The evaluation of health classes is based on different methods; the analysis of results obtained by administering a questionnaire at the beginning and at the end of the course; a continuous process of evaluation was also undertaken in each session, and, finally, the evaluation looks into the aims and objectives of the health classes and assesses whether these have been achieved.

The different sections of the evaluation i.e.:
- Individual Sessions Report
- Achievement of Aims
- Achievement of Objectives
- Overall Evaluation
- Evaluation of Questionnaire

will be presented here separately.

---------------------------------------------------------------------------------------------------------------------------------------------

HEALTH SESSIONS
INDIVIDUAL SESSIONS
REPORT


FIRST SESSION:

Date: 03/03/1987

Tutor: Steering Group

Session: Welcome, Introduction and quiz

The first session was the welcome and introduction of the Steering group to the women. We explained what the classes would be about abd told them how everything would be. We wanted women to feel comfortable so we also explained that their participation would be essential. We then divided women into smaller groups and conducted the quiz. They showed a lot of enthusiasm. They answered the questions very openly and were discussing everything with us.


SECOND SESSION:

Date: 10/03/1987

Tutor: Dr. Fran Reader

Session: Anatomy and Family Planning

Eleven women attended this session, all of them except one were those who attended the first session. Information was given by the tutor in an informal way and the women found it very interesting. The tutor discussed menstruation; how and why it happens and what changes occur in the body during this period.

The tutor also talked about family planning and the methods used. She demonstrated the different kinds of contraceptive methods. The women watched with interest and curiosity. A lot of new things were learnt regarding the menstrual cycle, contraceptive methods and their uses. Some of the contraceptive methods were known to these women, but only a few have ever used some kind of contraception.


THIRD SESSION:

Date: 17/03/1987

Tutor: Kate Newsam

Session: Anatomy and Menstruation

Nine women attended this session. The menstrual cycle was discussed in more detail and women were very interested to know more of what goes on inside their bodies during this time. This was especially so when the tutor was talking about why periods come, how and from which parts. The tutor distributed some pictures to the women showing the different parts of the female reproductive system and they studied them with great interest. A lot of questions were put to the tutor by the women which made the discussion more lively. It was clear that women were becoming less shy and, after three sessions, they seemed to be gaining confidence in putting questions to the tutor about their doubts. Discussions between the women had also started.


FOURTH SESSION:

Date: 24/03/1987

Tutor: Dora Opuku

Session: Pregnancy and Ante-Natal Care

Nine women attended this session. The atmosphere had become more friendly and less tense. They were more relaxed which showed that they were getting used to the classes. The tutor explained at length different stages of pregnancy and the importance of ante-natal care, and what it is all about.

This session was particularly interesting because almost all of the women have had children and were therefore on more familiar ground. They have, however, learnt a great deal about ante-natal care for they knew very little about it. In fact, they confessed that they had never considered it important and had not, therefore, made uses of these services.


FIFTH SESSION:

Date: 31/03/1987

Tutor: Gulu Hussein

Session: Baby Delivery

Not many women attended this session. The women who attended found this session very interesting because the tutor, who has worked in Africa, had had similar experiences to some of the women. She also explained using examples and citing experiences from Africa which made the discussion very interesting.

The tutor gave plenty of time for the women to ask questions or talk about experiences which they could share with others. She explained clearly what happens during birth, and the different kinds of birth. The effects of the complications of female circumcision during birth were also discussed. A simulation of the delivery of a baby was also shown. Many questions, explanations and queries were also put forward by the women.


SIXTH SESSION:

Date: 07/04/1987

Tutor: Amina A. Ibrahim

Session: Traditional Health Practices in Somalia

A lot of women did not turn up to this session but those who came enjoyed it. Some of the women did most of the talking because they had a lot of experience in this particular area. They explained some methods which they use when the need arises and their strong belief in traditional medicine.


SEVENTH SESSION:

Date: 14/04/1987

Tutor: Julia Reindorp

Session: Cervical and Breast Cancer Screening

For this session the tutor could not come in the morning so it began at 2.00pm, as was agreed by the tutor and Steering Group. A lot of women turned up. The tutor talked about the frequency of cancer in the developed as well as the developing world and made some comparisons between them.

During the discussion the tutor made some breast examinations while the rest watched how it was done , eager to learn. Some women made appointments with the tutor to have a breast/ cervical screening in her clinic. Many more have learnt where to go for these tests. It has been good to see how much interest women have shown in knowing and understanding more of the problems and in learning to do something about it. They have all said they will soon go to a clinic for screening which, as they said, they had never done before.


EIGHTH SESSION:

Date: 21/04/1987

Tutor: Shamis Dirir

Session: Female Circumcision

The majority of women who attended were familiar with the topic. A long discussion took place. Each woman talked about her own experience of female circumcision and cited problems and disadvantages associated with it. The tutor recently returned from a conference on female circumcision held in Africa, and gave details of what people, particularly women, say about female circumcision and what needs to be done. The women have shown great interest in the debate and came up with many positive points. Many of them even spelt out that it is high time people stopped the practice. It was a great day in which the women clearly have shown their concern over the continuation of the practice.


NINTH SESSION:

Date: 28/03/1987

Tutor: Cynthia Dickson

Session: Menopause and other Health Issues

Some of the women who came to this session were in their menopause. The tutor explained how women undergo a lot of pressure during this period. The tutor also talked about what happens and gave them advice. She brought handouts which the women asked us to translate into Somali. This is one of the sessions which the women asked to be done again. And it is one of the sessions that all the women who attended became tutors to others, explaining all that was said in this session and in some of the other sessions.


TENTH SESSION:

Date: 05/05/1987

Tutor: Efua Graham

Session: Problems Associated with Female Circumcision

This session was well attended and the women showed a great interest. The tutor brought with her a projector, showing different kinds of female circumcisionand other problems associated with it. The women were familiar with them and discussed these with her. Some of the women openly said that they regret having had their daughters circumcised. This is very interesting to see such a thing happening because it shows how women's behaviour and attitudes might change in the future.


ELEVENTH SESSION:

Date: 12/05/1987

Tutor: Steering Group

Session: Plenary Session

At the end of the sessions we again did the quiz which we presented at the start, but added more questions. The number of women who attended this session was less than those who turned up for the first quiz but the answers show that there is an increase in knowledge. Women asked to have more videos instead of tutor lecturing and a support group was formed. They want some of the sessions to be repeated and they asked to have exisiting videos with Somali 'voice overs'.

---------------------------------------------------------------------------------------------------------------------------------------------

EVALUATION OF HEALTH CLASSES
3rd March - 12th May 1987

Assessment of whether the aims and objectives of the health classes were achieved is based on an on-going evaluation of the course in general and individual sessions in particular. During each session, women's views, interests, worries and queries were written down. Observations on how women were getting along with the classes, and their participation in the discussions were also made.

Whether the aims and objectives of the classes are achieved, and how, will be dealt with one at a time in the following pages.

AIMS

1. 'Specifically, to raise the issue of female circumcision (both as an open and hidden agenda), and hopefully to affect a reduction in it's practice'.

It has been known previously, through experience with the Somali women, that female circumcision (F.C.) is a very sensitive issue and that women will not easily indulge in debates or discussions about it. Bearing that in mind, the sessions on female circumcision were arranged to be in the last sessions of the course. This was to prepare the ground and familiarise the women with the environment under which discussions will take place.

The first part of this aim has been successfully achieved. It has been observed throughout the sessions dealing specifically with F.C., as well as in others where the practice was brought in, that women were becoming more aware of the problems and the risks associated with the practice. Women were becoming increasingly more confident and open in expressing their views about it. They talked about their personal experiences, revealed their views about the disadvantages of F.C., and the vast majority had the confidence and courage to talk about abolishing the practice.

The knowledge the women have aquired from the sessions dealing with the anatomy and physiology of the female reproductive system, sharing their experiences and exchanging views, and the atmosphere under which classes were held were all factors which contributed to achieving this aim.

The other part of the aim ('and hopefully to effect a reduction in it's practice') still remains to be explored concretely. It's hoped that the practice of F.C. will decrease if the majority of women were made aware of the problems related to it and thus take a different attitude from their previous one, as this group of women have done. Their knowledge, views, stands, and attitude towards female circumcision may well have an important impact and influence upon others.


2. 'More generally, to address a variety of women's health issues and, by raising awareness, affect attitude and eventually behaviour'.

This aim has also been fulfilled. A few examples will be taken to illustrate this. Female Circumcision is one of the issues affecting the health of women which has been addressed during the classes. As mentioned earlier, women's awareness of the health and psycho-social risks and complications associated with female circumcision was definitely raised.

Cervical Cancer was another issue. Cancer, in general, has been a taboo among Somali women and they usually do not take any interest in it for they believe it could never happen to them. They have learnt a lot about cervical cancer and how to prevent it. It was amazing to see that the majority of women were now aware of the risks of cervical cancer, and how to prevent to prevent it and where to go for a smear test. The session on cervical cancer has been one of the most useful and interesting ones, and it happened that many women made appointments with the tutor of that session to arrange a smear test. The women, who have not heard of this test before or never knew what cervical cancer was, have, at the end of the sessions, become aware of the problem and have taken immediate action.

Breast cancer was also another similar issue. Women attending the course, like many others, regarded female breasts as sacred parts of their body which one could not easily touch or talk about. This barrier has been broken after the sessions and for the first time the women have learnt how to examine their breasts. They were taught how to examine breasts and afterwards, practiced on each other. Awareness was created towards breast cancer and women gained knowledge of what to do and where to go if they were in doubt. Above all, they have aquired the simple skill of examining their own breasts regularly and have shown the confidence and commitment to do so.

---------------------------------------------------------------------------------------------------------------------------------------------

EVALUATION OF HEALTH CLASSES
3rd March - 12th May 1987


OBJECTIVES

1. To provide a forum for discussion on women's health issues and, by bringing women together in a group, help reduce the social isolation that is a problem for many of the target group.

This objective has been achieved for the health classes, which were first of this kind, have proved to be a good forum for discussing issues in a relaxed atmosphere. As the sessions progressed the women became more aware of the problems common to them by sharing experiences and exchanging views. Discussions were not always confined to issues set out in the classes, but also included others, such as housing, domestic affairs and problems and/or difficulties encountered in daily life. The discussions were all informal, this set up has made appositive contribution to the breaking down of barriers and reservations. These informal discussions, and the issues discussed, all taking place under a very friendly and relaxed atmosphere have brought about another dimension to the women's thinking: the sense of belonging to a social group. This has been a great achievement for women have realised the usefulness of getting together in a group to discuss or tackle problems that may arise. They have requested that more classes be organised.


2. To help women gain personal self-confidence to express their own health and social needs - thus encourage the development of self-assertion.

The informality of the discussions, the friendliness of the atmosphere and the participatory nature of the class have all helped in the achievement of this objective. The background of how this was achieved can also be found in the proceeding paragraphs. Women were encouraged to talk about their experiences and express their views about the issues that were being addressed at each session. For instance, experiences of female circumcision and of pregnancy under difficult circumstances was shared by the women. They have shown interest and enthusiasm in participating in discussions and have become more confident in expressing their needs, as well as identifying problems. Some of them explained topics that had been covered in earlier sessions to women who were absent for those sessions.


3. To raise awareness of what N.H.S. services are available and how to gain access to them.

This has also been fulfilled. The services that are available under N.H.S were listed and access to each was discussed. Women were now very clear about what different health professionals do and what their roles are. At the beginning, they could not distinguish between the roles of the Social Worker and the Health Visitor. In fact, the Health Visitor was not known to the women as a Health Worker. They have learnt where to go for help or advice when and if needed. Areas where particular interest was shown in this regard included cervical screening, ante-natal care and family planning.


4. To help improve understanding of the female anatomy and physiology, examine female body processes and associated health issues and look at how they are related to female circumcision.

This objective has been met with enormous success. The knowledge of women about the anatomy and physiology of female reproductive organs was exceedingly limited at the beginning of the course. That was why sessions dealing with these aspects preceded those concentrating on female circumcision. Women have benefited a great deal from these sessions and they have, for the first time, become aware of the existence of some parts of the reproductive system and how it works. Damage done to anatomical parts by female circumcision and the physiological changes that occur, and the inevitability permanent ill-effects, have been a common feature of the discussion. Each part of the reproductive organs was taken separately and the ffects of female circumcision examined.


5. To help set up support networks at the end of the course, if this is deemed useful.

At the end of the course, a support network was set up, following the belief that this would be useful. Many of the women who attended the health classes have stated that they would want to become members of this support network. The support group would collaborate closely with the Steering Group in carrying on the activities. They will, for instance, work together to produce some visual aids, such as advising on videos which were recommended by women attending the classes. The creation of the support network is regarded as an important product of these health classes.


6. To assess the adequacy of current health educational material on black women's health issues and recommend improvements and developments where appropriate.

The women felt that there was no health educational materials addressing women's health issues (and specifically black women's health issues) in Somali. Since reading Somali can be a problem with some Somali women, video was thought to be the most appropriate means of communication. Although a ling-term aim would be to have access of videos specifically produced in Somali for black women, in the short-term use of existing videos with Somali 'voice-overs' would be most acceptable and helpful.


7. To consider the information needs of health professionals in dealing with specific black women's health needs, as highlighted in group discussions.

This objective has been achieved too. It has been highlighted in the discussions that there is a lack of material dealing with the black woman's health issues. It has also been agreed that health professionals are not very aware of the social and cultural determinants of black women's ill-health. These and others have been earmarked for inclusion in an information package for health professionals.


8. To explore some of the major issues which came out of group discussions and which could be followed-up later on as on going community based projects.

A follow-up committee was formed in order to look into the progress of otherhealth classes for specific issues. For instance, female circumcision, although it was dealt with as a hidden agenda, has been an interesting issue. Many women regret having allowed their daughters to undergo such an operation. It is expected that women may change their attitude towards female circumcisionand this would need to be addressed again and at the same time follow-up changes that might occur in people's attitudes and practices towards female circumcision.

---------------------------------------------------------------------------------------------------------------------------------------------

EVALUATION OF HEALTH CLASSES
3rd March - 12th May 1987



As is clearly depicted in the aforgoing chapter, it could be confidently said that the health classes have been highly successful.

At the end of the course, it was undoubtedly clear that women have gained confidence in expressing their views, ideas and needs regarding their own health. Group discussions have proved invaluable in this regard. They also aquired some knowledge about some of the major health issues that affect women. But, perhaps, more importantly, they also had a much clearer idea of where to go for help and advice in case of difficulties.

The evaluation of the health classes is based on the conclusions we have made after careful analysis of the questionnaire that was presented to the women both before and after the classes. The results show that the women learnt a great deal during the health classes. The knowledge which the women have aquired from the classes about anatomy and physiology of the female reproductive system, discussing the problems, gaining a lot of confidence and sharing their experiences has contributed more to the success of the health classes.

After the health classes we were expecting that there might have been a change of behaviour towards, for example, female circumcision, however, what was noticeable was the sense of regret shown by some of the women. This was shown by them saying that they had already circumcised their daughters but promised that they would pass on their knowledge to those who were not able to come to the classes. The other thing that happened was that women started to go to Women's Clinics, this after a session dealing with cervical and breast cancer screening. This had never happened before.

In conclusion it must be said that the health classes were a great success but that this positively shows the necessity for them to be repeated throughout London on a continuing basis.

The Steering Group must be thanked for their continued help and support in making a success of the health classes:

Cynthia Dickson
Aiysha Mirreh
Shamis Dirir
Alison Egan
Lindsey Ahmed

Produced by:
Amina A. Ibrahim
Health Classes Co-ordinator

---------------------------------------------------------------------------------------------------------------------------------------------

EVALUATION OF HEALTH CLASSES
3rd March - 12th May 1987
QUESTIONNAIRE

At the first session of health classes, held on 3rd March 1987, eighteen women came, much less than previously anticipated. After tea, the Steering Group made some welcoming remarks and women participants were divided into two groups of eight. Then, the quiz was taken with the help of the questionnaire. Alison and Shamis were the team leaders of one group whilst Lindsey and Amina were team leaders of the other.

During the last session of the classes, on the 12th May 1987, the same questionnaire with a few additional questions about the course and sessions, were again administered to women participants.

The responses obtained for each question at the beginning and end of the course are given below. An attempt will be made to discuss any change that may appear in the responses given during theses two stages.

Questionnaire

Question 1:
What have you been taught about monthly periods?

Answer:
- Before Course
They said that periods are necessary for pregnancy and having babies. They all believe that it is the natural thing to have periods and it is a gift to women from God.

- After Course
The same set of answers were also given at the end of the health classes.


Question 2:
Which of the following problems are associated with monthly periods?

Answer:
- Before Course
The majority of respondents state irritability, mood changes, depression and tension. Others go for abdominal cramps and uncomfortable abdominal swelling.

- After Course
The same responses are given again, but a few mention tender breasts aswell.


Question 3:
Do you think that some of the problems might even be worse in women who are circumcised?

Answer:
- Before Course
They all agreed that the answer is YES and added that before marriage, it could be a real problem, but after defibulation it would not get worse.

- After Course
They all gave an 'YES' answer, and again, mention serious problems before marriage.


Question 4:
Which of the following types of circumcision are you familiar with?

Answer:
- Before Course
Sunna and Infibulation only

- After Course
Sunna, Infibulation and Clitoridectomy. All women were not aware of the circumcision but have learnt about it during classes.


Question 5:
Why do you think some women are circumcised?

Answer:
- Before Course
Some said that it is for the male's sexual pleasure, others said it's for purity of chastity. One woman said that the Vulva looks better and more beautiful after circumcision.

- After Course
Male sexual pleasure is given by a few. Some said it's for economic reasons, since their parents won't get a dowry if their daughter is not circumcised.


Question 6:
How does the law in Britain deal with female circumcision?

Answer:
- Before Course
Everyone clearly knows that the law prohibits female circumcision in Britain, but some of the women think that it isi an interference with their tradition.

- After Course
Exactly the same set of responses are given again.


Question 7:
Could any of the following problems be associated with female circumcision?

Answer:
- Before Course
Marriage difficulties and delayed delivery in childbirth.

- After Course
Infection, infertility, marriage difficulties and delayed delivery during childbirth. It seems that women have gained more knowledge about problems associated with female circumcision.


Question 8:
Which of the following places would you go for Family Planning?

Answer:
- Before Course
A few would go to a Family Planning Clinic or a G.P. But the majority do not want to know about family planning because it is against their religion (Islam) and it's a crime to prevent or cut short the normal course of pregnancy.

- After Course
Family Planning Clinics, Women's Health Clinics and G.P.s are all cited.


Question 9:
Who would seriously be affected by Rubella?

Answer:
- Before Course
None of them knew what Rubella was, but some said that it's probably a children's disease.

- After Course
The same responses as before were given. It's apparent that there is little knowledge about this serious disease and this should be taken into account in future classes.


Question 10:
Which of the following might you be entitle to?

Answer:
- Before Course
Everyone knew about Pension Allowance and Child Benefit.

- After Course
Pension Allowance, Supplementary Benefit, Child Benefit were mentioned.


Question 11:
Which of the following Family Planning methods have you heard about?

Answer:
- Before Course
Pill, condoms, IUD were known to the majority of respondents, some however, mentioned breast feeding.

- After Course
The pill, condoms, IUD were all known to the women and they have also mentioned other methods such as breast-feeding and rhythm.


Question 12:
Do you think it is wise to have Family Planning?

Answer:
- Before Course
'NO'. All of them said that it is wise to space children, but to have them is even wiser.

- After Course
'YES' was the predominant response, but they also spelt out that child spacing is always better than Family Planning.


Question 13:
What do you know about the jobs of the G.P., Midwife, Health Visitor?

Answer:
- Before Course
Although they mentioned that these have different roles, there has been a big confusion about the roles of Health Visitors and Social Workers.

- After Course
They have stated that these Health Workers have different roles, and more importantly perhaps, the confusion surrounding the roles of Health Visitor and Social Worker have been cleared.


Question 14:
Why do you think ante-natal care is important?

Answer:
- Before Course
The majority said that it's to check your health and the unborn baby's health. None have mentioned advice as an important element.

- After Course
Checking your health and the unborn baby's were the main reasons given together with giving advice.


Question 15:
Which if the following types of childbirth have you heard about?

Answer:
- Before Course
Normal childbirth, breech, caesarean and instrumental were all heard about.

- After Course
The same set of answers were given.


Question 16:
Which of the following could be good reasons for having a Caesarean section?

Answer:
- Before Course
Big baby and small pelvis and baby's life in danger were all cited.

- After Course
In addition to previous answers, cosmetic effects and circumcision were also given to be good reasons.


Question 17:
Which of the following infections have you heard about?

Answer:
- Before Course
Everyone mentioned AIDS and thrush and some cystitis. Earlier infection causing infertility was also mentioned.

- After Course
AIDS, cystitis, thrush and infertility due to previous infection were all heard about. But some added other infections such as candida infection.


Question 18:
When is the best time to examine your breasts?

Answer:
- Before Course
Half of the women said just after the period is the best time because the breasts are soft. The half had absolutely no idea.

- After Course
All women stated that just after periods is the best time. This indicates that women have not gained some knowledge and understanding about how to examine their breasts and the best time to do so.


Question 19:
Where would you go for a Cervical Smear Test?

Answer:
- Before Course
Half of them (8) said they would go to G.P.s whilst the rest were divided and mentioned Women's Health Clinic, Family Planning Clinic. One said she would not go to anyone as she thought cancer would not affect her and that if it did it would be scary to know that she was suffering from cancer.

- After Course
The vast majority said they would go to Women's Health Clinic and Family Planning Clinics. None of them was reluctant to go for a cervical smear test. Their concern over this type of cancer seems to have grown quite substantially.


Question 20:
Do you know how to examine your breasts?

Answer:
- Before Course
None of the 16 women present knew how to examine their breasts.

- After Course
The majority of women did know how to examine their breasts. The demonstration shown during the classes have proved very useful indeed.


Question 21:
Which of the following are associated with menopause?

Answer:
- Before Course
Gaining weight was the response of all women. No one knows about symptoms associated with menopause.

- After Course
Tension and depression, hot flushes and ageing were cited to be associated with menopause by all women. Participants gained more knowledge and understanding of the symptoms associated with menopause.



When the classes were close to the end, the final quiz included some additional questions that dealt with some of the topics discussed at length during the sessions. Some general questions about the health classes and specific sessions were also included in the final quiz.

We will now examine the kind of responses obtained from these further questions, some which give an indication of the overall success or failure of the course.



Question 22:
When do you think is the best time for a woman to get pregnant?

Answer:
The vast majority of respondents said; 'around the 14th day from the 1st day of the menstrual period'. A few opted for; 'just after the period'. It seems that the method of counting the days of the cycle was confusing. Most of them previously started the count from the 1st day when menstrual blood ceases rather than from the 1st which it starts. This has come up during the discussions and women participants were rather pleased to learn the method of counting and relate it to 'safe days to have sex and avoid pregnancy'.


Question 23:
What do you know about the Female Reproductive System?

Answer:
The majority of respondents stated that it consists of the vagina, ovaries, fallopian tubes and the uterus. Some however, said that it is only the uterus, and a few more said it is the ovaries and the fallopian tubes only. Although some were still not certain if the organs which the female reproductive system is composed of, the majority have learnt of the important parts and their functions. This will certainly help women understand more their own reproductive organs, their functions, and related disease afflictions.


Question 24:
It is more likely to get cervical cancer if : …?

Answer:
The vast majority said 'if you are sexually active'


Question 25:
What do you think of this course?

Answer:
All women stated that they found the health classes 'very useful' and have strongly expressed their desire to have more of these kinds of health classes. They have shown an appreciation and great admiration for this discussion and for participating in these health classes which they think have given them very useful information about many essential issues which affect both their health and social well-being.


Question 26:
Which session did you find most useful?

Answer:
The vast majority agreed that the most useful sessions were: anatomy and menstruation; cervical and breast cancer screening; female circumcision; problems associated with female circumcision and; family planning.


Question 27:
Why did you find the above sessions most useful?

Answer:
Most women have stated that these sessions had one thing in common - 'we were learning and hearing new things each time. It was exciting', they said. 'We were discovering new territories each time and learning more about them'. 'We have realised', women added, 'that we were ignorant of the anatomy of our own bodies and the functions of our reproductive systems'.

Other Comments and Suggestions:

The women pinpointed that they would have liked to know more of the anatomy of the female reproductive system. They also suggested that similar health classes be held.

They also recommended that leaflets be translated into Somali and have also indicated the need for a video to be made in Somali.