Solomon four group design

Effects of health empowerment intervention on
resilience of adolescents in a tribal area: A
study using the Solomon four-groups design
Presenter: Avantika Gupta
Moderator: Prof Brogen Singh Akoijam
Social Science & Medicine xxx (2017) 1e10

Why this article?
Study design

SOLOMON FOUR GROUP DESIGN
An experimental design that assesses the effect of having been pretested
on the magnitude of the treatment effect
Richard L. Solomon

A
B
C
D
Randomised
groups
Pre-test Intervention Post-test
a
a1
b c
d
e
f

Pre PrePost Post
Outcome
Outcome
Treatment effect Treatment and
testing effect
Pre-test sensitization
I pre-post C pre-post I post C post

RESILIENCE
Ability of a vulnerable individual to cope in the presence of an
adverse situation is labelled resilience
Exposure to significant
threat or adversity
Achievement of positive
adaptation despite
major assaults on the
developmental process

Positive adaptation
Positive
view of self
High
intellectual
functioning Self-
regulations
of emotions
Learned
helplessness
Coping with
stressors

Resilience characteristics
Self
determination
HLC (health
locus of control)
Internal
External

LIFE SKILLS
Are the abilities for adaptive and positive behaviour, that enable
individuals to deal effectively with the demands and challenges of
everyday life

Knowledge
Attitudes
values
Life skills
Behaviour
reinforcement
or change
Positive health behaviour
Prevention of health problems

Decision
making
Empathy
Critical
thinking
Creative
thinking
Self-
awareness
Coping with
emotions
Problem
solving
Coping
with stress
Effective
communicat
-ion
Inter-
personal
relationship
LIFE
SKILLS

Effects of health empowerment intervention on
resilience of adolescents in a tribal area: A
study using the Solomon four-groups design
(good title)

ABSTRACT
Rationale: Resilience prevents the emergence of stress-related mental health problems among adolescents. Adolescents in
tribal areas of India are more prone to develop such problems.
Objectives: The primary objective was to determine the effect of combined life skills-based health empowerment
intervention on the resilience of school-going adolescents in a tribal area. The secondary objectives were to determine the
effect of the intervention on internal health locus of control and self determination and to compare the effect of
intervention on resilience between non-tribal and tribal adolescents.
Methods: We conducted this quasi-experimental study using a Solomon four-group design among 742 adolescents in two
schools of Purulia, West Bengal, India. Students of the pretested group were examined for resilience using the Child
Youth Resilience Measurement scale. A life skills education-based health empowerment intervention was administered
among students of the experimental group. Post-test data on resilience, self-determination, internal health locus of control
and pathological behaviour was obtained 3 months after the completion of intervention. A multi-level general linear
mixed model was constructed to determine the effect of intervention on resilience.
Results: Resilience was less among tribal adolescents at baseline. The intervention significantly improved resilience
[βAdjusted = 11.19 (95% CI ¼ 10.55, 11.83], with a greater increase for tribal adolescents [βtribal-nontribal = 1.53 (95%
CI ¼ 0.03, 3.03)]. The intervention also significantly improved internal health locus of control (marginal mean increment
1.38 ± 0.05), self-determination (marginal mean increment 3.71 ± 0.09) and reduced pathological behaviour of the
adolescents.
Conclusion: Our study informed the current health policy that the existing life skills education-based programme should
be reviewed and modified to include generic life skills, and the life skills education-based programme should be coupled
with developmental interventions aimed at improving adult education and family climate for optimum effect on mental
health and health behaviour of adolescents.
(Structured and informative)

• Mental health problems are linked to the negative affect state and
unsuccessful coping in the presence of stress
• Indian adolescents residing in tribal areas are exposed to an even
greater risk of developing stress-related mental health problems
• They face greater adversity in life course and are deprived of even the
basic amenities

• Threats and stressors: poverty, violence, disaster and war
• Low stress resilience in adolescence is associated with greater risk of
receiving medications for depression and anxiety in middle age
• Empowerment has been shown as an effective method to increase
resilience

• Strength-based approaches focus on local capacity building by
attending to inherent resources or strengths of individuals, families,
groups or organizations ‘deploying personal strengths to aid recovery’
• Popular form of strength-based intervention is life skills education
• Success of LSE depends on the fidelity of implementation

• To inform the current health policy regarding the effect of a short-term
modified LSE-based empowerment intervention on the resilience of
school-going adolescents
(scientific background and rationale well explained)

• Primary:
 To determine the effect of combined life skills-based health
empowerment intervention on the resilience of school-going
adolescents in a tribal area
OBJECTIVES

• Secondary:
 To determine the effect of the intervention on internal health
locus of control and self determination
 To compare the effect of intervention on resilience between non-
tribal and tribal adolescents
(SMART with good action verb)

Study design:
Quasi-experimental study using Solomon four-group design
Study duration:
2013 to 2015 (period of 24 months)
(appropriate to answer objective)
(study duration mentioned)

Study setting:
• Purulia district of West Bengal
• One-fifth of district’s population is tribal
• Majority are residents of rural areas
• Tribal Health Project was started in 10 blocks of the district in 2007
by the Department of Health & Family Welfare, Purulia

• Literacy rate in the district is substantially lower than the state
average, while infant and maternal mortality rates are high
(not well described)

West Bengal
Purulia
Balarampur
Purulia-I

Study population:
School students of Purulia district

Inclusion criteria:
• Students of grade VI-IX (who had completed primary education at
the time of baseline survey)
• Age of the students ranged from 11 to 17 years

Exclusion criteria:
• Those who had any acute or chronic illness that would preclude their
participation in the study
• Those who failed to attend the pre-test, intervention or post-test
• Those whose parents did not give consent
(eligibility criteria for participants mentioned)

Sample size:
• According to Child Youth Resilience Measurement scale (CYRM-28)
development manual, the mean total resilience score of complex-needs
youth was 103.85 with a SD of 20.18
Non-inferiority limit (d) 10% (i.e., M = 10.39)
Significance level (α) 5%
Power (1-β) 90%

• Sample size : 65 each for the experimental and control groups
• For two schools, pretesting for the resilience score at baseline revealed
ρ = 0.073
• Therefore, calculations target the total effective sample size at 738
(sample size calculation well explained)

Sampling method:
20 Community development blocks of Purulia district
Line listing of blocks with ≥ 2000 households and headed by ST person
15 community development blocks
2 blocks selected at random

High schools were line listed List of West
Bengal Council of
Higher Secondary
Education
One co-ed school was selected from each block
For ethical reasons, all students
of each school were included in the study population
(sampling method not well described)

Purulia District
15 CD Blocks
Random selection of 2
blocks
Balarampur
Block
Purulia I Block
3 Co-ed Gvt. Hr.
Sec schools
2 Gvt. Sponsored
Hr. Sec schools

1 school selected
randomly
1 school selected
randomly
All students studying from class VI to IX eligible for study
School I
Total eligible participants: 674
Total students excluded: 153
Total participating students: 521
School II
Total eligible participants: 283
Total students excluded: 62
Total participating students: 221

Distribution of students according to plan of administration of
intervention
Intervention
given:
Section A (187)
Section B (194)
Intervention
not given:
Section C (140)
Intervention
not given:
Section A & B
(221)
Pretested
Section
A
Not
Pretested
Section B
Pretested
(67)
Not
Pretested
(73)
Pretested
Section B
(114)
Not
Pretested
Section A
(107)
Fig. 1. Selection of study population and allocation of groups into the trial

Study variables
Independent variables:
• Age
• Sex
• Ethnicity
• Parental education level
• Occupation
• Type of family

• Per capita monthly income
• Family climate related risk factors:
 Violence among parents
 Physical abuse on the adolescent by any family member
 Substance abuse among parent
• Academic performance

• Primary outcome:
 Assessment of individual resilience
• Secondary outcome:
 Internal HLC
 Self-determination
 Screened for the presence of any pathological behaviour
Outcomes:

Outcome measurement:
Primary outcome:
Individual resilience CYRM-28 Questionnaire
Cronbach’s α : 0.91

CYRM-28
Individual Relationship
with
primary
caregiver
Context
• Personal skills
• Peer support
• Social skills • Physical care-giving
• Psychological care
giving
• Spiritual
• Education
• Cultural

Secondary outcomes:
• Internal HLC
Internal domain of multidimensional
health locus of control scale A
• Self-determination Self Determination Scale
• Pathological behaviour Goodman's SDQ tool
All the questionnaires were culturally adapted, validated and pretestedCronbach’s α: 0.70 – 0.80
SELF DETERMINATION SCALE (SDS):
Items Subscale: Awareness of self
2
A. My emotions sometimes seem alien to me
B. My emotions always seem to belong to me
4
A. I feel that I am rarely myself
B. I feel like I am always completely myself
6.
A. When I accomplish something, I often feel it wasn't really me who did it.
B. When I accomplish something, I always feel it's me who did it.
8.
A. My body sometimes feels like a stranger to me.
B. My body always feels like me.
10.
A. Sometimes I look into the mirror and see a stranger.
B. When I look into the mirror I see myself.
SELF DETERMINATION SCALE (SDS)
Items Perceived choice
1
A. I always feel like I choose the things I do
B. I sometimes feel that its not really me choosing the things I do
3
A. I choose to do what I have to do
B. I do what I have to, but I dont feel like it is really my choice
5
A. I do what I do because it interests me
B. I do what I do because I have to
7
A. I am free to do whatever I decide to do.
B. What I do is often not what I'd choose to do.
9
A. I feel pretty free to do whatever I choose to.
B. I often do things that I don't choose to do.
Cronbach’s α : >0.80

Data source:
• Secondary data: School academic record used to assess the academic
performance of the students in the previous annual examination

INTERVENTION
• Intervention module had two parts:
 Basic life skills (adapted from intervention module of Adolescent
Girl Empowerment Programme)
 Specific health interventions (adapted from existing life skill
education module)

Several discussion sessions were held with the respective class teachers
of the selected schools, and priority areas for LSE were identified
From an exhaustive list of identified choices for domains of
intervention, the experts of Community Medicine and experts of
Education identified a limited number of individual empowerment-
specific domains
Intervention module was prepared on the basis of the priorities

NIMHANS Module of
LSE : Domains
Motivation
Discipline
Nutrition
Health and
hygiene
Relationship
Social
responsibility
Self-
awareness
Sexuality:
understanding
body and
mind

Domains:
Nutrition
• ‘Healthy and unhealthy food’ was renamed as ‘I
decide my food, I decide my health’
• Names of foods were changed based on local food
availability and dietary practices
Health and
hygiene domain
• Intervention related to hand washing was retained
• Goal setting and achieving for increasing the motivation of the
students towards a goal-directed life approach and it was included
from the AGEP module

• All the modules, charts and handouts were translated into Bengali
and culturally adapted by bilingual experts
• Sessions ranged from 45 to 120 min
• The intervention was administered by K.S. following training by
A.D. and M.P.S.
• To ensure 100% attendance of the students, attendance was made
compulsory on the intervention days by school authorities
(Details about the intervention was given)

DATA COLLECTION
• At baseline, all the students were surveyed by K.S.
• Data regarding primary outcome were obtained from students of the
pretested group only
• All students of the experimental groups were also examined with SDQ
• Data regarding academic performance were obtained for all students at
baseline

• Post-intervention data individual resilience, self-determination and
HLC were obtained at 3 months of follow-up from all the four groups
• Data regarding the strength and difficulties of the experimental group
students were obtained at the same time
• Section-wise examination was conducted within the classrooms in
sessions similar to pre-test sessions
(data collection well described)

• Bivariate correlations obtained for all independent variables with pre-
test resilience scores
• Standard statistical analysis plan to determine the effect of intervention
and pre-test on primary outcome (Braver and Braver, 1988)
• Multi-level mixed effect general linear modelling
STATISTICALANALYSIS

• Random effect of ethnicity nested within each class of study in
addition to considering the fixed effect of ethnicity to obtain an
adjusted effect averaged for the population
• Path analysis performed to determine the direct and indirect effects of
intervention on resilience taking:
 Pre-test scores of resilience, internal HLC, self-determination
and intervention as exogenous variables

 Post-test scores of internal HLC and self-determination as
endogenous variables
 Post-test scores of resilience as outcome variables
• Statistical analysis was performed using STATA 13
• Repeated measure ANOVA was performed in SPSS v20
• overall and ethnicity- and sex-stratified marginal means of resilience
before and after intervention (unadjusted and adjusted for baseline
variables) were plotted
(adequate and appropriate)

ETHICAL ISSUES
Not well addressed:
• Assent
• Approval from ethics committee
• Registration no. not mentioned
For ethical reasons, all students of each school were included in the
study population

Table 1. Comparison of socio-demographic characteristics, family
climate, and academic performance between experimental and control
groups (n = 742)
Variables
Category
or
statisticaa
Experimental
Group
(n=381)n(%)
Control Group
(n=361)n (%)
p
Socio-demographic characteristics
Age (years) Mean (SD) 13.50 (1.53) 13.66 (1.56) 0.15
Sex
Male 239 (62.7) 232 (64.3)
0.67
Female 142 (37.3) 129 (35.7)
a For continuous variables, mean (SD) is reported instead of n (%)

Variables
Category
or
statisticaa
Experimental
Group
(n=381)n(%)
Control Group
(n=361)n (%)
p
Ethnicity
Scheduled
Tribe
114 (29.9) 119 (33.0)
0.37
Others 267 (70.1) 242 (67.0)
Type of
family
Nuclear 184 (48.3) 202 (56.0)
0.04
Joint 197 (51.7) 159 (44.0)
Table 1. Cont.

Variables
Category
or
statisticaa
Experimental
Group
(n=381)n(%)
Control Group
(n=361)n (%)
p
Education of
father
Primary
& below
97 (25.4) 91 (25.2)
0.94
Above
Primary
284 (74.6) 270 (74.8)
Education of
mother
Primary
& below
144 (37.80) 127 (35.18)
0.46
Above
Primary
237 (62.20) 234 (64.82)
Table 1. Cont.

Variables
Category or
statisticaa
Experimental
Group
(n=381)n(%)
Control Group
(n=361)n (%)
p
Occupation
of father
Unemployed 19 (5.0) 7 (1.9)
0.31
Unskilled
worker
82 (21.5) 72 (19.9)
Semi-skilled
Worker
64 (16.8) 70 (19.4)
Skilled
Worker
80 (21.0) 79 (21.9)
Business 75 (19.7) 73 (20.2)
Service 61 (16.0) 60 (16.6)
Table 1. Cont.

Variables
Category or
statisticaa
Experimental
Group
(n=381)n(%)
Control Group
(n=361)n (%)
p
Occupation
of mother
Homemaker 247 (64.8) 245 (67.9)
0.67
Unskilled
worker
43 (11.3) 29 (8.0)
Semi-skilled
Worker
22 (5.8) 22 (6.1)
Skilled
Worker
80 (21.0) 79 (21.9)
Business 54 (14.2) 50 (13.9)
Service 15 (3.9) 15 (4.2)
Table 1. Cont.

Table 1. Cont.
Variables
Category
or
statisticaa
Experimental
Group
(n=381)n(%)
Control
Group
(n=361)n (%)
p
PCI Mean (SD) 4082.3 (2281.1) 4377.4(2339.9) 0.08
Family climate
Physical abuse by
family members
Present 180 (47.2) 193 (53.5) 0.09
Violence among
parents
Present 105 (27.6) 115 (31.9) 0.20
Substance abuse
among parents
Present 165 (43.3) 208 (57.6) <0.001

Variables
Category
or
statisticaa
Experimental
Group
(n=381)n(%)
Control
Group
(n=361)n(%)
p
Academic performance
Academic
performance
Math
Mean (SD)
62.34 (18.76) 63.27 (18.12) 0.50
1st
Language
Mean (SD)
52.94 (14.18) 54.49 (14.24) 0.14
Table 1. Cont.

Table 2. Comparison between pretested experimental and pretested
control groups at pre-test of resilience, self-determination and internal
HLC score
Variables
Pretested
Experimental
Group
(n =194)a
M (SD)
Pretested
Control Group
(n=181)a
M (SD)
Mean diff.
ΔM
(95% CI)
Resilience Individual
Personal 15.99 (3.11) 15.62 (3.37)
0.37 (-0.28
to 1.03)
Peer 6.32 (1.29) 6.19 (1.38)
0.13 (-0.14
to 0.40)

Variables
Pretested
Experimental
Group
(n =194)a
M (SD)
Pretested
Control
Group
(n=181)a
M (SD)
Mean diff.
ΔM
(95% CI)
Resilience Individual
Social 13.35 (2.44) 13.12 (2.39)
0.23 (-0.26
to 0.72)
Total 35.66 (6.04) 34.93 (6.02)
0.73 (-0.50
to 1.95)
Table 2. Cont.

Variables
Pretested
Experimental
Group
(n =194)a
M (SD)
Pretested
Control Group
(n=181)a
M (SD)
Mean diff.
ΔM
(95% CI)
Resilience Caregiver
Physical 7.41 (1.63) 7.17 (1.64)
0.25 (-0.08
to 0.58)
Psycho-
logical
16.71 (4.21) 16.16 (4.08)
0.55 (-0.30
to 1.39)
Total 24.12 (5.76) 23.33 (5.64)
0.79 (-0.37
to 1.95)
Table 2. Cont.

Variables
Pretested
Experimental
Group
(n =194)a
M (SD)
Pretested
Control
Group
(n=181)a
M (SD)
Mean diff.
ΔM
(95% CI)
Resilience Context
Spiritual 8.82 (2.07) 8.59 (2.09)
0.23 (-0.19
to 0.65)
Educa-
tional
5.88 (1.54) 5.73 (1.51)
0.15 (-0.16
to 0.46)
Cultural 14.49 (3.30) 14.18 (3.37)
0.41 (-0.26
to 1.09)
Total 29.28 (6.49) 28.50 (6.53)
0.79 (-0.54
to 2.11)
Table 2. Cont.

Table 2. Cont.
Variables
Pretested
Experimental
Group
(n =194)a
M (SD)
Pretested
Control
Group
(n=181)a
M (SD)
Mean diff.
ΔM
(95% CI)
Resilience Total score 89.06 (18.11) 86.76 (17.98)
2.31 (-1.36 to
5.97)
Self-
determina-
tion
Perceived Choice 14.63 (3.20) 14.77 (3.20)
0.14 (-0.61 to
0.32)
Awareness of self 14.74 (3.28) 14.79 (3.14)
0.05 (-0.51 to
0.41)
Total 29.37 (6.42) 29.57 (6.27)
0.20 (-1.11 to
0.72)
Internal
HLC
21.22 (4.77) 20.59 (5.28)
0.63 (-0.09 to
1.35)

Bivariate correlations:
• At baseline, all exogenous and endogenous variables considered in this
study had statistically significant association with resilience factors,
except type of family and age of students, generally in the expected
directions
• For example, greater levels of violence experienced were associated
with lower resilience

Pre-test sensitization:
• In 2-way ANOVA to determine the main effect and interaction effect
of the two factors (i.e., pre-test and intervention), only the intervention
effect was statistically significant on the post-test scores
• Mean difference of estimated marginal means between the intervention
and non-intervention group was 12.86 (p < 0.001)

Variables β (95% CI)
Intervention
(ref: No intervention)
11.19 (10.55, 11.83)
Mother's education
(ref: below primary)
Primary 5.97 (3.72, 8.22)
Middle 5.11 (0.70, 9.54)
Secondary 5.01 (1.40, 8.62)
Higher secondary 9.75 (4.56, 14.94)
Graduate or higher 16.61 (12.26, 20.94)
Table 3: Adjusted model in relation to post-test resilience score
(n = 742)

Father's education
(ref: below primary)
Primary 1.83 (-0.87, 4.53)
Middle -2.23 (-6.07, 1.60)
Secondary 1.50 (-4.02, 7.02)
Higher secondary 2.00 (-0.46, 4.46)
Graduate or higher -0.48 (-5.48, 4.52)
Mother's occupation
(Ref: Homemaker)
0.45 (-1.41, 2.31)
Table 3: Cont.

Table 3: Cont.
Father's occupation
(Ref: unemployed &
unskilled worker)
Semi-Skilled worker 0.90 (-2.11, 3.90)
Skilled worker -0.59 (-3.92, 2.74)
Business -2.51 (-3.88, -1.15)
Service -3.22 (-8.18, 1.74)
Male (ref: Female) -1.28 (-2.33, -0.22)
Ethnicity (ref: others) 3.81 (1.30, 6.31)

Table 3: Cont.
PCI (Ref: <median) 1.19 (-1.49, 3.88)
Standardized academic score
(Ref: <median)
1.26 (-0.36, 2.87)
Substance abuse among parents
(Ref: absent)
-3.26 (-4.31, -2.19)
Violence in the family
(Ref: absent)
-13.22 (-15.78, -10.65)
Physical abuse (Ref: absent) -13.85 (-15.25, -12.45)
Note. Shown are coefficients for fixed-effect parameters. Random-effect parameters
included in the model: Class (ethnicity). PCI and standardized academic score were
dichotomized based on their medians.

Effect of ethnicity:
Baseline Resilience
Before adjustment ∆M (tribal – nontribal) -5.48 (-9.50, - 1.46)
After adjustment ∆M (tribal – nontribal) -0.29 (-3.88, 3.31)
After intervention
Before adjustment Resilience Increased both in
tribal and nontribal groups
F(1,373)=326.62;p<0.001
After adjustment F(1,362)=9.86;p=0.005

Model Variable β (95% CI) p
Model 1 (outcome:
pre-test resilience score)
Ethnicity (Ref: tribal) 5.55 (1.68, 9.42) <0.005
Model 2 (outcome:
post-test resilience score)
Ethnicity (Ref: tribal)
-1.53 (-3.02, -
0.03)
0.046
Pre-test resiliencea 0.99 (0.95, 1.03) <0.001
a For pre-test resilience, the coefficient β refers to the association or correlation
between pre-test and post-test resilience scores
Table 4. Effect of ethnicity on the impact of health empowerment
intervention on resilience: Results of moderation analysis (n = 375)

Intervention
Internal HLC
Self determination
Resilience
Internal HLC
Self determination
Resilience
PosttestPretest
Time
cov=17.57 (14.87 to 20.26)
cov=83.52 (72.59 to 94.44)
cov=59.86(50.92to68.80)
r=0.96 (0.93 to 0.98)
r=0.96 (0.93 to 0.98)
r=0.98 (0.97 to
0.99)
β=1.20 (1.07 to 1.34)
cov= -0.14
(-0.26 to
-0.02)
β=0.03
(0.002 to
0.06)
Fig. 2. Structural equation model showing effects of intervention on resilience, self-determination and internal HLC
* Only significant paths has been shown

• In line with the objectives
• Some table column headings missing
• Figures are self explanatory
• Footnotes are given
• All statistical analysis has been done
• Number of participants (n) for intervention and control group given

STRENGTHS:
• Solomon's four-group design used to avoid the bias of pre-test
sensitization
• 100% participation rate by the students throughout the intervention

LIMITATIONS:
• First stage sampling was limited to only two community development
blocks because of limitation of resources
• Students were allocated to different groups through section-wise
allocation, which was a non-random allocation

• Data on family climate-related variables were based on self-reports
of the adolescents, which may be exaggerated/under-reported
• Academic performance of the students was measured using record
of school performance only, which may contain recording errors
(strengths and limitations well addressed)

• LSE-based health empowerment intervention successfully increases
resilience and two important resilience characteristics, self-
determination and HLC
• Reduces the gap in resilience between tribal and non-tribal
adolescents
CONCLUSIONS
(conclusions are in line with objectives)

RECOMMENDATIONS:
• Quality-assured training of the teachers and quality control of
intervention
• Study informs the existing health policy that school mental health
services should be coupled with developmental activities
• Follow-up study to determine washout period of effect of intervention
(specific, doable but not derived from study findings)

FUNDING
CONFLICT OF INTEREST
(Funding details and conflict of interest has not been
declared by the authors)

GENERALIZABILITY
Generalizable in similar setting

What I Learnt?
• Solomon group four design
• Resilience

Solomon four group design

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Editor's Notes