Designing and Evaluating the Effectiveness of an Educational Intervention Based on the Health Belief Model (HBM) in Promoting Self-Care Behavior Among Healthcare Workers

Self-care encompasses learned, conscious, and purposeful actions performed by individuals for themselves, their children, and families to stay healthy, maintain good mental and physical health, meet social and psychological needs, prevent diseases or accidents, provide care for chronic illnesses, and support health after an acute illness or hospital discharge (1, 2). The most important health-promoting self-care behaviors include healthy eating, physical activity, stress management, interpersonal communication, spiritual growth, and taking responsibility for one's health (3, 4).

Self-care plays a crucial role in improving the national health system (1, 5). To reduce the burden on health systems, individuals need to adopt self-care behaviors (6). Studies indicate that about three-quarters of medical visits are unnecessary (2, 7), and self-care can address individuals' problems. Evidence from the UK shows that self-care support can reduce general practitioner visits by up to 40%, outpatient visits by up to 17%, and days of absence from work by 50% (2, 7).

Several factors influence individuals' self-care behavior. Studies indicate that age, social class (8), gender, literacy level (9), and individuals' attitudes and beliefs can significantly impact the adoption of self-care behaviors (10, 11). Previous studies on self-care have highlighted its unfavorable condition in Iran (12). However, in the present study, the average self-care behavior is higher in women than in men and higher in married employees than in single employees. Additionally, higher levels of education and economic status correlate with higher average self-care behavior. Teaching a healthy lifestyle and self-care is an appropriate and efficient way to achieve health and prevent disease (13, 14). People have the ability to take care of themselves and can be supported through direct compensatory and educational-supportive care whenever their ability is impaired, helping to restore their capacity for self-care. Creating health and self-care behavior is at the core of education and health promotion programs (15). Health education experts believe that choosing a model for health education is the first step in the "design or development" of educational interventions, ensuring that the program starts in the right direction and stays on track. The Health Belief Model (HBM), selected as the educational framework for the present study, is a highly accurate model specifically designed for health-related behaviors and is instrumental in developing and designing preventive programs.

This model includes six constructs: Perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy, and cues to action. These constructs are defined as follows: (1) perceived susceptibility: A person's belief about the likelihood of contracting a disease or experiencing a harmful state as a result of certain behaviors; (2) perceived severity: A person's belief about the extent of harm that can be caused by an illness or harmful condition resulting from specific behaviors; (3) perceived benefits: Beliefs about the advantages of the proposed methods for reducing the risk or severity of the disease or harmful state caused by particular behaviors; (4) perceived barriers: Beliefs about the actual and perceived costs of adopting a new behavior; (5) perceived self-efficacy: Confidence in one's ability to successfully perform a behavior; (6) cues to action: Triggers or forces that prompt the individual to take action (16, 17). Studies on self-care primarily focus on medicine and patients (2, 18); however, little attention is paid to self-care in healthy individuals who have not yet become ill. This is especially true for health workers who are expected to model a healthy lifestyle in society and provide self-care training at individual, organizational, and social levels according to the executive instructions of health education and promotion programs. Given that the HBM is a comprehensive model widely used for disease prevention, it effectively focuses on individual motivation for action (17, 19).

The present study aimed to determine the effect of training based on the HBM on the adoption of self-care behaviors, including physical activity, nutrition, spiritual growth, interpersonal relationships, health responsibility, and stress management, among health staff at comprehensive health centers in Rudbar city, Gilan.

The age range of most participants (43%) was 30 - 39 years, with 86% being female and 13.5% male. The economic situation of most employees participating in the study was moderate (69%). Job status for most employees was contracted (41%). The level of education for most employees was a bachelor's degree (73%). The chi-square test indicated that both intervention and control groups were comparable on demographic characteristics (gender, marital status, education level, job status, economic status, age, and work experience) and there were no significant differences between the two groups at pretest (Table 2). Additionally, there were no differences between groups on the outcomes measured at pretest, including all constructs of the HBM and aspects of health-promoting self-care behavior (P > 0.05) (Table 3).

As shown in Table 3, three months after the designed educational intervention, the mean scores of the constructs of the HBM (perceived sensitivity, perceived severity, perceived self-efficacy, and cues to action) except for perceived benefits improved significantly in the intervention group compared to the control group. Additionally, three months after the training, the mean score of all aspects of health-promoting self-care behavior (physical activity, spiritual growth, healthy diet, stress management, health responsibility, and interpersonal relationships) in the intervention group was significantly higher than in the control group (P < 0.05, Table 4). The average score of self-care behavior in the intervention group increased from 128.4 before the intervention to 148.37 after the intervention.

The results of the present study, which aimed to determine the effect of an educational intervention based on the HBM on adopting self-care behaviors among health workers, indicated that the training program improved dimensions of self-care behavior in the intervention group based on constructs of the HBM.

In this study, the mean scores of self-care behavior in the intervention group showed a significant increase after the training program, with notable improvements seen in self-care behaviors such as a healthy diet, physical activity, stress management, health responsibility, spiritual growth, and interpersonal relationships compared to the control group. The research results were consistent with several studies in which training based on the HBM was able to increase mean self-care behavior (2, 28-30). In a study by Torshizi et al. (31), training had no effect on calcium intake to prevent osteoporosis, likely due to the individuals' economic status. Similarly, Anderson et al. (32) indicated that despite providing necessary information to pregnant women, their eating behaviors did not improve. To explain the ineffectiveness of the training, the researchers cited factors such as lifestyle, social beliefs, and economic issues. Since self-care is effective in improving the quality of life and reducing the medical costs for societies, its implementation can prevent diseases or delay their side effects (1, 18). Educational interventions like the present study should be designed and implemented to increase individuals' participation in self-care. In the present study, the mean scores of susceptibility and perceived severity constructs in the post-educational intervention group were significantly higher than in the control group. This result indicates that training strengthens the belief in individuals that if self-care behavior is not adopted, they are exposed to diseases and their complications. Today, awareness alone is not enough to perform health behaviors; individuals' beliefs about a phenomenon or disease are crucial factors in adopting or not adopting health-oriented behaviors such as self-care. Therefore, increasing the perceived threat through educational intervention is an important result of the present study. Consistent with our findings, previous studies (17, 19) have also proven an increase in the mean score of the perceived threat construct after training. However, contrary to our findings, Heydari et al. (33) and Pirzadeh and Sharifirad (34) did not find any significant increase in the mean score of perceived susceptibility after educational intervention. The discrepancy may be due to the short duration of the training program (two one-hour sessions) in the above studies.

In the present study, the mean score of perceived benefits in the intervention group did not increase significantly after training. Given the mean score of the perceived benefits construct at the beginning of the study, it can be argued that the participants, who were health workers, had a high perception of benefits of adopting self-care behaviors. The lack of effect of training on increasing the mean score of perceived benefits construct was also observed in studies by Gursoy et al. (35), Torshizi et al. (31), and Asadzandi et al. (36). However, the results of several studies indicated the effect of training on increasing the mean score of the perceived benefits construct (2, 17, 37). In the present study, a significant decrease in mean scores of perceived barriers after the educational intervention between the two groups indicated the positive effect of training on the reduction of perceived barriers in the intervention group. This result was consistent with studies by So et al. in Hong Kong (38), Lee et al. in Taiwan (29), and Cyr A et al. in the United States (39). Contrary to our findings, Abood et al. (40) indicated that the mean score of perceived barriers did not significantly decrease after the intervention. Abood suggested that the inconsistency might be due to lower pursuit and social and cultural determinants outside individual control, which can impact the effectiveness of educational interventions in reducing perceived barriers. Since the perceived benefits and barriers in the HBM pave the way for adopting behavior, special attention should be paid to training programs to encourage participation in self-care programs and influence their beliefs. The results of the present study indicated an increase in the mean score of self-efficacy in the intervention group compared to the control group. This finding was consistent with studies by Zamani-Alavijeh et al. (14) and Jadgal et al. (41). Previous studies have also emphasized the importance of increasing individual confidence and self-efficacy as key factors and important preconditions for self-care and the promotion of health behaviors (1, 18). Cegala and Lenzmeier Broz believes that training and applying effective strategies to create self-efficacy in employees can lead to self-satisfaction and customer satisfaction (42). Therefore, it seems that using self-efficacy improvement strategies can be useful in fostering health-promoting behaviors such as self-care.

Data collection through self-report was a limitation of the present study. To address this limitation, it is essential to reassure employees about the confidentiality of their information.

Educational interventions alone (i.e., not supplemented by behavior change techniques) are weakly effective in changing behaviors; the level of exposure to the intervention (i.e., the number of sessions attended) could have contributed to the limited improvement in the outcomes; the delivery of the intervention (issues of fidelity and competence) may not have been optimal, resulting in minimal improvement in the outcomes.