Volume 11, Issue 4 (2023)
Health Educ Health Promot 2023, 11(4): 659-666 |
Back to browse issues page
Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
Didehvar M, Rakhshani T, Janfaza E, Soltani A, Nazari M, Ghahremani L. Effect of the PRECEDE-PROCEED Model-Based Training on the Cutaneous Leishmaniasis Preventive Behaviors among Rural Population under the Coverage of the Comprehensive Health Centers of Larestan, Iran; A Quasi-Experimental Study. Health Educ Health Promot 2023; 11 (4) :659-666
URL: http://hehp.modares.ac.ir/article-5-72034-en.html
URL: http://hehp.modares.ac.ir/article-5-72034-en.html
1- Department of Health Education and Promotion, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
2- Department of Public Health, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
3- “Research Center for Health Sciences, Institute of Health” and “Department of Medical Entomology and Vector Control, School of Health”, Shiraz University of Medical Sciences, Shiraz, Iran
2- Department of Public Health, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
3- “Research Center for Health Sciences, Institute of Health” and “Department of Medical Entomology and Vector Control, School of Health”, Shiraz University of Medical Sciences, Shiraz, Iran
Keywords: Leishmaniasis, Cutaneous [Mesh], Health Personnel [MeSH], Prevention and Control [MeSH], Health Education [MeSH]
Full-Text [PDF 698 kb]
(276 Downloads)
| Abstract (HTML) (370 Views)
Full-Text: (60 Views)
Introduction
Cutaneous Leishmaniasis (CL) is a skin disease caused by the single-celled parasite Leishmania [1]. This disease is transmitted to healthy people by mosquito bites from infected animals (rodents and dogs) or infected humans, and non-purulent papules develop at the site of the bite, progressing to painless ulcers with dense margins that can heal spontaneously over months to years or cause scarring and disfigurement [2]. Three-quarters of two million new cases of leishmaniasis in the world are CL [3]. Leishmaniasis is a major public health concern around the world. This disease is native to Asia, Africa, parts of South and Central America, and the Mediterranean and has affected nearly 98 countries [4]. It is reported that 12 to 15 million people are affected worldwide. Also, around 350 million people worldwide are at risk of leishmaniasis. The World Health Organization (WHO) has designated leishmaniasis as one of the world's seven most serious tropical diseases [4]. Each year, approximately 200,000 cases of CL are reported in Iran [5]. The Isfahan province has the highest prevalence (66%), while Kermanshah has the lowest. Its prevalence in Fars province has been estimated to be around 63% [6]. CL is not fatal, but some of the disease's unfortunate consequences are malformed lesions, social and psychological complications, and the high cost of treatment [7, 8]. This vector-borne disease has many negative effects on economic growth and people's quality of life, making it a major economic burden on households and public health systems every year [9]. Because researchers have not succeeded in developing a vaccine against CL, and because the disease is so widespread, the WHO has made health education a top priority. Many researchers have proposed disease control and prevention programs, such as vaccine and drug production, environmental improvement, rat eradication and spraying, and health education programs [10]. One of the ways to prevent and control the disease is to increase the awareness of society about the ways of disease transmission as well as preventive measures. The use of educational theories and models determines the effectiveness of health interventions. A model directs the educational program and provides a framework for measuring and evaluating educational programs [11].
The PRECEDE-PROCEED model is one of the health education models that provides a framework for identifying predisposing factors (knowledge, attitudes, and perceptions), reinforcing factors (influence of others, family, and peers), and enabling factors (accessibility, resources, and skills) that can be used to identify effective factors on behavior. Predisposing, reinforcing, and enabling structures in educational diagnosis and evaluation policy, regulatory, and organizational structures in educational and environmental development (PRECEDE-PROCEED) is a useful theoretical framework for planning, implementing, and evaluating [12]. The most useful application of this model is to explain behavioral factors [13]. Greene developed the PRECEDE section to identify health and education needs and later added the PROCEED section by adding the elements of policy, regulation, organization, and environment to emphasize the impact of ecological aspects in the modified model, which includes eight phases, namely social assessment, epidemiological assessment, educational/environmental assessment, administrative/policy assessment and intervention planning, implementation, process evaluation, impact evaluation, and performance evaluation. It is a multi-step approach to developing and implementing a health promotion program [14]. As a result, using the PRECEDE-PROCEED model improves preventive behaviors and can be used to plan health [15, 16]. For example, in the field of infection, the effect of using the PRECEDE-PROCEED model on increasing performance and knowledge has been confirmed [17]. It has also been used in Iran [18, 19].
The effectiveness of this model was confirmed by Jeihooni et al., where an educational intervention based on the PRECEDE-PROCEED model was carried out in order to improve behavior to prevent and control disease among housewives in Fasa, Iran [20]. Nazari et al. reported that the mentioned model improved the preventive behavior of the families in Kharameh [21]. The result of a systematic review showed that health education interventions are not sufficient to prevent and control CL, as knowledge is not always put into practice. The authors recommended interventions that address other factors, such as financial barriers and access to healthcare. This could explain the application of the PRECEDE model in leishmaniasis education, with a focus on the facilitating factor [22].
Instead of reliable sources, people get their information from family members, neighbors, and friends, who are likely to convey incomplete information and false beliefs to members of the community [23, 24].
The WHO has recommended that primary healthcare workers receive health education in order to prevent and control the disease [25]. Because health workers are the primary service providers in the country's healthcare team and are directly responsible for providing basic health services to the people of the society, particularly the villagers [26], increasing their knowledge and correct performance can play an important role in health education to different people and groups according to the culture of the region [27]. Health education in the field of disease control and prevention is an important function of healthcare workers [28]. Kashfi et al. found that training healthcare workers in Marvdasht, Iran regarding leishmaniasis improved the performance of the population they served [24]. Given the prevalence of leishmaniasis in Fars province and the importance of health workers in health education and disease control, as well as the fact that studies in the field of using the PRECEDE model for education about this disease are limited, we investigated the effect of training based on the PRECEDE model on leishmaniasis preventive behaviors, with a focus on the mediation role of healthcare workers in Larestan.
Materials and Methods
This was a semi-experimental study conducted on health workers acting as mediators and their covered households. Two comprehensive rural health centers in the most common leishmaniasis endemic areas of Larestan, Iran, were randomly assigned to the experimental and control groups (Khor Comprehensive Health Service Center as the experimental group and Latifi Comprehensive Health Service Center as the control group). Using Nazari et al.'s theoretical study [21] and the NCSS-PASS version 15 software, 160 households were chosen considering a 10% sample dropout rate, the test power of 0.95, and the influence coefficient of 1.45%.
All health workers from the mentioned centers and the health houses under their supervision (each comprehensive health center has four health houses) took part in this study. In addition, 20 households were chosen at random from the list of households covered by each health house, and 160 people (heads of households) were studied (80 cases in the intervention group and 80 in the control group; Figure 1). The inclusion criteria were no history of leishmaniasis and being motivated to participate in the educational program, while the exclusion criteria were unwillingness to continue cooperation and contracting leishmaniasis during the research.
Figure 1. CONSORT Diagram.
Data Collection
A demographic information questionnaire and a researcher-made questionnaire based on the PRECEDE-PROCEED model were used to collect data. The demographic questionnaire for the heads of the household asked about their age, occupation, gender, education level, average monthly income, and history of leishmaniasis.
The PRECEDE-PROCEED model-based questionnaire included questions on predisposing factors (12 questions regarding knowledge and nine questions regarding attitude), reinforcing factors (11 questions), and enabling factors (14 questions). The knowledge section included 12 questions with four answers about people's knowledge of the symptoms and methods of contracting and spreading the disease. The correct answer received one point, while the incorrect answer received zero. The minimum and maximum knowledge scores were 0 and 12, respectively, and a higher score indicated that people were more aware of this disease. The attitude section included nine questions with 6-point Likert scale responses (strongly agree, agree, slightly agree, slightly disagree, disagree, strongly disagree) about leishmaniasis prevention behaviors. The attitude score ranged from 9 to 54, with a higher score indicating a more positive attitude toward leishmaniasis prevention behaviors. The enabling factors included 14 questions about access to leishmaniasis insect disposal facilities, which were scored by answering yes or no. A yes answer is worth one point, while a no answer is worth zero points. The minimum and maximum enabling factor scores were 0 and 14, respectively, and a higher score indicated the presence of controlling factors to prevent leishmaniasis. The reinforcing factor questionnaire contained 11 questions with a three-point Likert scale (yes, somewhat, and no) about the reinforcing factors of leishmaniasis preventive behaviors, with minimum and maximum scores of 0 and 22, respectively.
A panel of experts was formed to validate this questionnaire. Cronbach's alpha coefficient for questionnaire reliability was 0.79, CVR for attitude questions was 0.77, for knowledge was 0.72, for reinforcement was 0.69, and enabling factors was 0.73, and Cronbach's alpha coefficient for knowledge was 0.72.
Study Design
Before the intervention, the PRECEDE-PROCEED model questionnaire (predisposing factors, enabling factors, and reinforcing factors) was completed to assess the condition of the studied health workers and the population served by them. Then, a training program was held for the health workers of the intervention group, but no training was held for the control group. The training intervention included four two-day training sessions in person with full compliance with health protocols (maintaining social distancing and wearing masks) for the patients. The first session was spent familiarizing students with leishmaniasis and its carrier, the second session was spent familiarizing students with methods of prevention and combating the leishmaniasis disease, the third session was spent familiarizing students with interpersonal communication skills, and the final session was spent familiarizing students with group work and participation. It should be noted that a group was formed in the context of a social network for better communication between the students and the researcher so that if the students had any questions during the training, the researcher would answer them and these answers were shared with other people. Then, health workers were given up to two months to train the population under their coverage. The questionnaires were completed again for the heads of the households covered by them eight weeks after the training. After the post-test stage, the researcher conducted training sessions for the control group in order to comply with the research's ethical and professional principles, as well as to thank and appreciate the control group's cooperation.
Statistical Analysis
Data were analyzed using SPSS 20 software and the Chi-square test, independent t-test, paired t-test, ANCOVA, and Cohen's D. It should be noted that in all tests, the significance level of 0.05 was used.
The first step in data analysis is to determine their normality using the Kolmogorov-Smirnov test. The data were then processed at the descriptive level using central tendency and dispersion indices and at the inferential level using the ANCOVA to determine the effect of training on leishmaniasis preventive behaviors based on the PRECEDE model and to check the significance of the difference between the intervention group's mean scores.
Findings
The two groups were not significantly different in terms of demographic variables (age, level of education, monthly income, occupation, history of leishmaniasis, history of training about leishmaniasis, and source of information about leishmaniasis) (p>0.05; Table 1)
Table 1. The mean score of predisposing factors (knowledge and attitude), enabling factors, reinforcing factors, and behavior in the intervention and control groups
The results of the independent and paired t-tests showed that the scores of predisposing factors (Knowledge and attitude), reinforcing factors, enabling factors, and behavior increased significantly after the intervention in the intervention group compared to the control group. Cohen's D coefficient can express the positive effect of training on all constructs (Table 2).
Table 2. The mean score of predisposing factors (knowledge and attitude), enabling factors, reinforcing factors, and behavior in the intervention and control groups
Discussion
The findings of this study revealed a significant difference in the mean scores of enabling factors, predisposing factors, reinforcing factors, and behavior between the intervention and control groups after the intervention. This means that the increase in the scores of these constructs was greater in the intervention group, indicating the effect of training. The score of reinforcing factors in the intervention group increased significantly both before and after the intervention compared to the control group. Support and encouragement from others, such as a spouse, family members, clergy, friends, and healthcare workers, were considered reinforcing factors in this study. Li et al. [29], Ebrahim Fard et al. [30], and other studies [31-33] reported results in line with our findings. Encouragement and social support of people improve self-efficacy and help them to perform a behavior. Satisfaction and having social support, as well as positive emotions, are indicators of perceived social support. Reinforcing factors predicted the adoption of preventive behavior, according to Hajjari et al.'s study, which used the PRECEDE model to assess the educational needs for the prevention of Malt fever in rural areas of Isfahan. People's expectations from veterinary personnel, health workers, and family members were strengthened by encouraging them to adopt correct preventive behaviors such as vaccination of animals, and the use of masks and gloves when entering the animal shelter and during milking [34]. Reinforcing factors were not predictive of preventive behaviors of CL in the study by Jajarmi et al., which was conducted to investigate preventive behavior of leishmaniasis based on the questionnaire in families with children under ten years of age [19], which was inconsistent with our study. Encouragement and support from others to perform preventive behaviors against CL (using mosquito nets, installing nets on doors and windows, and using insect-repellent ointment) were identified as reinforcing factors in the mentioned study. Jajarmi et al. believed that changing societal customs in rural communities is difficult. Influential people, such as a chief or dean, usually can promote unusual behavior in society and encourage others to do the same. Behavior change will be facilitated if these people support and encourage people to adopt healthy behaviors.
Money to purchase facilities, such as insecticides and insect repellant pens, holding training classes, and providing an educational pamphlet about leishmaniasis from the health center, as well as the health liaisons themselves as the people who answered the participants' questions, were considered enabling factors in the current study. After training, the mean score of this construct in the intervention group increased significantly more than in the control group. In line with this finding, we can refer to the study by Jeihooni et al. [20] on leishmaniasis control in housewives, Ghahremani et al. [33] on malaria prevention, and Jahangiri et al. [33]. The results of Fadaei et al. [35] on the preventive behavior of Malt fever did not agree with our findings. They discovered the reason for the lack of influence of the enabling factor on the failure to achieve Malt fever preventive behaviors, which is a set of factors, such as supervisory and management department interventions to increase the budget and resources required in brucellosis control projects (livestock vaccination programs, killing, and compensation to livestock owners).
In our study, the score of predisposing factors with two components of knowledge and attitude increased significantly after training in the intervention group compared to the control group. This finding is consistent with several studies [36, 37]. According to Hajjari et al., the construct of attitude and knowledge of the PRECEDE model predicted Malt fever preventive behavior [34]. All constructs except attitude were significantly different in the study by Moaieni et al., who used the PRECEDE model to reduce occupational stress in nurses. The difference in attitude scores before and after training was not significant compared to the control group, and the reason for the high attitude and need to deal with stress in nurses could be due to their level of education and scientific knowledge [38].
The behavior score was also significant when comparing the intervention and control groups. After the training, the intervention group participants outperformed the control group in terms of adopting leishmaniasis preventive behaviors; this result was consistent with some studies [20, 24, 39]. The PRECEDE model states that behavior change is dependent on increasing knowledge and improving attitude, the availability of facilities and resources as an enabling factor, and the support and encouragement of those around you as a reinforcing factor. In our study, improvements in the reinforcing, predisposing, and enabling factors resulted in the desired and meaningful behavior change. According to the current research, Jajarmi et al., who measured the predictive power of the PRECEDE model in the preventive behavior of leishmaniasis in families with children under the age of ten, concluded that by relying on predisposing and enabling factors, the chances of people to adopt health behaviors are higher, while reinforcing factors do not play an important role [19]. Employees in the healthcare system can take action to control and prevent diseases by emphasizing the role of this model's predisposing, reinforcing, and enabling factors. The government and officials must pay attention to and support social workers as pioneers in providing health services.
The use of teachers as a mediator in training is a strength of this study. Training is done based on the culture of each region and will be more effective due to their familiarity with the culture and characteristics of the region under their cover. One of the limitations was the overlap of the educational program with the COVID-19 pandemic, which could have a negative impact on education quality and subject participation in face-to-face sessions. Another limitation of our study was the small number of health workers in each group, which made comparing the intervention and control groups in this population impossible. In future studies, it is suggested to use a larger number of health workers to enable comparison between the two groups.
Conclusion
Training health workers as mediators using the PRECEDE model has a positive effect on changing the behavior of the population they serve.
Acknowledgments: The research team wishes to express gratitude to the Larestan health centers and healthcare workers for their cooperation and assistance.
Ethical Permissions: The current study was approved by the Faculty of Nursing and Midwifery of Shiraz University of Medical Sciences (IR.SBMU.PHARMACY.REC.1398.134).
Author’s Contribution: Didehvar M (First Author), Introduction Writer/Original/Main Researcher/Statistical Analyst (25%); Rakhshani T (Second Author), Methodologist/Assistant Researcher (15%); Janfaza E (Third Author), Assistant Researcher/Discussion Writer (15%); Slotani A (Forth Author), Methodologist/Assistant Researcher/Statistical Analyst (15%); Nazari M (Fifth Author), Assistant Researcher/Discussion Writer/Statistical Analyst (15%); Ghahremani L (Sixth Author), Introduction Writer/Methodologist (15%)
Conflicts of Interests: There are no conflicts of interests.
Funding/Support: This research received financial support from the Shiraz University of Medical Sciences.
Cutaneous Leishmaniasis (CL) is a skin disease caused by the single-celled parasite Leishmania [1]. This disease is transmitted to healthy people by mosquito bites from infected animals (rodents and dogs) or infected humans, and non-purulent papules develop at the site of the bite, progressing to painless ulcers with dense margins that can heal spontaneously over months to years or cause scarring and disfigurement [2]. Three-quarters of two million new cases of leishmaniasis in the world are CL [3]. Leishmaniasis is a major public health concern around the world. This disease is native to Asia, Africa, parts of South and Central America, and the Mediterranean and has affected nearly 98 countries [4]. It is reported that 12 to 15 million people are affected worldwide. Also, around 350 million people worldwide are at risk of leishmaniasis. The World Health Organization (WHO) has designated leishmaniasis as one of the world's seven most serious tropical diseases [4]. Each year, approximately 200,000 cases of CL are reported in Iran [5]. The Isfahan province has the highest prevalence (66%), while Kermanshah has the lowest. Its prevalence in Fars province has been estimated to be around 63% [6]. CL is not fatal, but some of the disease's unfortunate consequences are malformed lesions, social and psychological complications, and the high cost of treatment [7, 8]. This vector-borne disease has many negative effects on economic growth and people's quality of life, making it a major economic burden on households and public health systems every year [9]. Because researchers have not succeeded in developing a vaccine against CL, and because the disease is so widespread, the WHO has made health education a top priority. Many researchers have proposed disease control and prevention programs, such as vaccine and drug production, environmental improvement, rat eradication and spraying, and health education programs [10]. One of the ways to prevent and control the disease is to increase the awareness of society about the ways of disease transmission as well as preventive measures. The use of educational theories and models determines the effectiveness of health interventions. A model directs the educational program and provides a framework for measuring and evaluating educational programs [11].
The PRECEDE-PROCEED model is one of the health education models that provides a framework for identifying predisposing factors (knowledge, attitudes, and perceptions), reinforcing factors (influence of others, family, and peers), and enabling factors (accessibility, resources, and skills) that can be used to identify effective factors on behavior. Predisposing, reinforcing, and enabling structures in educational diagnosis and evaluation policy, regulatory, and organizational structures in educational and environmental development (PRECEDE-PROCEED) is a useful theoretical framework for planning, implementing, and evaluating [12]. The most useful application of this model is to explain behavioral factors [13]. Greene developed the PRECEDE section to identify health and education needs and later added the PROCEED section by adding the elements of policy, regulation, organization, and environment to emphasize the impact of ecological aspects in the modified model, which includes eight phases, namely social assessment, epidemiological assessment, educational/environmental assessment, administrative/policy assessment and intervention planning, implementation, process evaluation, impact evaluation, and performance evaluation. It is a multi-step approach to developing and implementing a health promotion program [14]. As a result, using the PRECEDE-PROCEED model improves preventive behaviors and can be used to plan health [15, 16]. For example, in the field of infection, the effect of using the PRECEDE-PROCEED model on increasing performance and knowledge has been confirmed [17]. It has also been used in Iran [18, 19].
The effectiveness of this model was confirmed by Jeihooni et al., where an educational intervention based on the PRECEDE-PROCEED model was carried out in order to improve behavior to prevent and control disease among housewives in Fasa, Iran [20]. Nazari et al. reported that the mentioned model improved the preventive behavior of the families in Kharameh [21]. The result of a systematic review showed that health education interventions are not sufficient to prevent and control CL, as knowledge is not always put into practice. The authors recommended interventions that address other factors, such as financial barriers and access to healthcare. This could explain the application of the PRECEDE model in leishmaniasis education, with a focus on the facilitating factor [22].
Instead of reliable sources, people get their information from family members, neighbors, and friends, who are likely to convey incomplete information and false beliefs to members of the community [23, 24].
The WHO has recommended that primary healthcare workers receive health education in order to prevent and control the disease [25]. Because health workers are the primary service providers in the country's healthcare team and are directly responsible for providing basic health services to the people of the society, particularly the villagers [26], increasing their knowledge and correct performance can play an important role in health education to different people and groups according to the culture of the region [27]. Health education in the field of disease control and prevention is an important function of healthcare workers [28]. Kashfi et al. found that training healthcare workers in Marvdasht, Iran regarding leishmaniasis improved the performance of the population they served [24]. Given the prevalence of leishmaniasis in Fars province and the importance of health workers in health education and disease control, as well as the fact that studies in the field of using the PRECEDE model for education about this disease are limited, we investigated the effect of training based on the PRECEDE model on leishmaniasis preventive behaviors, with a focus on the mediation role of healthcare workers in Larestan.
Materials and Methods
This was a semi-experimental study conducted on health workers acting as mediators and their covered households. Two comprehensive rural health centers in the most common leishmaniasis endemic areas of Larestan, Iran, were randomly assigned to the experimental and control groups (Khor Comprehensive Health Service Center as the experimental group and Latifi Comprehensive Health Service Center as the control group). Using Nazari et al.'s theoretical study [21] and the NCSS-PASS version 15 software, 160 households were chosen considering a 10% sample dropout rate, the test power of 0.95, and the influence coefficient of 1.45%.
All health workers from the mentioned centers and the health houses under their supervision (each comprehensive health center has four health houses) took part in this study. In addition, 20 households were chosen at random from the list of households covered by each health house, and 160 people (heads of households) were studied (80 cases in the intervention group and 80 in the control group; Figure 1). The inclusion criteria were no history of leishmaniasis and being motivated to participate in the educational program, while the exclusion criteria were unwillingness to continue cooperation and contracting leishmaniasis during the research.
Figure 1. CONSORT Diagram.
Data Collection
A demographic information questionnaire and a researcher-made questionnaire based on the PRECEDE-PROCEED model were used to collect data. The demographic questionnaire for the heads of the household asked about their age, occupation, gender, education level, average monthly income, and history of leishmaniasis.
The PRECEDE-PROCEED model-based questionnaire included questions on predisposing factors (12 questions regarding knowledge and nine questions regarding attitude), reinforcing factors (11 questions), and enabling factors (14 questions). The knowledge section included 12 questions with four answers about people's knowledge of the symptoms and methods of contracting and spreading the disease. The correct answer received one point, while the incorrect answer received zero. The minimum and maximum knowledge scores were 0 and 12, respectively, and a higher score indicated that people were more aware of this disease. The attitude section included nine questions with 6-point Likert scale responses (strongly agree, agree, slightly agree, slightly disagree, disagree, strongly disagree) about leishmaniasis prevention behaviors. The attitude score ranged from 9 to 54, with a higher score indicating a more positive attitude toward leishmaniasis prevention behaviors. The enabling factors included 14 questions about access to leishmaniasis insect disposal facilities, which were scored by answering yes or no. A yes answer is worth one point, while a no answer is worth zero points. The minimum and maximum enabling factor scores were 0 and 14, respectively, and a higher score indicated the presence of controlling factors to prevent leishmaniasis. The reinforcing factor questionnaire contained 11 questions with a three-point Likert scale (yes, somewhat, and no) about the reinforcing factors of leishmaniasis preventive behaviors, with minimum and maximum scores of 0 and 22, respectively.
A panel of experts was formed to validate this questionnaire. Cronbach's alpha coefficient for questionnaire reliability was 0.79, CVR for attitude questions was 0.77, for knowledge was 0.72, for reinforcement was 0.69, and enabling factors was 0.73, and Cronbach's alpha coefficient for knowledge was 0.72.
Study Design
Before the intervention, the PRECEDE-PROCEED model questionnaire (predisposing factors, enabling factors, and reinforcing factors) was completed to assess the condition of the studied health workers and the population served by them. Then, a training program was held for the health workers of the intervention group, but no training was held for the control group. The training intervention included four two-day training sessions in person with full compliance with health protocols (maintaining social distancing and wearing masks) for the patients. The first session was spent familiarizing students with leishmaniasis and its carrier, the second session was spent familiarizing students with methods of prevention and combating the leishmaniasis disease, the third session was spent familiarizing students with interpersonal communication skills, and the final session was spent familiarizing students with group work and participation. It should be noted that a group was formed in the context of a social network for better communication between the students and the researcher so that if the students had any questions during the training, the researcher would answer them and these answers were shared with other people. Then, health workers were given up to two months to train the population under their coverage. The questionnaires were completed again for the heads of the households covered by them eight weeks after the training. After the post-test stage, the researcher conducted training sessions for the control group in order to comply with the research's ethical and professional principles, as well as to thank and appreciate the control group's cooperation.
Statistical Analysis
Data were analyzed using SPSS 20 software and the Chi-square test, independent t-test, paired t-test, ANCOVA, and Cohen's D. It should be noted that in all tests, the significance level of 0.05 was used.
The first step in data analysis is to determine their normality using the Kolmogorov-Smirnov test. The data were then processed at the descriptive level using central tendency and dispersion indices and at the inferential level using the ANCOVA to determine the effect of training on leishmaniasis preventive behaviors based on the PRECEDE model and to check the significance of the difference between the intervention group's mean scores.
Findings
The two groups were not significantly different in terms of demographic variables (age, level of education, monthly income, occupation, history of leishmaniasis, history of training about leishmaniasis, and source of information about leishmaniasis) (p>0.05; Table 1)
Table 1. The mean score of predisposing factors (knowledge and attitude), enabling factors, reinforcing factors, and behavior in the intervention and control groups
The results of the independent and paired t-tests showed that the scores of predisposing factors (Knowledge and attitude), reinforcing factors, enabling factors, and behavior increased significantly after the intervention in the intervention group compared to the control group. Cohen's D coefficient can express the positive effect of training on all constructs (Table 2).
Table 2. The mean score of predisposing factors (knowledge and attitude), enabling factors, reinforcing factors, and behavior in the intervention and control groups
Discussion
The findings of this study revealed a significant difference in the mean scores of enabling factors, predisposing factors, reinforcing factors, and behavior between the intervention and control groups after the intervention. This means that the increase in the scores of these constructs was greater in the intervention group, indicating the effect of training. The score of reinforcing factors in the intervention group increased significantly both before and after the intervention compared to the control group. Support and encouragement from others, such as a spouse, family members, clergy, friends, and healthcare workers, were considered reinforcing factors in this study. Li et al. [29], Ebrahim Fard et al. [30], and other studies [31-33] reported results in line with our findings. Encouragement and social support of people improve self-efficacy and help them to perform a behavior. Satisfaction and having social support, as well as positive emotions, are indicators of perceived social support. Reinforcing factors predicted the adoption of preventive behavior, according to Hajjari et al.'s study, which used the PRECEDE model to assess the educational needs for the prevention of Malt fever in rural areas of Isfahan. People's expectations from veterinary personnel, health workers, and family members were strengthened by encouraging them to adopt correct preventive behaviors such as vaccination of animals, and the use of masks and gloves when entering the animal shelter and during milking [34]. Reinforcing factors were not predictive of preventive behaviors of CL in the study by Jajarmi et al., which was conducted to investigate preventive behavior of leishmaniasis based on the questionnaire in families with children under ten years of age [19], which was inconsistent with our study. Encouragement and support from others to perform preventive behaviors against CL (using mosquito nets, installing nets on doors and windows, and using insect-repellent ointment) were identified as reinforcing factors in the mentioned study. Jajarmi et al. believed that changing societal customs in rural communities is difficult. Influential people, such as a chief or dean, usually can promote unusual behavior in society and encourage others to do the same. Behavior change will be facilitated if these people support and encourage people to adopt healthy behaviors.
Money to purchase facilities, such as insecticides and insect repellant pens, holding training classes, and providing an educational pamphlet about leishmaniasis from the health center, as well as the health liaisons themselves as the people who answered the participants' questions, were considered enabling factors in the current study. After training, the mean score of this construct in the intervention group increased significantly more than in the control group. In line with this finding, we can refer to the study by Jeihooni et al. [20] on leishmaniasis control in housewives, Ghahremani et al. [33] on malaria prevention, and Jahangiri et al. [33]. The results of Fadaei et al. [35] on the preventive behavior of Malt fever did not agree with our findings. They discovered the reason for the lack of influence of the enabling factor on the failure to achieve Malt fever preventive behaviors, which is a set of factors, such as supervisory and management department interventions to increase the budget and resources required in brucellosis control projects (livestock vaccination programs, killing, and compensation to livestock owners).
In our study, the score of predisposing factors with two components of knowledge and attitude increased significantly after training in the intervention group compared to the control group. This finding is consistent with several studies [36, 37]. According to Hajjari et al., the construct of attitude and knowledge of the PRECEDE model predicted Malt fever preventive behavior [34]. All constructs except attitude were significantly different in the study by Moaieni et al., who used the PRECEDE model to reduce occupational stress in nurses. The difference in attitude scores before and after training was not significant compared to the control group, and the reason for the high attitude and need to deal with stress in nurses could be due to their level of education and scientific knowledge [38].
The behavior score was also significant when comparing the intervention and control groups. After the training, the intervention group participants outperformed the control group in terms of adopting leishmaniasis preventive behaviors; this result was consistent with some studies [20, 24, 39]. The PRECEDE model states that behavior change is dependent on increasing knowledge and improving attitude, the availability of facilities and resources as an enabling factor, and the support and encouragement of those around you as a reinforcing factor. In our study, improvements in the reinforcing, predisposing, and enabling factors resulted in the desired and meaningful behavior change. According to the current research, Jajarmi et al., who measured the predictive power of the PRECEDE model in the preventive behavior of leishmaniasis in families with children under the age of ten, concluded that by relying on predisposing and enabling factors, the chances of people to adopt health behaviors are higher, while reinforcing factors do not play an important role [19]. Employees in the healthcare system can take action to control and prevent diseases by emphasizing the role of this model's predisposing, reinforcing, and enabling factors. The government and officials must pay attention to and support social workers as pioneers in providing health services.
The use of teachers as a mediator in training is a strength of this study. Training is done based on the culture of each region and will be more effective due to their familiarity with the culture and characteristics of the region under their cover. One of the limitations was the overlap of the educational program with the COVID-19 pandemic, which could have a negative impact on education quality and subject participation in face-to-face sessions. Another limitation of our study was the small number of health workers in each group, which made comparing the intervention and control groups in this population impossible. In future studies, it is suggested to use a larger number of health workers to enable comparison between the two groups.
Conclusion
Training health workers as mediators using the PRECEDE model has a positive effect on changing the behavior of the population they serve.
Acknowledgments: The research team wishes to express gratitude to the Larestan health centers and healthcare workers for their cooperation and assistance.
Ethical Permissions: The current study was approved by the Faculty of Nursing and Midwifery of Shiraz University of Medical Sciences (IR.SBMU.PHARMACY.REC.1398.134).
Author’s Contribution: Didehvar M (First Author), Introduction Writer/Original/Main Researcher/Statistical Analyst (25%); Rakhshani T (Second Author), Methodologist/Assistant Researcher (15%); Janfaza E (Third Author), Assistant Researcher/Discussion Writer (15%); Slotani A (Forth Author), Methodologist/Assistant Researcher/Statistical Analyst (15%); Nazari M (Fifth Author), Assistant Researcher/Discussion Writer/Statistical Analyst (15%); Ghahremani L (Sixth Author), Introduction Writer/Methodologist (15%)
Conflicts of Interests: There are no conflicts of interests.
Funding/Support: This research received financial support from the Shiraz University of Medical Sciences.
Article Type: Original Research |
Subject:
Health Education and Health Behavior
Received: 2023/10/17 | Accepted: 2023/11/18 | Published: 2023/11/30
Received: 2023/10/17 | Accepted: 2023/11/18 | Published: 2023/11/30
References
1. Amarasinghe A, Wickramasinghe S. A comprehensive review of cutaneous leishmaniasis in Sri Lanka and identification of existing knowledge gaps. Acta Parasitol. 2020;65(2):300-9. [Link] [DOI:10.2478/s11686-020-00174-6]
2. Mann S, Frasca K, Scherrer S, Henao-Martínez AF, Newman S, Ramanan P, et al. A review of leishmaniasis: Current knowledge and future directions. Curr Trop Med Rep. 2021;8(2):121-32. [Link] [DOI:10.1007/s40475-021-00232-7]
3. Artun O. Ecological niche modeling for the prediction of cutaneous leishmaniasis epidemiology in current and projected future in Adana, Turkey. J Vector Borne Dis. 2019;56(2):127-33. [Link] [DOI:10.4103/0972-9062.263726]
4. Torres-Guerrero E, Quintanilla-Cedillo MR, Ruiz-Esmenjaud J, Arenas R. Leishmaniasis: A review. Faculty of 1000. 2017;6:750. [Link] [DOI:10.12688/f1000research.11120.1]
5. Momen HM, Rahimi H, Hesami AM. The study of epidemiological cutaneous leishmaniasis in Aran and Bidgol city, and the impact of climatic factors on that during 2016-2019. J Environ Health Sci Eng. 2022;9(2):173-88. [Persian] [Link] [DOI:10.61186/jehe.9.2.173]
6. Sabzevari S, Teshnizi SH, Shokri A, Bahrami F, Kouhestani F. Cutaneous leishmaniasis in Iran: A systematic review and meta-analysis. Microbial Pathog. 2021;152:104721. [Link] [DOI:10.1016/j.micpath.2020.104721]
7. Chahed MK, Bellali H, Ben Jemaa S, Bellaj T. Psychological and psychosocial consequences of zoonotic cutaneous leishmaniasis among women in Tunisia: preliminary findings from an exploratory study. PLoS Negl Trop Dis. 2016;10(10):e0005090. [Link] [DOI:10.1371/journal.pntd.0005090]
8. Chelbi I, Mathlouthi O, Zhioua S, Fares W, Boujaama A, Cherni S, et al. The impact of illegal waste sites on the transmission of zoonotic cutaneous leishmaniasis in central Tunisia. Int J Environ Res Public Health. 2021;18(1):66. [Link] [DOI:10.3390/ijerph18010066]
9. Javanbakht M, Argani M, Ezimand K, Saghafipour A. Modeling spatial-temporal variations of cutaneous leishmaniasis incidence in Southern, Razavi and northern Khorasan provinces based on environmental and ecological criteria in northeast Iran. Iran J Epidemiol. 2021;17(1):21-33. [Persian] [Link]
10. Alizadeh G, Shahnazi H, Hassanzadeh A. Application of BASNEF model in students training regarding cutaneous leishmaniasis prevention behaviors: A school-based quasi experimental study. BMC Infectious Diseases. 2021;21(1):1164. [Link] [DOI:10.1186/s12879-021-06874-2]
11. Mazaheri Dehosta A, Aghamolaei T, Mohseni S, Mooseli A, Dadipoor S. Effect of an educational program based on the health belief model on physical activity of obese women. J Prev Med. 2022;9(2):194-205. [Link]
12. Arshad A, Shaheen F, Safdar W, Tariq MR, Navid MT, Qazi AS, et al. A PRECEDE‐PROCEED model‐based educational intervention to promote healthy eating habits in middle school girls. Food Sci Nutr. 2023;11(3):1318-27. [Link] [DOI:10.1002/fsn3.3167]
13. Eisapareh K, Nazari M, Kaveh MH, Cousins R, Mokarami H. Effects of an educational intervention program based on the PRECEDE-PROCEED model for anger management and driving performance of urban taxi drivers: A comparison of traditional and online methods. Safety Sci. 2023;157:105933. [Link] [DOI:10.1016/j.ssci.2022.105933]
14. Kim J, Jang J, Kim B, Lee KH. Effect of the PRECEDE-PROCEED model on health programs: A systematic review and meta-analysis. Syst Rev. 2022;11(1):213. [Link] [DOI:10.1186/s13643-022-02092-2]
15. Bab N, Khodadadi H, Nasirzadeh M. Planning, implementation, and evaluation of educational intervention based on PRECEDE-PROCEED model for mothers about oral health promotion on children aged 3-6 years. J Educ Health Promot. 2022;11(1):243. [Link] [DOI:10.4103/jehp.jehp_561_21]
16. Vamos CA, Kline N, Vázquez-Otero C, Lockhart EA, Lake PW, Wells KJ, et al. Stakeholders' perspectives on system-level barriers to and facilitators of HPV vaccination among Hispanic migrant farmworkers. Ethn. 2022;27(6):1442-64. [Link] [DOI:10.1080/13557858.2021.1887820]
17. Lin H, Wang X, Luo X, Qin Z. A management program for preventing occupational blood-borne infectious exposure among operating room nurses: An application of the PRECEDE-PROCEED model. J Int Med. 2020;48(1):300060519895670. [Link] [DOI:10.1177/0300060519895670]
18. Bahadori F, Ghofranipour F, Zarei F, Ziaei R, Ghaffarifar S. Application of the PRECEDE-PROCEED model in prevention of brucellosis focused on livestock vaccination process. BMC Vet Res. 2021;17(1):1-13. [Link] [DOI:10.1186/s12917-021-03099-y]
19. Jajarmi H, Gholian-Aval M, Esmaily H, Hosseini H, Rajabzadeh R, Tehrani H. Predicting the preventive behaviors of cutaneous leishmaniasis in families with children under 10 years, applied the precede model. Iran J Health Educ Health Promot. 2022;9(4):360-71. [Persian] [Link] [DOI:10.52547/ijhehp.9.4.360]
20. Jeihooni AK, Harsini PA, Kashfi SM, Rakhshani T. Effect of educational intervention based on the PRECEDE-PROCEED model on preventive behaviors of cutaneous leishmaniasis among housewives. Cad Saude Publica. 2019;35:e00158818. [Link] [DOI:10.1590/0102-311x00158818]
21. Nazari M, Taravatmanesh G, Kaveh MH, Soltani A, Ghaem H. The effect of educational intervention on preventive behaviors towards cutaneous leishmaniasis at Kharameh city in 2014. Shiraz E-Med J. 2016;17(10):e39957. [Link] [DOI:10.17795/semj39957]
22. Polidano K, Wenning B, Ruiz-Cadavid A, Dawaishan B, Panchal J, Gunasekara S, et al. Community-based interventions for the prevention and control of cutaneous leishmaniasis: A systematic review. Soc Sci. 2022;11(10):490. [Link] [DOI:10.3390/socsci11100490]
23. Alharazi TH, Haouas N, Al-Mekhlafi HM. Knowledge and attitude towards cutaneous leishmaniasis among rural endemic communities in Shara'b district, Taiz, southwestern Yemen. BMC Infectious Dis. 2021;21(1):269. [Link] [DOI:10.1186/s12879-021-05965-4]
24. Kashfi SM, Jeihooni AK, Rezaeianzade A. Effect of health workers' training programs on preventive behavior of leishmaniosis based on BASNEF model. J Res Health Sci. 2012;12(2):114-8. [Link]
25. Carvalho AGd, Alves I, Borges LM, Spessatto LB, Castro LS, Luz JGG. Basic knowledge about visceral leishmaniasis before and after educational intervention among primary health care professionals in Midwestern Brazil. Rev Inst Med Trop Sao Paulo. 2021;63:e56. [Link] [DOI:10.1590/s1678-9946202163056]
26. Kafrani SD, Zolfagharnasab A, Torabi F. Primary health care quality improvement patterns: A Systematic Review Study. SJSPH. 2019;17(2):169-82. [Persian] [Link]
27. Rouhani Z, Vaez Mahdavi MR, Montazei A, Faghihzadeh S, Khoda Doost M. Effectiveness of training Persian medicine principles for maintaining health on the lifestyle of health workers. Payesh (Health Monitor). 2019;18(3):261-8. [Persian] [Link]
28. Hartzler AL, Tuzzio L, Hsu C, Wagner EH. Roles and functions of community health workers in primary care. Ann Fam Med. 2018;16(3):240-5. [Link] [DOI:10.1370/afm.2208]
29. Li J, Pu J, Liu J, Wang Q, Zhang R, Zhang T, et al. Determinants of self-management behaviors among pulmonary tuberculosis patients: A path analysis. IDP. 2021;10:1-11. [Link] [DOI:10.1186/s40249-021-00888-3]
30. Azar FE, Solhi M, Darabi F, Rohban A, Abolfathi M, Nejhaddadgar N. Effect of educational intervention based on PRECEDE-PROCEED model combined with self-management theory on self-care behaviors in type 2 diabetic patients. Diabetes Metab Syndr. 2018;12(6):1075-8. [Link] [DOI:10.1016/j.dsx.2018.06.028]
31. Ghahremani L, Azizi M, Moemenbellah-Fard MD, Ghaem H. Malaria preventive behaviors among housewives in suburbs of Bandar-Abbas City, south of Iran: interventional design based on PRECEDE model. Pathog Glob Health. 2019;113(1):32-8. [Link] [DOI:10.1080/20477724.2019.1583847]
32. Didehvar M, Zareban I, Jalili Z, Bakhshani NM, Shahrakipoor M, Balouchi A. The effect of stress management training through PRECEDE-PROCEED model on occupational stress among nurses and midwives at Iran hospital, Iranshahr. J Clin Diagn Res. 2016;10(10):LC01-5. [Link] [DOI:10.7860/JCDR/2016/22569.8674]
33. Jahangiry L, Khazaee-Pool M, Mahdavi B, Ponnet K, Sarbakhsh P. Preventive factors related to brucellosis among rural population using the PRECEDE model: An application of path analysis. Trop Anim Health Prod. 2019;51:419-28. [Link] [DOI:10.1007/s11250-018-1708-2]
34. Hajari A, Shams M, Afrooghi S, Nobari RF, Najafabadi RA. Using the precede-proceed model in needs assessment for the prevention of brucellosis in rural areas of Isfahan, Iran. Armaghan-e Danesh. 2016;21 (4):396-409. [Persian] [Link]
35. Fadaei E, Borhani M, Hosseini ZS, Mehri A, MahinTatari. Effect of health educational intervention based on the educational phase of the PRECEDE-PROCEED model on the promotion of preventive behaviors of brucellosis in the villagers of Minoodasht, Iran. J Educ Community Health. 2021;8(3):203-8. [Link] [DOI:10.52547/jech.8.3.203]
36. Azizzadeh Pormehr A, Shojaezadeh D. The effects of educational intervention for anxiety reduction on nursing staffs based on PRECEDE-PROCEED Model. Health Educ Health Promot. 2019;7(3):119-23. [Link] [DOI:10.29252/HEHP.7.3.119]
37. Azar FE, Solhi M, Nejhaddadgar N, Amani F. The effect of intervention using the PRECEDE-PROCEED model based on quality of life in diabetic patients. Electronic Physician. 2017;9(8):5024-30. [Link] [DOI:10.19082/5024]
38. Moeini B, Hazavehei SMM, Hosseini Z, Aghamolaei T, Moghimbeigi A. The impact of cognitive-behavioral stress management training program on job stress in hospital nurses: Applying PRECEDE model. J Res Health Sci. 2011;11(2):114-20. [Link]
39. Gholampour Y, Khani Jeihooni A, Momenabadi V, Amirkhani M, Afzali Harsini P, Akbari S, et al. The effect of educational intervention based on PRECEDE model on health promotion behaviors, hope enhancement, and mental health in cancer patients. Clin Nurs Res. 2022;31(6):1050-6. [Link] [DOI:10.1177/10547738211051011]
| Rights and permissions | |
 |
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |