that it would have a positive outcome on reproductive health practices (73.1% and 72.6%) respectively. The following chapter will expound more on the statistical results of the needs assessment.
Chapter V Discussion and Conclusions
The results revealed a relationship between age and the domain of self-efficacy, race/ethnicity and the domain of self-efficacy, and conflicting knowledge on the menstrual cycle. In addition, a desire for an educational opportunity was reflected in the survey results. The following chapter discusses the results and their implications.
Discussion
The demographic results are reflective of the CSUN population with slightly higher representation from the African-American and the White/Caucasian student body.
Age and “body literacy” self-efficacy were positively correlated (as age increases the score on “Body Literacy” increases) . The small sample size of those who were married and had children could have let to poor statistical power to determine statistical significance for those respective hypotheses. Future research should focus on larger samples of older females, married females, and parous females, perhaps among the population of CSUN graduate students, to increase the power.
There was inconsistent knowledge on the menstrual cycle. On one hand approximately 61% of students recognized the change in cervical mucus around ovulation yet approximately 46% did not recognize the change back to dry and pasty after ovulation. The high percentage of respondents who recognized the change around ovulation could be explained by the fact that the change in cervical mucus is noticeable on a physical and visual level, (Weschler, p. 62, 2001) and the change back to dry may not be as noticeable. Since change in BBT is not as noticeable on a physical or visual level, this may have accounted for 42.7% of participants stating that they did not know how BBT changed during the menstrual cycle.
However the changes in cervical position during the menstrual cycle not noticeable on a visual level may not be as noticeable on a physical sensation level unless a female physically inspects for cervical position changes (Weschler, p. 65, 2001) and yet over 50% of participants knew that the cervix became high and soft around ovulation. This may be because education on cervical position changes during the menstrual cycle, which may have been discussed in the Women and Health classes.
Although the hypotheses “White/Caucasian women will have an increase in knowledge on the menstrual cycle than other women” and “White/Caucasian women will have more self-efficacy in fertility awareness than other women” were not statistically significant, ethnic/racial differences were found between Hispanic/Latinos and African-Americans. Hispanic/Latinos had higher perceived self-efficacy scores than African-Americans. This result seems to have touched a weakness in the literature. As stated in the first chapter, Fertility Awareness research is primarily done on its contraceptive effectiveness and not on its non contraceptive benefits, therefore there was very little research on ethnic differences and fertilty awareness knowledge. A personal communication with Jeannette A. Cachan and Irint Sinai (2006) from the Institute of Reproductive Health at Georgetown University, mentioned that they have not seen information on ethnic differences and fertility awareness knowledge; the institute’s research is primarily on homogeneous ethnic/racial groups. Another possible explanation maybe due to religious differences. The Catholic Church only allows NFP as a form of birth control and 72.6% of Hispanics are Catholic compared to 9% of African-Americans (2002, United States Conference on Catholic Bishops). Therefore Hispanics may have had prior exposure due to religious background however, the needs assessment did not measure religious affiliation or religious observances.
Women with an increased knowledge of the menstrual cycle did not have a significantly higher score on “body literacy” self-efficacy but they did have a significantly higher score on the completing tasks score and total self-efficacy score (“body literacy” subtotal + completing tasks subtotal). A literature review exposed a lack of research pertaining to menstrual cycle knowledge and self-efficacy. The literature review did reveal that menstrual cycle and pre-menstrual syndrome (PMS) education programs can lead to less perceived PMS symptoms as measured in questionairre post-tests (Chau & Chang, 1999), and that educated Mexican women (in terms of years of schooling) reported more PMS symptoms than less-educated Mexican women (Marván & Escobedo, 1999). It seems that various types of education can influence perception of PMS symptoms and in turn quality of life, yet there is little research on how menstrual cycle and fertility awareness education can impact a woman’s perception and knowledge on her physiological capabilities, an how it pertains to her health . This gap shows a need for an educational program or curriculum.
The need for a curriculum was also evident by 73.1% of the participants stating that they would want an educational opportunity on fertility awareness and 72.6% believed it would have a positive effect on their reproductive health practices. In addition for the variables of menstrual knowledge and “body-literacy” self-efficacy, the average scores were below 50%.
Summary
The results of the needs assessment revealed a desire for a curriculum in fertility awareness and body literacy.
Chapter VI Curriculum Overview and Curriculum Matrix
The results of the needs assessment revealed that 72.6% of the participants would be interested in an educational opportunity about fertility awareness; in addition 72.6% believed that such an educational opportunity would have a positive effect on their reproductive health practices. For this curriculum project the lessons will be based on the symptothermal method for fertility awareness. The following chapter covers the format, structure, relationship offerings, learning activities, time allotment, source factors, instructional strategies, and limitations of the curriculum lesson plans.
Format and Structure
The following curriculum contains six lessons plans structured in a vertical and horizontal manner, meaning the lesson plans become the basis for additional lessons (vertical) and lesson plans that have an interrelationship among them (horizontal) (Fodor, Dalis, & Girratano-Russell, 2002, pgs. 129-135). The curriculum uses the following constructs from Social Cognitive Theory (Table 15)
Table 15: Constructs Used for Curriculum Project
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Relationship of Offerings
The first two lessons (reproductive anatomy and the menstrual cycle respectively) will provide a foundation for lessons two through five which cover fertility biomarkers and charting the fertility biomarkers. Lesson six is used for review to answer any questions and for the students to provide feedback.
Activities
The learning activities of the curriculum will consist of lectures, note taking, discussions, and journal entries. The method of relaying the information from the instructor to the learner will be through a power point presentation. Other visual aids will be used throughout the curriculum as noted in the lesson plans.
Time Allotment
The total clock time for lessons 1-6 is four hours. There is a time period of one week between lessons five and six that would put the clock time of lessons one through five at 3hrs. 30 minutes. Lessons one through five could be done continuously in a one-day period if the Klotz Student Health Center at CSUN wanted to do a one-day workshop. If CSUN instructors wanted to implement the curriculum for one of their classes the time format of the curriculum would be best in classes that met twice a week for a period of eighty minutes a class or classes that met once a week for a period of three hours a class. For those that meet twice a week lessons one and two could be done in one class session, (clock time 1 hour and 15 min.) followed by three and four for the second class session (clock time 1 hour and 15 min.). Lessons five and six would be done alone (clock time sixty min. and thirty min. respectively). Classes that meet once a week for three hours could do lessons one through four in one session (clock time two hrs. and thirty min.), and subsequently implement lesson five alone followed by lesson six the following week.
Source Factors
The lesson plans will be presented in a power point format.
Internet access is needed for the presentation. The CSUN campus contains wireless internet connection in every building on campus. The computer CPU and overhead projector can be obtained at any main department office.
The other materials such as the digital thermometer, lotion, rubber cement, and egg can be purchased at any drug store. The blank fertility charts are available at http://www.gardenoffertility.com/fertilitycharts.shtml. The large laminated fertility chart is available in the Health Promotion department of the Klotz Student Health Center with the EROS (Education and Resources on Sexuality) program.
Instructional Strategies
Effective teaching strategies make it possible for learners to gain knowledge of particular information, a particular way to do a skill, or a particular concept (Fodor et al., 2002). The instructor will utilize information acquisition strategy, concept development strategy, value awareness strategy, and skill development strategy.
Information Acquisition instructional strategy is used to promote learners’ acquisition of information. As an outgrowth of this strategy, learners should be able to demonstrate the acquisition of knowledge through listing, defining, matching, labeling, etc. The value of the information acquisition strategy is that it provides the instructor with a systematic process to impact positively the behaviors, attitudes, decision-making, and intent of the learners (Fodor et al., 2002, p. 90).
Concept Development instructional strategy is defined as a way to “promote learners’ knowledge of a concept definition and their ability to use that concept”. The value of concept development instructional strategy is that is provides the instructor with a process that empowers learners to effectively interpret, understand, and explain the world around them (Fodor et al., 2002, p. 90).
Value Awareness instructional strategy is used to promote learners’ awareness of their own values and the values of others. As an outgrowth of using this strategy, learners should report values that undergird preferred actions, decisions, or judgments. The value of the value awareness instructional strategy is that it provides the instructor with a systematic process that facilitates learners’ awareness of personal values and beliefs (Fodor et al. 2002, p. 93).
Skill Development Strategy is used to promote learners’ development of a skill. As an outgrowth of this strategy, learners should be able to demonstrate the intellectual performance of a skill. The value of skill development strategy is that it provides the instructor with a systematic process that empowers learners to interact positively and effectively with their physical and social environment (Fodor et al., 2002, pg. 90).
Limitations
With modern contraceptive technologies women have more control not only of the timing of pregnancy and number of children, but also whether or not they chose to menstruate at all. It is possible to not have menstrual periods at all through continuous use of hormonal contraception (i.e. no placebo week). This can be very beneficial to women who are bothered by premenstrual syndrome, heavy menstrual flow and cramping. In addition the use of hormone contraception can reduce the risk of ovarian an endometrial cancers (Hatcher & Nelson, 2004, p. 400). Therefore, there may be less of a need for fertility awareness as a form of birth control with the exception of those who use FA for religious reasons or are bothered by side effects of hormonal contraception. However the information that can be gathered from the curriculum can still be beneficial for women who get off of hormonal contraception to plan a pregnancy, especially since it can take two months to a year for fertility to return after discontinuation (Hatcher & Nelson, 2004, p. 398, 2004; Hatcher p. 461).
Disclaimer
Although fertility awareness is largely seen as a form of contraception, this curriculum should not be used to teach fertility awareness as a contraceptive. Females who are interested should attend classes from an instructor who is certified to teach fertility awareness as contraception. This curriculum should be only be used it was outlined in the learning objectives of the lesson plans.
Chapter VII Curriculum Validation, Recommendations, and Curriculum Matrix
A requirement of this curriculum is to have the curriculum validated by an expert panel on the content and format. The validation panel reviewed the curriculum and made their responses known on a validation instrument survey (Appendix F). The validation panel consisted of four persons who were recruited because of their experience in teaching and researching fertility awareness methods.
Validation Panel
- Amy Reichbach- Ms. Reichbach is a health educator in the health promotion department of the Klotz Student Health Center at CSUN. She is the advisor of the EROS (Education and Resources on Sexuality) peer education group and had been teaching FA as a contraception to CSUN students for over 20 years.
- Toni Weschler MPH- Ms. Weschler is the author of Taking Charge of Your Fertility: The Definitive guide to Natural Birth Control, Pregnancy Achievement, and Reproductive Health. She founded Fertility Awareness Counseling and Training Seminars (FACTS) and has lectured at hospitals, clinics, and universities since 1982.
- Jeannette A. Cachan, MA - Ms. Cachan is the Director of Training at the Institute of Reproductive Health at Georgetown University. She has over thirteen years of experience working in family planning programs. As an instructional designer and trainer, she is responsible for developing and testing training curricula in natural methods of family planning, including the Standard Days Method. Ms. Cachan also oversees the development and production of communication and educational materials at the institute.
- Barbara Kass-Annese, R.N., CNP, MSN – Ms. Kass-Annese has been a leading expert in the field of fertility awareness and natural family planning for a over 30 years. She has directed training program for family planning instructors throughout the United States, Asia, Africa, and Latin America and has co-authored the book Natural Birth Control Made Simple. Past professional positions include being the Director of Clinical Services and the Center for Health Enhancement at St. John’s Health Center in Santa Monica, CA. Currently Ms. Kass-Annese is working as a Medical Specialist in the Department of Provider Services at the California Family Health Council assisting agencies, clinic sites, and community organizations with the implementation and delivery of family health programs.
Validation Instrument
The instrument was modeled after the recommended format used in the CSUN Curriculum Development graduate course. The instrument contains 11 questions and an accompanying 10-point Likert Scale. The questions ask the validation panel to rate the curriculum’s content accuracy, organization, and clarity.
Validation Results
The validation panel received a validation instrument with the purpose of rating the curriculum on goals and objectives, content, organization, and clarity on a ten point Likert-scale, summarized on Table 16. The validation instrument was modeled after the survey instrument recommended in the graduate Curriculum Development course at CSUN.
Table 16 – Validation Summary
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Comments from the validation panel included observations on semantics. One committee member recommended using more generalities when discussing events that may occur during the menstrual cycle, (i.e. using the phrase “you may experience” vs. “you will experience”). Three panel members stated to use either the term cervical fluid or cervical mucus consistently, and not alternate the two terms as to not to confuse the learner.
All panel members stated that the content was accurate and was separated and sequenced into lessons nicely. Criticism on content involved the menstrual cycle with one panel member stating that the menstrual cycle could be divided into three phases and not four ( where the menstrual and follicular phase were one phase and not two unique phases). To validate this, a literature review was done on descriptions on the menstrual cycle via text books and online sources (King, pgs. 59-60, 2005, Hatcher et al. pgs. 66-67, 2004, & Merck, 2003). From the text reviewed the first two sources broke down the menstrual cycle into four phases while Merck website (2003) broke it down into three putting the menstrual and follicular phases into one. Therefore the content of lesson plan two of the curriculum was changed to show both breakdowns of the menstrual cycle.
Other criticism included the delivery mechanisms. One panel member recommended more activities for the learners and another encouraged more activities to prevent the lesson plans from appearing “dry”. A visual aide was added to the power point presentation showing the hormonal changes during the menstrual cycle and corresponding visuals of physiological changes.
Overall the curriculum rated highly with the highest score being 8.3 (for “Is the content of the educational curriculum appropriate for the target group?”, “Is the content on the menstrual cycle accurate?”, and “Is the review and summation of lesson 6 thorough?”). The lowest score was 7.3 (for “Is the content of the educational curriculum easy to understand?” and “Is the content on basal body temperature accurate?”). The evaluation by the validation panel reflected that the content was accurate and sequenced appropriately if a little tedious at times.
Chapter VIII Thesis Contributions to Health Education and Compliance with Health Education Responsibilities and Competencies
To conclude this project, this chapter will be devoted to outlining how the implementation of the needs assessment and creation of the curriculum is in compliance with the responsibilities and competencies set forth by the National Commission for Health Education Credentialing (NCHEC, 2002).
RESPONSIBILITY I - ASSESSING INDIVIDUAL AND COMMUNITY NEEDS
FOR HEALTH EDUCATION
Competency A
Obtain health-related data about social and cultural environments, growth and development factors, needs and interests.
Sub-Competencies:
1. Select valid sources of information about health needs and interests.
2. Utilize computerized sources of health-related information.
3. Employ or develop appropriate data-gathering instruments.
4. Apply survey techniques to acquire health data.
The first phase of the project was devoted to a review of sources of information on fertility awareness, reproductive health and menstruation education, social cognitive theory, and information on the intended population of college females. In addition a needs assessment survey was created and approved for use by the CSUN Institutional Review Board.
Competency B
Distinguish between behaviors that foster and those that hinder well-being.
Sub-Competencies:
1. Investigate physical, social, emotional and intellectual factors influencing health behaviors.
2. Identify behaviors that tend to promote or compromise health.
3. Recognize the role of learning and affective experience in shaping patterns of health behavior.
The goal of fertility awareness education and educators is to give females more of an intellectual understanding of the physiological events and changes of their fertility cycle. When fertility awareness is successfully implemented by females it “stresses behavioral changes and personal responsibility as important tools in maintaining health. By enhancing women’s self- knowledge, it encourages a paradigm of collaboration with medical experts and decreases reliance on drugs and medical technologies” (Yewchuk, 2006).
Competency C
Infer needs for health education on the basis of obtained data.
Sub-Competencies:
1. Analyze needs assessment data.
2. Determine priority areas of need for health education.
The second phase of this project involved implementing the needs assessment and analyzing the data from the survey using statistical analyses. The results revealed a strong desire for a curriculum in fertility awareness with a priority area of better education on the menstrual cycle. Hypotheses testing found self-efficacy differences in the domains of race/ethnicity and age respectively.
RESPONSIBILITY II - PLANNING EFFECTIVE HEALTH EDUCATION PROGRAMS
Competency A
Recruit community organizations, resource people and potential participants for support and assistance in program planning.
Sub-Competencies:
1. Communicate need for the program to those who will be involved.
2. Obtain commitments form personnel and decision makers who will be involved in the program.
3. Seek ideas and opinions of those who will affect, or be affected by the program.
4. Incorporate feasible ideas and recommendations into the planning process.
Community stakeholders that were recruited for opinions and information on the intended population included university professors that teach Women and Health courses and Marriage and Family Health courses. In addition experts in Fertility Awareness education were recruited to validate the curriculum for accuracy, clarity, and structure.
Competency B
Develop a logical scope and sequence plan for a health education program.
Sub-Competencies:
1. Determine the range of health information requisite to a given program of instruction.
2. Organize the subject areas comprising the scope of a program in logical sequence.
The lesson plans created for the curriculum include a range of reproductive anatomy, to fertility biomarkers, to recording and deciphering what the biomarkers reveal. The structure of the lesson plans follows a vertical and horizontal structure where the lesson plans either follow a logical sequence or have an interdependent relationship with each other.
Competency C
Formulate appropriate and measurable program objectives.
Sub-Competencies:
1. Infer educational objectives that facilitate achievement of specified competencies.
2. Develop a framework of broadly stated, operational objectives relevant to proposed health education program.
Competency D
Design educational programs consistent with specified program objectives.
Sub-Competencies:
1. Match proposed learning activities with those implicit in the stated objectives.
2. Formulate a wide variety of the alternative educational methods.
3. Select strategies best suited to implementation of educational objectives in a given setting.
4. Plan a sequence of learning opportunities building upon, and reinforcing mastery of preceding objectives.
The instructional strategies include Information Acquisition, Concept Development, Value Awareness, and Skill Development strategies. The various learning strategies were used so the behavioral, affective, and cognitive domains of learning could be utilized. Learning objectives were fashioned to be measurable by having the learner demonstrate acquired knowledge through activities that includes listing, naming, recording, identifying, verbal recall, and journal writing.
Conclusions
This thesis project simultaneously fulfilled the objectives of the Master in Public Health program at California State University Northridge and the Responsibilities and Competencies put forth by NCHEC. It accomplished this through:
- Survey Development
- IRB approval
- Survey/Needs Assessment implementation
- Data analyses
- Curriculum Development
- Curriculum Validation
Health Educators have a duty to diffuse accurate health information and create innovate ways for people to implement positive health behaviors into their daily lives. With fertility awareness education, females can become more in tuned with their reproductive physiology, lifting a layer of mystery that has been clouding females for too long. In addition, health educators must be perceptive to cultural health norms. Whereas other contraceptives are primarily directed towards heterosexual females, fertility awareness with its non-contraceptive benefits can allow inclusion of the lesbian community, as well as those with religious beliefs that forbid traditional contraception and those who wish to take a non-pharmacological approach to their health.
References
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Appendix A: Effectiveness of Current Available Birth Control Methods
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As the table reveals the perfect user ratings for NFP/FAM is comparable with other perfect user ratings for barrier methods and has a lower perfect failure rate than spermicides used alone and cervical cap for nulliparous women. The typical user failure rates are also analogous to those of other barrier and non-hormonal methods such as spermicides and withdrawal. Therefore NFP/FAM should be seen as practical options to those women who do not want to use hormonal methods of contraception.
Appendix B
Questionnaire on fertility awareness
Please choose only one answer for the questions below by putting a check mark in the space provided on items 2-6. For items 7-12 please circle or highlight the item that you believe is the correct answer.
1. WHAT IS YOUR DATE OF BIRTH? (month/date/year) _____/_____/______
2. WHAT RACE/ETHNICITY DO YOU IDENTIFY YOURSELF AS?
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3. WERE YOU BORN IN THE UNITED STATES?
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4. DO YOU SPEAK A LANGUAGE OTHER THAN ENGLISH AT HOME?
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5. WHAT IS YOUR MARITAL STATUS?
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6. HOW MANY CHILDREN DO YOU HAVE?
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7. A MENSTRUAL CYCLE:
A. Begins on the first day of bleeding and ends when bleeding stops.
B. Begins on the last day of bleeding and ends on the day it starts again.
C. Begins on the first day of bleeding and ends the day before bleeding starts again.
D. Don’t know.
8. MENSTRUATION SHOULD OCCCUR:
A. 5-10 days after ovulation.
B. 12-16 days after ovulation
C. 16-20 days after ovulation
D. Don’t know
9. A FEW DAYS BEFORE THE EGG LEAVES THE OVARY, CERVICAL MUCUS BECOMES:
A. Sticky, pasty, and crumbly
B. Dry, flaky, and disappears
C. Wet slippery, and stretchy
D. Don’t know
10. A FEW DAYS BEFORE THE EGG LEAVES THE OVARY, THE CERVIX BECOMES:
A. High, soft and open
B. High, soft and closed
C. Low, firm and closed
D. Don’t know
11. A WOMAN’S BASAL BODY TEMPERATURE IS USUALLY:
A. 97.0°-97.5° before ovulation and rises to 97.6°-98.6° after ovulation.
B. 97.6°-98.6° before ovulation an drops to 97.0°-97.5° after ovulation.
C. Is the normal 98.6°-98.7° throughout the cycle
D. Don’t know.
12. AFTER OVULATION OCCURS, CERVICAL MUCUS
A. Loses its dry feeling and becomes wet and stretchy.
B. Loses its wet feeling and becomes sticky and pasty
C. Remains wet and stretchy for at least 10 days.
D. Don’t know
Self-Efficacy in Reproductive Health and Knowledge
There are a number of things a woman can gather about her reproductive health if she is knowledgeable about changes in her body during her menstrual cycle. Please rate in each of the blanks on the column how certain you are able to do the tasks below.
Rate your degree of confidence in the space provided by recording a number from 1 to 100 using the scale given below:
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Self-efficacy in reproductive health knowledge:
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Self-efficacy in completing these tasks:
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If there were an educational opportunity that could teach you how to do items 1-10, would you be interested?
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How do you think this knowledge would benefit your reproductive health practices?
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Appendix C
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Appendix D
Information Form to participate in study titled “A Curriculum to Increase the Self-Efficacy in Reproductive Awareness in College Females"
Purpose
Serena Holguin (Principal Investigator) and Dr. Kathleen Young (Co-Principal Investigator) at California State University Northridge are conducting this survey as part of Serena Holguin’s master’s project in health education.
The purpose of this study is to survey CSUN female students on their knowledge on fertility awareness and reproductive health as a needs assessment for a curriculum project.
Procedures
You will be asked to complete a short survey that should take 10-15 minutes to complete; you will not be paid for participating in this study.
Your participation in this research study is completely voluntary. You are free to participate in this research study or to withdraw at any time. If you chose not to participate or if you chose to withdraw, there will be no penalty against you. If you decide to participate, you are free to withdraw at anytime without consequence.
Risks and Discomforts
This study involves no more than minimal risk to you. The only manipulation to your environment will be the presence of the survey on your desk. There is the possibility of discomfort from not knowing the correct answer to some of the questions.
Your privacy will be kept confidential to the extent of the law. Your name, place of work, social security number, or other specific identifiers will not be asked. There will be questions on your ethnicity and date of birth.
Benefits
By taking part in this study, you may increase the knowledge of the Klotz Student Health Center and Department of Health Sciences on the need for a curriculum on fertility awareness
Concerns
If you wish to voice a concern about the research, you may direct your question(s) to Research and Sponsored Projects, 18111 Nordhoff St. Northridge, CA 91330, mail code 8232 or phone 818-677-2901. If you have specific questions about this study please contact serena_holguin@yahoo.com or Dr. Kathleen J. Young at Department of Health Sciences California State University Northridge 18111 Nordhoff Street
Northridge, CA 91330-8285 mail code 8285; kathleen.young@csun.edu or, 818-677-4725.
Appendix E
Thank you for your participation! J
If you are interested in learning about items 1-10 in the self-efficacy scale you can get more information from:
Taking Charge of Your Fertility: The definitive guide to natural birth control, pregnancy achievement, and reproductive health. By Toni Weschler, MPH
ISBN # 0-06-039406-4 (hardcover)
ISBN# 0-06-093764-5 (paperback)
If you are interested in private classes please contact Amy R. at the Klotz Student Health Center. (818)
Appendix F
Validation Instrument
This is a validation questionnaire to evaluate the curriculum on fertility awareness as “body literacy” for college females. Please take a few minutes to fill out the following questions about the curriculum. Please rate your answers to the following questions using the rating scale and circling the number that reflects your opinions.
Rating Scale
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1. Does the content of the educational curriculum adhere to the lesson plan goals and objectives?
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2. Is the content of the educational curriculum appropriate for the target group?
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3. Is the content of the educational program well organized?
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4. Is the content of the educational curriculum easy to understand?
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5. Is the content on the female sexual anatomy accurate?
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6. Is the content on the menstrual cycle accurate?
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7. Is the content on cervical mucus accurate?
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8. Is the content on basal body temperature accurate?
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9. Is the content on charting fertility signs accurate?
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10. Is the review and summation of lesson 6 thorough?
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11. Overall does the content of the curriculum provide proper education for college females on fertility awareness and body literacy?
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Additional Comments:
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