Impact of Education Based on the Health Belief Model on the Nutritional Knowledge and Performance of Female Health Ambassadors

The nutrition of every individual is closely correlated with their physical and mental health. Adequate consumption of nutrients maintains health and increases efficiency, while improper nutrition leads to physical and mental complications. Foodborne illnesses constitute a very large group of diseases in the world and are considered to be a major health concern in different countries. Improper nutrition is an inherent element of an unhealthy lifestyle, as well as an important cause of this issue. Improper nutrition leads to the further progression of chronic diseases, such as type II diabetes, cardiovascular diseases, and cancers, which cost billions of dollars in medical care and reduce annual production. Malnutrition and obesity are among the major causes and contributing factors to mortality. Studies of the dietary patterns of Iranians have indicated significant deficiencies in the daily food consumption of various social groups. Furthermore, a national health survey has shown that Iranians consume more saturated fatty acids and energy than the recommended amount. Changing health behaviors is the greatest hope for reducing the burden of disease and mortality worldwide. The importance of womenchr('39')s nutritional health as part of the society and mothers and their impact on maintaining the health of other family members make them a suitable target group to improve nutritional behavior. Women constitute about half of the worldchr('39')s population, and their health guarantees community health and is of particular importance. With the implementation of the comprehensive program of health ambassadors in the urban and rural health centers in Iran, women were considered as the main educators of the family. The majority of health ambassadors are women, who are often selected from among the covered families by various healthcare units. Female health ambassadors are the housewives or employed women who help improve community health by receiving education and passing it on to other family members and the population under their care. Studies have indicated that using the patterns and theories of behavior change could increase the likelihood of the higher impact of health education programs by considering the individual and environmental characteristics that influence behaviors. Researchers have used multiple models for behavioral change, with the training primarily based on an educational model, so that the initiation and continuity of the training would be more effective. The health belief model is an effective model to provide education on various aspects of health, including nutritional behaviors. It is a waiting value model that emphasizes decision balance. The present study aimed to evaluate the effect of nutrition education based on the health belief model on the nutrition knowledge and performance of female health ambassadors.

This study was conducted as an evaluation research with effect analysis and a pretest-posttest design on the female health ambassadors of the health centers of Saqez, Iran in 2019. In total, 48 subjects were selected via simple random sampling using a random numbers table. Sampling started on November 5, 2019 and ended on December 12, 2019. A written training program in the field of nutrition based on the health belief model was implemented in three sessions (120 minutes each). Data were collected using the structured questionnaire of the Iranian Ministry of Health and Medical Education, which was designed in 2011 in collaboration with Tehran University of Medical Sciences (NUTRI-KAP). The questionnaire was completed by the participants before the training intervention and one month after the training in three sections containing questions on demographic characteristics (age, education level, marital status, occupation status, number of family members, and history of working as a health ambassador), nutrition knowledge, and nutrition performance regarding the basic principles of nutrition, food groups, nutrient sources, and nutritional needs at different stages of life. The reliability of the tool was measured using the retest method. For this purpose, the tool was completed by 18 individuals with the same characteristics as the research community (not among the research samples) and re-completed by the same individuals two weeks later. Based on these data, the reliability of the tool was calculated using the Kuder-Richardson formulas. The reliability for knowledge was estimated at 83% and 97% for performance, which indicated the acceptable reliability coefficient. The validity of the educational content was also examined by three faculty members of the School of Nursing and Midwifery, and corrections were made based on their opinions. In terms of ethical considerations, the required permit was obtained from the Ethics Committee of Iran University of Medical Sciences, and the necessary coordination was also made with Kurdistan University of Medical Sciences. The research process was explained to the participants, and they were morally informed that participating in the research was voluntary. In addition, the female health ambassadors were assured of the confidentiality of their personal information. After completing the training sessions and data collection, data analysis was performed in SPSS version 16 using descriptive and inferential statistics. With regard to the descriptive statistics, frequency distribution tables were used for the qualitative variables, and the numerical indices of minimum, maximum, mean, and standard deviation were used for the quantitative variables. As for the inferential statistics, paired t-test was used, and the P-value of less than 0.05 was considered significant in all the statistical analyses.

Before the intervention, the mean score of the nutrition knowledge and performance of the participants was 18.39 ± 4.38 and 8.81 ± 1.87, respectively, which reached 24.70 ± 4.41 and 12.27 ± 2.67, respectively after the intervention. A significant difference was observed before and after the intervention in terms of knowledge (effect size: 1.43; P<0.001) and performance (effect size: 1.52; P<0.001). Moreover, the normality of the research variables was confirmed based on skewness and kurtosis.  

According to the results, the nutrition knowledge and performance of the female health ambassadors improved after the educational intervention based on the pattern of the health belief model, and the effects would persist even after the training. Given the efficiency, cost-effectiveness, and efficacy of this model, it could be used as a framework for nutrition educational programs alongside other educational methods in every healthcare center. It is also recommended that educational programs based on this model be developed and implemented for female health ambassadors on a larger scale, and model- and theory-based educational interventions are also suggested for this group, particularly training based on the health belief pattern.