Abstract
Background:
Crimean-Congo hemorrhagic fever (CCHF) is a fatal viral bleeding disease.Objectives:
This study conducted in 2016 and its aim was to determine the effect of education on promoting preventive behaviors in ranchers against the disease based on the health belief model (HBM).Methods:
In a quasi-experimental study, 183 subjects were selected and divided into intervention (n = 92) and control group (n = 91) using a multistage random sampling method. The data collection tool was a questionnaire, including specific and demographic questions that its validity and reliability was confirmed. At first, the data were collected in both groups and analyzed. An educational program based on the HBM, including educational content, media, and method was designed and two educational sessions were accomplished for experimental group. The data were analyzed by descriptive and analytic statistics with respect to the statistical significance level (P ≤ 0.05).Results:
After the intervention, the mean scores of behavior (1.55 ± 2.2), perceived susceptibility (2.06 ± 3.69), severity (0.92 ± 1.96), perceived benefits (2.06 ± 5.26), self-efficacy (2.85 ± 4.69), and cues to action (0.57 ± 3.14) significantly were increased in the intervention group compared to the control group and a positive correlation was found among them and preventive behaviors (P < 0.05). Moreover, perceived barriers in the intervention group significantly were decreased and self-efficacy was the most important predictor for preventive behaviors (P < 0.05).Conclusions:
HBM and particularly cues to action is an appropriate framework for educational interventions for promoting the preventive behaviors of Crimean-Congo fever among ranchers.Keywords
Educational Health Belief Model Crimean-Congo Fever Ranchers
1. Background
Crimean Congo hemorrhagic fever (CCHF) is a hemorrhagic viral disease that is transmitted to human by an infected tick bite or squishing it on the skin, direct contact with the blood or secretions of infected animals during or immediately after slaughter (1-5).
The disease has a high case-fatality and reported as a sporadic disease in the continents of Asia, Europe, and Africa (5-9).
Throughout the time of January 2000 to September 2010, 738 established cases of CCHF and 108 related mortalities were stated in Iran (10). Also, CCHF has been reported in 23 out of the 30 provinces of Iran. Among provinces, Sistan- Baluchistan, Fars, Isfahan, and Golestan had the highest presented cases.
Sistan and Baluchistan is located in southeastern of Iran and Zabol city is located in the northern of Sistan and Baluchistan province, which has long borders with two CCHF endemic countries, Afghanistan and Pakistan (2, 10-12).
This study was carried out in Zabol villages whose inhabitants were ranchers or farmers who keep animals and these people are always at high-risk of the disease. The residents of these areas in addition to keeping the livestock and pets are also butchering the animals, as a result, they are severely exposed to the disease and thereby promoting the preventive behaviors has an important role in improving their health in this region.
From June 1999 to February 2004, 255 patients were documented in Sistan and Baluchistan (13).
Given the high morbidity and mortality in Sistan and Baluchistan province, theory-based interventions can lead to improve preventive behaviors against the disease among ranchers and not only prevent them from infection but also prevent new fatal fates in the community (14).
Studies show that ranchers, farmers, veterinarians, butchers, slaughterhouse workers, and laboratory workers are the people who are at high-risk of the disease (14, 15).
Selecting a health training model is the first stage in the process of planning an education program to achieve educational goals before the operation of health education plans (16-19).
The HBM is a psychosocial framework, which initially developed in the1950s. Accordingly, there is a relationship between beliefs and behaviors. People will do more a healthy behavior if they feel susceptibility to a danger such as disease or cancer (perceived susceptibility), or the individuals who believe the disease is a serious danger (perceived severity), they will be familiar with more benefits of behavior change with regard to behavior change barriers, thus they gain more self-confidence for obtaining a healthy behavior and obtain a cue to action (18, 20-25).
2. Objectives
This study was aimed to determine the effect of education on preventive behaviors of CCHF among ranchers based on HBM in the Zabol city in 2016 whether the results could be used in CCHF care system planning at the local and national level.
3. Methods
3.1. Study Area
This study was conducted in the Zabol city in 2016 that is one of the southeastern cities of Iran and is located in the neighborhoods of Afghanistan and Pakistan, which the majority of the population are ranchers and farmers.
3.2. Sampling Method
This study was a quasi-experimental study and the sample size was calculated with regard to 5% alpha and 0.2 beta and standard deviation, which was calculated 86 individuals in each group. According to the possible lost in each group, the sample size was considered 100 individuals.
The sampling method was a multi-stage sampling method, first, from five rural health centers in Zabol city, two centers were randomly selected and divided into the control and experimental groups, then two primary health centers in each group randomly designated, and finally, the samples were selected and surveyed.
The inclusion criteria were living in the villages covered by the project, having contact with animals, giving written informed consent to participate in this study. The exclusion criteria were also the participants’ refusal to complete the requested information and not to participate in the training program.
3.3. Framework and Data Collecting Tools
A researcher-made questionnaire in two sections was used for data collection. The first part included demographic characteristics and the second part consisted of questions about CCHF and HBM constructs.
To study the perceived susceptibility, severity, and benefits of the individuals there were six items, but to study the perceived barriers and self-efficacy eight items and to study the cues to action three questions were used.
Responses to perceived susceptibility, severity, benefits, barriers, self-efficacy, and cues to action questions were designed at three levels following as agree, no idea, and disagree that were scored by 3,2, and 1, respectively. Responses to the behavior questions were designed as always, sometimes, and never, which were scored 3, 2 and 1, respectively.
Content validity was used for the validity of the questionnaire, a ten expert’s panel, including infectious specialists, general practitioners, and health education specialists evaluated the questions. The questions were excluded when they had a content validity index and content validity ratio scores less than 0.80 and 0.62 respectively. To determine the reliability of the questionnaire, Cronbach’s alpha test was used and the alpha coefficient for the constructs was as follow: Susceptibility (90%), severity (69%), benefits (92%), barriers (74%), self-efficacy (91%), behavioral intention (91%), and the total questionnaire (88%).
3.4. Procedures
After the selection of the people who met the inclusion criteria, they were randomly divided into intervention and control groups. Then the objectives of the study were explained to the groups and written informed consent was obtained from them and the pre-test questionnaire was completed directly. Due to illiteracy or low level of literacy of the participants in the study, the data were obtained via a face to face interview.
After analyzing the data, individuals’ training needs were determined and consequently, educational program was developed based on the HBM constructs.
Educational intervention consisted of two 45-minute-training sessions.
After 3 months the data were collected again and descriptive statistics and analytical tests, including percentage, mean Mann-Whitney test, Spearman correlation coefficient test, and linear regression were performed using SPSS software version 18. Finally, the training program was administered in the control group. Furthermore, the significance level of the tests was considered at 0.05 levels. This research was conducted under ethical considerations.
4. Results
In this study, 183 people were studied in the intervention (n = 92) and control (n = 91) groups. Here, 52.2% and 55.6% of the individuals in the intervention and control groups were farmers and ranchers, respectively. In general, the subjects in the two groups did not differ in terms of their demographic characteristics (P > 0.05) (Table 1).
| Variable | Intervention (N = 92) | Control (N = 91) | P Valueb |
|---|---|---|---|
| Gender | 0.21 | ||
| Male | 81 (88) | 85 (93.4) | |
| Female | 11 (12) | 6 (6.6) | |
| Education | 0.91 | ||
| Illiterate | 39 (42.4) | 41 (45.1) | |
| Elementary | 25 (27.2) | 23 (25.3) | |
| Guidance | 18 (19.6) | 17 (18.7) | |
| Diploma and above | 10 (10.9) | 11 (12.1) | |
| Occupation | 0.22 | ||
| Rancher | 15 (16.3) | 22 (24.2) | |
| Farmer | 33 (35.9) | 29 (31.4) | |
| Housewife | 11 (12) | 9 (6.6) | |
| Employee/worker | 12 (13.1) | 7 (7.7) | |
| Other | 21 (22.8) | 24 (26.4) | |
| Experience of livestock slaughter | 0.59 | ||
| Yes | 60 (65.2) | 58 (63.04) | |
| No | 38 (34.8) | 33 (31.86) |
Findings of the present study didn’t show significant differences between the two groups before the intervention in the mean scores of perceived susceptibility, perceived severity, perceived benefits, perceived barrier, and self-efficacy.
But after the intervention in the intervention group a significant difference was seen between the two groups. Also there was a significant reduction in the perceived barrier construct (P = 0.001) (Table 2).
Comparison of Mean and Standard Deviation Scores of Health Belief Model Constructs in the Two Research Groupsa
| Variable | Before Intervention | After Intervention | P Value |
|---|---|---|---|
| Behavior | |||
| Intervention | 10.16 ± 1.98 | 11.71 ± 1.43 | 0.02 |
| Control | 10.07 ± 2.26 | 10.08 ± 2.32 | 0.21 |
| Perceived susceptibility | |||
| Intervention | 14.79 ± 3.67 | 16.85 ± 2.20 | 0.001 |
| Control | 14.71 ± 3.71 | 14.75 ± 3.67 | 0.82 |
| Cues to action | |||
| Intervention | 6.57 ± 1.82 | 7.15 ± 1.93 | 0.001 |
| Control | 6.20 ± 2.08 | 5.74 ± 2.10 | 0.207 |
| Perceived severity | |||
| Intervention | 16.46 ± 2.17 | 17.39 ± 1.15 | 0.001 |
| Control | 16.36 ± 2.13 | 16.45 ± 2.17 | 0.77 |
| Perceived barriers | |||
| Intervention | 16.14 ± 4.64 | 10.90 ± 3.55 | 0.003 |
| Control | 17.17 ± 4.59 | 14.74 ± 4.60 | 0.88 |
| Perceived benefits | |||
| Intervention | 15.45 ± 3.41 | 17.52 ± 3.57 | 0.001 |
| Control | 15.20 ± 3.79 | 15.48 ± 3.35 | 0.37 |
| Self-efficacy | |||
| Intervention | 19.31 ± 4.10 | 22.17 ± 2.72 | 0.001 |
| Control | 19.80 ± 4.94 | 19.78 ± 4.94 | 0.09 |
According to the results of Spearman correlation coefficient test, preventive behaviors had a positive significant relationship with perceived benefits, perceived severity, perceived susceptibility, and cues to action, but it had a negative significant correlation with perceived barriers (Table 3).
Spearman Correlation Coefficient Between HBM Constructs in the Intervention Group After the Intervention
To identify the predictors of predictive behaviors, linear regression test was used. Generally, the results showed that the statistical model was significant (F = 14.3369, P = 0.001) and 0.306 of behavior changes (depended variable) was predicted through the model (adjusted R square = 0.306). However, considering to significant level self-efficacy was the only predictor for behavior change (Table 4).
Predictive Variables Based on Linear Regression Coefficient Test in the Intervention Group After the Intervention
| Model | Unstandardized Coefficient | Standard Coefficient | t | Sig | |
|---|---|---|---|---|---|
| B | Std. Error | Beta | |||
| Construct | 5.174 | 2.882 | 1.795 | 0.076 | |
| Susceptibility | r = 0.117 | 0.083 | 0.178 | 1.408 | 0.163 |
| Severity | 0.084 | r = 0.130 | r = 0.067 | 0.645 | 0.520 |
| Benefits | r = 0.011 | r = 0.039 | 0.028 | 1.0292 | 0.771 |
| Barriers | -0.003 | 0.062 | -0.007 | -0.049 | 0.961 |
| Self-efficacy | 0.550 | 0.076 | 0.104 | 0.717 | 0.475 |
| Cues to action | 0.243 | 0.095 | 0.327 | 2.550 | 0.013 |
5. Discussion
Based on the finding of this research, the mean score of the preventive behavior of Crimean-Congo hemorrhagic fever in the experimental group was significantly increased as the main goal of this study. Consequently, it can be concluded that this educational intervention has been successful.
Because the majority of ranchers or other occupations that have near interaction with animals such as farmers are illiterate or has elementary education, they were at high-risk for CCHF disease; therefore, preventive intervention accomplishing is a necessary health practice (14, 15).
In this study before the intervention, there was no difference between two groups in perceived susceptibility but after the intervention, it was significantly increased in the intervention group. These findings are consistent with the results of studies conducted by Masoudi et al. (26) and Katz et al. (27) and inconsistent with the results of the study of Sharifirad et al. (28).
The findings of this study showed that after the intervention the mean scores of perceived severity was significantly increased only in the intervention group, which was consistent with the results of the studies conducted by Jeihooni et al. (22) and Chang et al. (29) and inconsistent with the results of the study of Torbaghan et al. (18).
Also, after the intervention, the experimental group was perceived more benefit and lower barriers for implementing the predictive behaviors of CCHF; as a result, it can be concluded that educational intervention has increased the likelihood of health behavior change and enhanced well-being among research participations. These results are consistent with other results obtained from previous studies (22, 26-28).
The findings of the study on self-efficacy construct showed that there was a statistically significant difference between the mean scores in the two groups after the intervention; as a result, it is concluded that the participants in the experimental group in post-training stage felt that their abilities to adherence of preventive behaviors such as, wearing suitable shoes, or using plastic gloves has increased and these results are consistent with some previous studies (18, 22, 29).
The results of the study in the preventive behavior area showed that after the intervention, the mean scores of this construct was significantly increased in the case group in comparison to control group. Since these results were the main objectives of the intervention, it is concluded that the study was a successful process. Also the results of studies of Masoudi et al. (26), Chang et al. (29) and Torbaghan et al. (18) confirmed these important findings.
The preventive behaviors in ranchers had a positive correlation with mean scores of perceived susceptibility, perceived severity, perceived benefits, cues to action and perceived self-efficacy but had a negative correlation with perceived barriers score, which these findings were similar to other conducted studies (26, 29). Multiple linear regression analysis showed that the cues to action was the only predictor variable for predictive behaviors, which was consistent with the results of another study (30).
Self-report responding and low level of literacy of the subjects were the most important limitations in this study, which completing the questionnaires through individual interviews and also these problems were relatively resolved with designing a simple training program.
The findings of this study showed that the use of HBM was effective in adopting preventive behaviors of Crimean-Congo fever in ranchers.
Therefore, given that in this intervention cues to action was the predictive construct for preventive behaviors of Crimean-Congo fever, it is recommended that educational programs must be conducted with an emphasis on cues to action.
5.1. Conclusions
In rural areas, where the majority of people are rancher or have near interaction with animals such as farmers, the population is at high-risk for CCHF disease. Preventive intervention, especially structured programs are very necessary. This study found that the health belief model, especially keys to action construct has an effective role to promote the preventive behaviors in CCHF and enhance the individual and community health.
Acknowledgements
References
-
1.
Hekimoglu HC, Demirci NA. Evaluation of cases with a preliminary diagnosis of Crimean- Congo hemorrhagic fever and comparison of characteristics in patients admitted to a secondary care hospital in Kastamonu, Turkey. Afr Health Sci. 2014;14(4):873-81. [PubMed ID: 25834496]. [PubMed Central ID: PMC4370066]. https://doi.org/10.4314/ahs.v14i4.15.
-
2.
Champour M, Chinikar S, Mohammadi G, Razmi G, Mostafavi E, Shah-Hosseini N, et al. Crimean-Congo hemorrhagic fever in the one-humped camel (camelus dromedarius) in east and northeast of Iran. J Arthropod Borne Dis. 2016;10(2):168-77. [PubMed ID: 27308275]. [PubMed Central ID: PMC4906756].
-
3.
Telmadarraiy Z, Chinikar S, Vatandoost H, Faghihi F, Hosseini-Chegeni A. Vectors of Crimean Congo hemorrhagic fever virus in Iran. J Arthropod Borne Dis. 2015;9(2):137-47. [PubMed ID: 26623426]. [PubMed Central ID: PMC4662786].
-
4.
Weidmann M, Avsic-Zupanc T, Bino S, Bouloy M, Burt F, Chinikar S, et al. Biosafety standards for working with Crimean-Congo hemorrhagic fever virus. J Gen Virol. 2016;97(11):2799-808. [PubMed ID: 27667586]. https://doi.org/10.1099/jgv.0.000610.
-
5.
Ince Y, Yasa C, Metin M, Sonmez M, Meram E, Benkli B, et al. Crimean-Congo hemorrhagic fever infections reported by ProMED. Int J Infect Dis. 2014;26:44-6. [PubMed ID: 24947424]. https://doi.org/10.1016/j.ijid.2014.04.005.
-
6.
Mertens M, Schmidt K, Ozkul A, Groschup MH. The impact of Crimean-Congo hemorrhagic fever virus on public health. Antiviral Res. 2013;98(2):248-60. [PubMed ID: 23458713]. https://doi.org/10.1016/j.antiviral.2013.02.007.
-
7.
Ergonul O, Celikbas A, Dokuzoguz B, Eren S, Baykam N, Esener H. Characteristics of patients with Crimean-Congo hemorrhagic fever in a recent outbreak in Turkey and impact of oral ribavirin therapy. Clin Infect Dis. 2004;39(2):284-7. [PubMed ID: 15307042]. https://doi.org/10.1086/422000.
-
8.
Ascioglu S, Leblebicioglu H, Vahaboglu H, Chan KA. Ribavirin for patients with Crimean-Congo haemorrhagic fever: A systematic review and meta-analysis. J Antimicrob Chemother. 2011;66(6):1215-22. [PubMed ID: 21482564]. https://doi.org/10.1093/jac/dkr136.
-
9.
Ceylan B, Calica A, Ak O, Akkoyunlu Y, Turhan V. Ribavirin is not effective against Crimean-Congo hemorrhagic fever: Observations from the Turkish experience. Int J Infect Dis. 2013;17(10):e799-801. [PubMed ID: 23773242]. https://doi.org/10.1016/j.ijid.2013.02.030.
-
10.
Ansari H, Shahbaz B, Izadi S, Zeinali M, Tabatabaee SM, Mahmoodi M, et al. Crimean-Congo hemorrhagic fever and its relationship with climate factors in southeast Iran: A 13-year experience. J Infect Dev Ctries. 2014;8(6):749-57. [PubMed ID: 24916874]. https://doi.org/10.3855/jidc.4020.
-
11.
Ansari H, Mansournia MA, Izadi S, Zeinali M, Mahmoodi M, Holakouie-Naieni K. Predicting CCHF incidence and its related factors using time-series analysis in the southeast of Iran: Comparison of SARIMA and Markov switching models. Epidemiol Infect. 2015;143(4):839-50. [PubMed ID: 25703403]. https://doi.org/10.1017/S0950268814001113.
-
12.
Pourhossein B, Irani AD, Mostafavi E. Major infectious diseases affecting the Afghan immigrant population of Iran: A systematic review and meta-analysis. Epidemiol Health. 2015;37. e2015002. [PubMed ID: 25666236]. [PubMed Central ID: PMC4371390]. https://doi.org/10.4178/epih/e2015002.
-
13.
Alavi-Naini R, Moghtaderi A, Koohpayeh HR, Sharifi-Mood B, Naderi M, Metanat M, et al. Crimean-Congo hemorrhagic fever in southeast of Iran. J Infect. 2006;52(5):378-82. [PubMed ID: 16182370]. https://doi.org/10.1016/j.jinf.2005.07.015.
-
14.
Leblebicioglu H, Sunbul M, Memish ZA, Al-Tawfiq JA, Bodur H, Ozkul A, et al. Consensus report: Preventive measures for Crimean-Congo hemorrhagic fever during Eid-al-Adha festival. Int J Infect Dis. 2015;38:9-15. [PubMed ID: 26183413]. https://doi.org/10.1016/j.ijid.2015.06.029.
-
15.
Chinikar S, Moghadam AH, Parizadeh SJ, Moradi M, Bayat N, Zeinali M, et al. Seroepidemiology of crimean congo hemorrhagic Fever in slaughterhouse workers in north eastern Iran. Iran J Public Health. 2012;41(11):72-7. [PubMed ID: 23304679]. [PubMed Central ID: PMC3521889].
-
16.
Bastami F, Mostafavi F, Hassanzadeh A. Effect of educational intervention on knowledge, perceived benefits, barriers and self-efficacy regarding AIDS preventive behaviors among drug addicts. J Educ Health Promot. 2015;4:90. [PubMed ID: 27462632]. [PubMed Central ID: PMC4946267]. https://doi.org/10.4103/2277-9531.171804.
-
17.
Farma KK, Jalili Z, Zareban I, Pour MS. Effect of education on preventive behaviors of breast cancer in female teachers of guidance schools of Zahedan city based on health belief model. J Educ Health Promot. 2014;3:77. [PubMed ID: 25250343]. [PubMed Central ID: PMC4165100]. https://doi.org/10.4103/2277-9531.139240.
-
18.
Torbaghan AE, Farmanfarma KK, Moghaddam AA, Zarei Z. Improving breast cancer preventive behavior among female medical staff: The use of educational intervention based on health belief model. Malays J Med Sci. 2014;21(5):44-50. [PubMed ID: 25977633]. [PubMed Central ID: PMC4418125].
-
19.
Mazloomymahmoodabad S, Masoudy G, Fallahzadeh H, Jalili Z. Education based on precede-proceed on quality of life in elderly. Glob J Health Sci. 2014;6(6):178-84. [PubMed ID: 25363108]. [PubMed Central ID: PMC4825517]. https://doi.org/10.5539/gjhs.v6n6p178.
-
20.
Rezaeian M, Sharifirad G, Mostafavi F, Moodi M, Abbasi MH. The effects of breast cancer educational intervention on knowledge and health beliefs of women 40 years and older, Isfahan, Iran. J Educ Health Promot. 2014;3:43. [PubMed ID: 25013836]. [PubMed Central ID: PMC4089115]. https://doi.org/10.4103/2277-9531.131929.
-
21.
Hajian-Tilaki K, Auladi S. Health belief model and practice of breast self-examination and breast cancer screening in Iranian women. Breast Cancer. 2014;21(4):429-34. [PubMed ID: 22990912]. https://doi.org/10.1007/s12282-012-0409-3.
-
22.
Jeihooni AK, Hidarnia A, Kaveh MH, Hajizadeh E, Askari A. Effects of an osteoporosis prevention program based on health belief model among females. Nurs Midwifery Stud. 2015;4(3). e26731. [PubMed ID: 26576440]. [PubMed Central ID: PMC4644602]. https://doi.org/10.17795/nmsjournal26731.
-
23.
Khani Jeihooni A, Hidarnia A, Kaveh MH, Hajizadeh E. The effect of a prevention program based on health belief model on osteoporosis. J Res Health Sci. 2015;15(1):47-53. [PubMed ID: 25821026].
-
24.
Sim SW, Moey KS, Tan NC. The use of facemasks to prevent respiratory infection: A literature review in the context of the Health Belief Model. Singapore Med J. 2014;55(3):160-7. [PubMed ID: 24664384]. [PubMed Central ID: PMC4293989].
-
25.
Cao ZJ, Chen Y, Wang SM. Health belief model based evaluation of school health education programme for injury prevention among high school students in the community context. BMC Public Health. 2014;14:26. [PubMed ID: 24410991]. [PubMed Central ID: PMC3922908]. https://doi.org/10.1186/1471-2458-14-26.
-
26.
Masoudi GR, Rezaie Kykha R, Shahraki Poor M, Naderi M, Zareban I. The effect of halth belief model-based training on preventing major thalassemia in thalassemia carrier couples. J Res Health. 2015;5(2):211-9.
-
27.
Katz DA, Graber M, Birrer E, Lounsbury P. Academic emergency medicine. 16. Philadelphia; 2009. 379 p.
-
28.
Sharifirad GR, Hazavehei SMM, Hasanzadeh A, Danesh Amouz A. [The effect of health education based on health belief model on preventive actions of smoking in grade one, middle school students]. Arak Med Univ J. 2007;10(38):79-86. Persian.
-
29.
Chang LC, Hung LL, Chou YW, Ling LM. Applying the health belief model to analyze intention to participate in preventive pulmonary tuberculosis chest X-ray examinations among indigenous nursing students. J Nurs Res. 2007;15(1):78-87. [PubMed ID: 17370235].
-
30.
Vakili MM, Hidarnia AR, Niknami S, Mousavinasab SN. [Effect of communication skills training on health belief model constructs about AIDS in Zanjan health volunteers (2010-11)]. Zanjan Univ Med Sci J. 2011;19(77):78-93. Persian.