Bioscience Biotechnology Research Communications

An International  Peer Reviewed Refereed Open Access Journal

P-ISSN: 0974-6455 E-ISSN: 2321-4007

Bioscience Biotechnology Research Communications

An Open Access International Journal

Reza Sadeghi1, Mostefa Shamsi2, Fatemeh Baghernezhad Hesary3 and Victoria Momenabadi4*

1PhD Candidate Scholar of Health Education and Health Promotion, Sirjan Faculty of Medical Sciences, Kerman University of Medical Sciences (KMU), Kerman, Iran

2MSc in Health Services Administration, Kerman University of Medical Sciences, Kerman, Iran

3PhD Candidate Scholar of Health Education and Promotion, Social Determinates of Health Research, Birjand University of Medical Sciences, Birjand, Iran

4PhD Candidate Scholar of Health Education and Health Promotion, Department of Health Education and Health Promotion, Faculty of Public Health, Shiraz University of Medical Sciences, Shiraz, Iran

Corresponding author Email: vici.momeni@yahoo.com

Article Publishing History

Received: 12/06/2017

Accepted After Revision: 10/09/2017

ABSTRACT:

Health promotion behaviors can promote physical and psychological health in individuals and population, especially in Afghan Pregnant Women. Therefore, this study performed to recognize the Effect of Educational intervention Based on Health Promotion Model (HPM) on promoting behavior in Safe Delivery among Afghan Pregnant Women in Sirjan city, 2016. This was a quasi- experimental study. 120 Pregnant Afghan Women attending health centers in Sirjan city were selected to participate in this study: (60 in intervention group and 60 in control group). The intervention was conducted over two sessions in 60 minutes. Data were collected by a validated and reliable questionnaire (39 questions) before intervention and three months after intervention. Data was analyzed by chi-square, Fisher’s exact, paired t-test and independent t-test. The average scores of both groups indicated that health-promoting behavior, perceived self-efficacy, perceived barriers, perceived benefits, perceived social support and interpersonal norms, had no meaningful differences before the intervention. But after education, the average scores of all variables increased meaningfully in the intervention group (P<0.001). But, there was no increase or significant difference in the control group. HPM was effective in educating Afghan Pregnant Women. Therefore, it is suggested that HPM can be used to improve the safe delivery in Afghan women.

KEYWORDS:

Health Promotion Model, Afghan Pregnant Women, Safe Delivery, Sirjan

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Sadeghi R, Shamsi M, Hesary F. B, Momenabadi V. Effect of Educational Intervention Based on Health Promotion Model (HPM) on Promoting Behavior in Safe Delivery Among Afghani Pregnant Women Refugees in Sirjan, Iran. Biosc.Biotech.Res.Comm. 2017;10(3).


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Sadeghi R, Shamsi M, Hesary F. B, Momenabadi V. Effect of Educational Intervention Based on Health Promotion Model (HPM) on Promoting Behavior in Safe Delivery Among Afghani Pregnant Women Refugees in Sirjan, Iran. Biosc.Biotech.Res.Comm. 2017;10(3). Available from: https://bit.ly/2ISHmqu


Introduction

Maternal and infant mortality due to complications of pregnancy is a very important health indicator. Whatever the percentage of deliveries in non-sanitary and out-of-hospital increase, the mortality rate of infants and pregnant women and neonatal tetanus infection will increase too (Wax et al., 2010). Great deals of investment have been spent to reduce maternal and infant mortality rate and to reach the World Health Organization goal in the country, and also maternity and childbirth facilities have been built in various parts of Iran (Karyani et al., 2015).

One of the most vulnerable groups in this regard is refugees Afghan pregnant women. Decades of war and internal conflict in Afghanistan has led to migrate a large number of Afghans to neighboring countries, including Iran. One of the problems of these immigrants in Iran is the high rates of non-safe and non-sanitary delivery despite the availability of maternity facilities (Kalafi et al., 2002). Even in the Sirjan city in spite of the existence of maternity and women’s specialists and well-equipped midwifery, 67% of Afghan women deliver babies at home in unsanitary conditions and by non-specialists, while this rate of giving birth at home is only 1% in developed countries (Sadeghi et al., 2015b). But in some developing countries, this ratio reaches to 50% or even more (Gloyd et al., 2001).

In the different studies, several reasons have been mentioned for giving birth at home, including high cost of delivery in the hospital, Fear of the hospital, husband’s opposition, wrong culture, mother’s emotional support at home and fear of cesarean section (Salehi and Pour, 2002).

The changing of this risky behavior in Afghan pregnant women requires proper education. The value of education depends on its Effectiveness and changing or creation of health behaviors, which is possible with the proper use of theories and educational models (Glanz et al., 2008). Theories identify the main factors that had influenced in question behaviors, specify the relationships between these factors, and outline the circumstances, the manner and the time of the occurrence of these relationships. Therefore, theories are useful in identifying the elements that should be considered as the main axis of interventions (Sadeghi et al., 2016). Health Promotion Pender Model is one of the comprehensive and predictive models which is used to study the health promoting behaviors and provides a theoretical framework for discovering affected factors in these behaviors (Pender, 2011).

The determinants of health promotion behaviors concepts in this model include: 1) individual experiences and Characteristics, 2) emotions and behavioral specific cognition, and 3) behavioral outcomes. The concept of individual experiences and Characteristics is a concept that directly or indirectly influences on the behaviors through cognition and behavioral emotions, including personal factors and previous related behaviors. While the concept of cognition and behavioral specific emotions directly influence on the behaviors and include constructs such as perceived benefits and barriers, perceived self-efficacy, behavioral emotions, interpersonal influences, and situational influences (Pender, 2011).

Professor Pender has identified models that have influenced on explanation of behavior in over 50% of the researches, including personal factors (perceived health status), perceived benefits, perceived barriers, perceived self-efficacy and interpersonal influences (Social support) (Pender, 2011).

Several studies have confirmed the effectiveness of this model. In this regard, a study by Morowati Sharifabad et al aimed at optimizing the health promotion model indicated that perceived self-efficacy was the most important determinant of health promotion behaviors and also perceived religious support was directly and indirectly have been effective by influencing on perceived self-efficacy, perceived benefits, perceived barriers, and perceived importance of health promotion behaviors (Morowati et al., 2005). The results of Maglione et al. showed that individuals with higher levels of social support, self-efficacy and with commitment of planning are more physically active (Maglione and Hayman, 2009). Considering the importance of the safe delivery and due to the high rate of delivery at Afghani homes; it seems that a similar study has not done in this regard. Therefore, the present study aimed to investigate the effect of educational intervention using the health promotion model in promoting behavior of Safe delivery among refugees Afghan Pregnant Women in Sirjan city in 2016.

Materials and Methods

This quasi- experimental study was conducted in 2016. The research environment was the health centers of Sirjan city and the study population was Afghani pregnant women. Subjects were selected by simple random sampling. The sample size was calculated by using the ratio difference formula by considering the confidence level of 95%, a power of 80%, and about 3/3 differences in score before and after the intervention with a standard deviation of 7 and 52 subjects in per group, but the sample size was finally calculated as 60 subjects with consideration of 10 percentage of possible number of subjects dropping out in each group (Mohammadipour et al., 2015).

The subjects were selected based on the inclusion criteria which were as follows: Afghans, being pregnant in the third up to fifth month and resident of Sirjan city; the exclusion criteria were: without chronic disease such as pregnancy diabetes and high blood pressure, non-residence until the end of pregnancy and unwilling to participate in the study. Data collection tool was a self-administered questionnaire. The questionnaires were set anonymously and encoded and were arranged in three parts. The first part contains the demographic characteristics including 5 questions about age, education, occupation, number of pregnancies, and residence. The second part was related to the evaluation of the structures of the Pender Health Promotion Model. This part contains seven questions for perceived benefits, seven questions of perceived barriers, seven questions of perceived self-efficacy, six questions of perceived interpersonal norms, and six questions of perceived social support structures. The third part was related to the measurement of safe delivery behavior. The questions were scored as follows. questions about perceived benefits, perceived barriers, perceived self-efficacy, interpersonal norms and perceived social support were scored 1-3 by Likert’s trilogy scale as agree (score 3) to disagree (score 1), The range of scores for perceived benefits, perceived barriers and perceived self-efficacy were from 7 to 21 and for interpersonal norms and perceived social support was from 6 to 18. Also, the assessments of safe delivery behavior were of yes/no type questions.

In this research the analyzing the validity of the content method was used for the analyzing the validity of the questionnaires. The questionnaire was approved by healthcare professionals to examine the issue’s comprehensiveness. The re-test method was also used in the distance of 2 weeks to determine the reliability of the study. The correlation coefficient has calculated between the two-time responses as follows, for perceived benefits, 0.79, perceived barriers, 0. 77, perceived self-efficacy, 0.74, perceived interpersonal norms, 0.84 and perceived social support, 0.81.

The method was as follows the researchers randomly divided subjects into intervention and control groups after the selection them based on inclusion criteria. At first, the pre-test questionnaire was completed by the interviewer, then the education program was conducted for the intervention group. Educational content included the definition of pregnancy, maternity care, and also the benefits of safe delivery.The educational program was conducted for four groups of 15 subjects (60 subjects in intervention group), which consisted of two, one-hour training sessions in a one-month interval that were held in a lecture and group discussion. Also, an individual counseling was held for a pregnant woman and their family. The educational classes were held in health centers and health care homes. After three months of conducting the classes, post-test questionnaires were completed by the researcher for the patients in the intervention and control groups.

The current research has been approved by the Ethics Committee of the Kerman University of medical sciences (ethics code: IR.KMU. REC. 1396.11). All the participants were voluntarily and consciously participated in the study and they were given the assurance that the information has been collected only in order to be used for research and will remain confidential and the written testimonial had been gotten from all of the participants in order to participate in the study. Meanwhile, although the control group was not under educational intervention, but after completing the post-test, educations were provided to them with the same quantity and quality.

Data were analyzed by using Chi-square, Fisher’s exact test, independent t-test and paired t-test through SPSS version 16. The significance level was considered less than 0.05.

Results And Discussion

In this study, 120 participants were randomly divided into two groups, intervention (n = 60) and control (n = 60) then the mean and standard deviation of the ages of subjects in the study and control groups were analyzed and they were respectively 24.83 ± 9.43 and 25.12 ± 9.26 years old. This difference based on independent t-test did not show significant differences in both intervention and control groups (P = 0.426). Also other demographic characteristics of the population did not show any significant differences between the two groups (Table 1).

Table 1: Comparing some variables among the refugees Afghan Pregnant Women in Sirjan city in the control and intervention groups
Variable intervention Group

(n= 60) Number (%)

Control Group

(n= 60) Number (%)

*p-value
Occupation Housewife 55 (50.4) 54 (49.6) 0.251
Employed 5 (45.4) 6 (54.6)
Pregnancy status First pregnancy 12 (52.1) 11 (47.9) 0.925
More than one pregnancy 48 (49.4) 49 (50.6)
Education Literate 10 (47.6) 11 (52.4)  

0.712

illiterate 50 (50.5) 49 (49.5)
Residence City 28 (49.1) 32 (50.8) 0.283
Village 29 (50.9) 31 (49.2)
*Chi-square test

The results showed that there wasn’t any significant difference between the mean scores of perceived benefits, perceived barriers, perceived self-efficacy, interpersonal norms and perceived social support before the intervention in the intervention and control groups, but after the intervention, the differences were significantly clear and Scores were increased (Table 2).

Table 2: The mean scores of refugees Afghan Pregnant Women in Sirjan between the control and intervention groups regarding Safe Delivery before and after the intervention
  Before intervention (n=60) p-value* After intervention (n=60) p-value*
Intervention group Mean± SD Control group Mean± SD Intervention group Mean± SD Control group Mean± SD
perceived benefits 12.14±2.21 11.94±1.87 0.212 18.42±0.64 12.02±1.56 <0.001
Perceived barriers 18.82±2.72 18.41±3.09 0.367 14.77±1.46 18.25±3.11 <0.001
perceived
self-efficacy
12.94±3.23 12.64±4.37 0.055 17.18±1.39 12.29±3.85 <0.001
interpersonal norms 10.19±2.61 10.71±2.83 0.412 14.21±1.67 11.14±2.78 <0.001
perceived social support 7.24±2.43 7.58±2.67 0.216 14.12±3.73 7.68±2.83 <0.001
*Independent t-test

The statistical results showed that in the study group, there was a significant increase between the mean scores of perceived benefits, perceived barriers, perceived self-efficacy, interpersonal norms and perceived social support before and after the intervention, and also the
educational intervention was effective (Table 3) .

Table 3: The comparison of the variables. The mean scores of refugees Afghan Pregnant Women in Sirjan between the control and intervention groups regarding Safe Delivery before and after the intervention
Intervention group (n=60) p-value* Control group (n=60) p-value*
Before Intervention

Mean± SD

After intervention Mean± SD Before Intervention Mean± SD After intervention Mean± SD
perceived benefits 12.14±2.21 18.42±0.64 <0.001 11.94±1.87 12.02±1.56 0.021
Perceived barriers 18.82±2.72 14.77±1.46 <0.001 18.41±3.09 18.25±3.11 0.424
perceived self-efficacy 12.94±3.23 17.18±1.39 <0.001 12.64±4.37 12.29±3.85 0.356
interpersonal norms 10.19±2.61 14.21±1.67 <0.001 10.71±2.83 11.14±2.78 0.172
perceived social support 7.24±2.43 14.12±3.73 <0.001 7.58±2.67 7.68±2.83 0.481
*Paired t-test

The results also showed that the safe delivery behavior in the intervention group have increased from 23% to 57% after the educational intervention.

Afghan women carry out childbirth at home and in unhealthy conditions, due to traditional beliefs and misconceptions of them and their followers, which unfortunately can lead to the death of mother or infant and may lead to complications such as neonatal tetanus.
Therefore, in order to control this important and fundamental dilemma, we evaluated the relevant training based on the health promotion model to promote safe delivery behavior.The findings showed significant increase in the safe and hygienic delivery of Afghan women from 23% to 57% in Sirjan city.

In the health promotion model, in the intervention group, all of the constructs of the model showed significant differences after the intervention.

In the health promotion model, perceived benefits are as a direct stimulus action of behavior and the adoption of an action to prevent the problem or action on a health behavior are dependent on its perceived benefits (Pender, 2011). The most important perceived benefits of safe delivery of Afghan pregnant women respectively included the baby’s health, their health, and the prevention of unwanted childhood complications at home. In the present study, the average of perceived benefits scores of patients in the intervention group has increased significantly than in the control group after the education, which was consistent with the results of similar studies (Morovati, 2007, Leslie et al., 2000, Sadeghi et al., 2014). But the results of the study of Ghaffari et al was inconsistent to the present study and did not indicate an increase in the average score of perceived benefits (Ghafari, 2007).

In the present study, financial problems, lack of medical insurance and lack of access to facilities were respectively the most important obstacles in the target group. The significant reduction in the average score of perceived barriers after educational intervention and inter-sectional collaboration in the health care system indicates that the education has a positive effect on removing the perceived barriers in the intervention group. The studies of Nowroozi et al. (Noroozi et al., 2011) and Karimi et al. (Karimi and Eshrati, 2012), which were conducted with this model, indicate that educational intervention are effective in reducing perceived barriers.

Self-efficacy is referred to a person’s confidence to his ability in performing an action (Bandura, 2006). In the present study, the average of self-efficacy score of the experimental group after the intervention was significantly increased, which were consistent with the studies of Morowati et al. (Morowati et al., 2005) and Sadeghi et al. (Sadeghi et al., 2015a), but they contradicted by the findings of Kinsler et al. (Kinsler et al., 2004).

Also, in the study, after the education, the average scores of the interpersonal norms of the intervention group were significantly higher than in the control group, which was consistent with the results of the studies of Chenari et al (Chenary et al., 2013) and Nosratabadi et al (Nosratabadi et al., 2015). In the present study, perceived social support was considered as the most important determinant of the behavior of delivery at home, which this issue was arisen from the influences of family and relatives on this unhealthy behavior. But after educational sessions for the participants and their relatives, the average score in the intervention group was significantly higher than in the control group, which is consistent with the results of conducted studies with this model (Lusk et al., 1997, Norouzi et al., 2010). According to this research and the findings, it is suggested that a precise educational program should be carried out based on the health promotion model for Afghan pregnant women, their spouses and their relatives, and planners should train them by using individual and group educational methods, in order to solve their financial and health problems, and to prevent the risks of unsafe deliveries at home.

One of the limitations of this study was the problem of Afghan women’s language and their accent, which was solved by Afghan inquirer and educator, as well as Unwillingness of some of the women to participate in the study, which it was solved by convincing them through local clerks and Afghan elders. Another limitation of the study was the financial and insurance problems of Afghan women, which it was reduced by inter-agency co-ordinations.

Acknowledgments

Researchers acknowledge the Faculty of Medical Sciences Research Committee of Sirjan city and Research Deputy of Kerman medical university, related staffs in health centers of Sirjan as well as all Afghan pregnant women who are participating in this study.

Authors’ Contributions

RS helped design the study, carried out data collection, data analysis, and drafted the manuscript. VM carried out the statistical analysis and interpretation. MS conceived the study, supervised the data collection and analyses, and helped draft the manuscript. BB edited and commented on the final draft. All authors read and approved the final manuscript.

Conflict of Interest

The authors declare no conflicts of interest.

References

  1. bandura, A. 2006. Guide For Constructing Self-Efficacy Scales. Self-Efficacy Beliefs Of Adolescents, 5.
  2. Chenary, R Noroozi, A. & Tahmasebi, R 2013. Effective Factors Of Health Promotion Behaviors Based On Health Promotion Model In Chemical Veterans Of Ilam Province In 2012-13. Www. Sjimu. Medilam. Ac. Ir, 21, 257-267.
  3. Ghafari, M. 2007. Comparing The Efficacy Of Health Belief Model And Its Integrated Model In Aids Education Among Male High School Students In Tehran. A Thesis For Degree Of Phd, Tehran: Tarbiat Modares University.
  4. Glanz, K., Rimer, B. K. & Viswanath, K. 2008. Health Behavior And Health Education: Theory, Research, And Practice, John Wiley & Sons.
  5. Gloyd, S., Floriano, F., Midwife, M. S., Chadreque, M. A., Nyangezi, J. M. & Platas, A. 2001. Impact Of Traditional Birth Attendant Training In Mozambique: A Controlled Study. Journal Of Midwifery & Women’s Health, 46, 210-216.
  6. Kalafi, Y., Hagh-Shenas, H. & Ostovar, A. 2002. Mental Health Among Afghan Refugees Settled In Shiraz, Iran. Psychological Reports, 90, 262-266.
  7. Karimi, M. & Eshrati, B. 2012. The Effect Of Health Promotion Model-Based Training On Promoting Students’ Physical Activity. Journal Of Kermanshah University Of Medical Sciences (J Kermanshah Univ Med Sci), 16, 192-200.
  8. Karyani, A. K., Azami, S. R., Rezaei, S., Shaahmadi, F. & Ghazanfari, S. 2015. Geographical Distribution Of Gynecologists And Midwives In Kermanshah Province (2008-2013). Journal Of Kermanshah University Of Medical Sciences (J Kermanshah Univ Med Sci), 19, 294-302.
  9. Kinsler, J., Sneed, C. D., Morisky, D. E. & Ang, A. 2004. Evaluation Of A School-Based Intervention For Hiv/Aids Prevention Among Belizean Adolescents. Health Education Research, 19, 730-738.
  10. Leslie, E., Fotheringham, M., Owen, N. & Veitch, J. 2000. A University Campus Physical Activity Promotion Program. Health Promotion Journal Of Australia: Official Journal Of Australian Association Of Health Promotion Professionals, 10, 51.
  11. Lusk, S. L., Ronis, D. L. & Hogan, M. M. 1997. Test Of The Health Promotion Model As A Causal Model Of Construction Workers’ Use Of Hearing Protection.
  12. Maglione, J. L. & Hayman, L. L. 2009. Correlates Of Physical Activity In Low Income College Students. Research In Nursing & Health, 32, 634-646.
  13. Mohammadipour, F., Izadi, T. A., Sepahvand, F. & Naderifar, M. 2015. The Impact Of An Educational Intervention Based On Pender’s Health Promotion Model On The Lifestyle Of Patients With Type Ii Diabetes.
  14. Morovati, M. 2007. The Effectiveness Of Modified Health Promotion Model In Change Of Health Promotion Behaviors In The Yazd Elderly. Tehran: Tarbiat Modares University.
  15. Morowati, S., Ghofranipour, F., Hidarnia, A. & Babaee-Ruchi, G. 2005. Modification Of Health Promotion Model And Its Application Together With Adult Education Theory In Changing Health Promoting Behaviors Of Older Adults In Yazd. J Med Tarbiat Modares U-Ni, 21, 54-8.
  16. Noroozi, A., Tahmasebi, R. & Ghofranipour, F. 2011. Effect Of Health Promotion Model (Hpm) Based Education On Physical Activity In Diabetic Women. Iranian Journal Of Endocrinology And Metabolism, 13, 361-367.
  17. Norouzi, A., Ghofranipour, F., Heydarnia, A. & Tahmasebi, R. 2010. Determinants Of Physical Activity Based On Health Promotion Model (Hpm) In Diabetic Women Of Karaj Diabetic Institute. Ismj, 13, 41-51.
  18. Nosratabadi, M., Halvaiepour, Z. & Sadeghi, R. 2015. Exploring The Relationship Between Social Capitals, And Social Support With Mother’s Health In Mothers Referring To Health Centers Of Sirjan City: A Structural Model. Journal Of Urmia Nursing And Midwifery Faculty, 13, 781-790.
  19. Pender, N. J. 2011. Heath Promotion Model Manual.
  20. Sadeghi, R., Khanjani, N., Hashemi, M. & Movagheripour, M. 2014. Using Health Belief Model To Prevent Skin Cancer Among Farmers. Iranian Journal Of Health Education And Health Promotion, 2, 215-222.
  21. Sadeghi, R., Mazloomy, S., Hashemi, M. & Rezaeian, M. 2016. The Effects Of An Educational Intervention Based On The Health Belief Model To Enhance Hiv-Preventive Behaviors Among Male Barbers In Sirjan. Journal Of Rafsanjan University Of Medical Sciences, 15, 235-246.
  22. Sadeghi, R., Rezaeian, M., Khanjani, N. & Iranpour, A. 2015a. The Applied Of Health Belief Model In Knowledge, Attitude And Practice In People Referred For Diabetes Screening Program: An Educational Trial. Journal Of Rafsanjan University Of Medical Sciences, 13, 1061-1072.
  23. Sadeghi, R., Rezaeian, M. & Mohseni, M. 2015b. The Effect Of An Educational Program Based On Basnef Model On Breast Self-Examination Practice Of 20-45-Year-Old Women In Sirjan City: A Training Trial Study.
  24. Salehi, M. & Pour, Z. G. 2002. Reasons For Zahedan’s Women For Not Referring To Delivery Ward For Child Delivery. Journal Of Reproduction & Infertility, 3.
  25. Wax, J. R., Lucas, F. L., Lamont, M., Pinette, M. G., Cartin, A. & Blackstone, J. 2010. Maternal And Newborn Outcomes In Planned Home Birth Vs Planned Hospital Births: A Metaanalysis. American Journal Of Obstetrics And Gynecology, 203, 243. E1-243. E8.