Application of HBM

8/12/2019 Application of HBM

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APPLICATION OF THE HEALTH BELIEF MODEL (HBM) IN ORAL

REHYDRATION THERAPY (ORT) EDUCATION PROVIDED BYNURSES

Olaide Bamidele EdetDepartment of Community Health/Nursing

University of CalabarP. M. B., 1115, Calabar, Cross River State, Nigeria

The health belief model was applied to determine how mothers view ORT and their propensity

to take action when their children have diarrhoea. Nurses with training in health education exposed

176 mothers who brought their children to the ORT unit to 59 health education sessions of 25 minutes

duration each, over a three month period. Information was collected on mother and child demographic

data, availability of materials for home preparation of ORT as well as on mothers knowledge,

perception, attitudes and skills regarding the cause, treatment and prevention of diarrhea and

dehydration prior to and after exposure to the educational session. Data analysis within the framework

of health belief model showed among others that the educational process of ORT promotion by nurses

should emphasis: the seriousness and consequence of diarrhea, the recognition of these complications

and skills in ORT preparation. These findings which are related to mothers perceived

susceptibility/severity/or diarrhoea, modifying factors (demographic and cues to action), perceived

health benefits/resource and social barriers of ORT use are presented.


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Introduction

Diarrhoea is still a major cause of morbidity and mortality in under- five children in

the developing counties of the world today. Four million children die yearly from diarrhea1.

Oral Rehydration Therapy (ORT) as pre-packed oral dehydration salts or home-prepared

sugar-salt solution (SSS) coupled with continuous feeding of children, during diarrhoea

episode can prevent majority of these deaths. Studies carried out in Nigeria have further

confirmed this fact2. However, only about 20% of the Worlds families know enough about

ORT to be able to use it3.

In the developing countries, nurses are the principal professional staff in health

centers, sub-centers, and assist doctors in diarrhoea training units in secondary and tertiary

centers4. Hence nurses often handle the educational component of the ORT service to satisfy

the larger goal of the unit which is to enable mothers prevent dehydration at home and protect

the childs nutritional health by early use of oral dehydration fluid. A major challenge

therefore exists for nurses to identify and emphasize factors which will enhance mothers

adherence to ORT.

An analysis of mothers use or non-use of ORT helps in focusing health education

objectives and in the choice of appropriate strategies5. The HBM has been used frequently to

explain and predict an individuals health behaviour. It is becoming increasingly popular and

has been applied to diverse sets of health behaviour6. It provides a framework for nurses to

understand how mothers might view ORT and predict their propensity for SSS usage. This

paper describes the application of the HBM to examine the factors that determine mothers

use or non-use of ORT following ORT education provided by nurses.


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Materials and Methods

Data were collected at the Oral Dehydration Therapy (ORT) Unit of the University

College Hospital, Ibadan by the researcher and her assistant. All children with diarrhea,

accompanied by their mother/caretaker, admitted in the ORT unit for about 5-6 hours daily

from June 3rd

to September 8th

, 1986 constituted the study population. Excluded were mothers

and children previously exposed to the educational session. The researcher and her assistant

obtained oral consent from the respondents. During this period, a nurse assesses the degree of

dehydration and determines the amount of ORS solution required for dehydration based on

the childs weight

8, 9.

In addition, the nurse with training in health education engages the mothers in an

educational discussion based on educational objectives which were inferred from the UNICEF

Manual for Nurses on ORT in Nigeria. The nurse uses posters proverbs and songs to drive

home her point. The lecture is usually followed by practical demonstrations on how to prepare

the home made salt sugar solution.

The study was a quasi-experimental study by design in which pre and post measurements

were taken from participants as they passed through the ORT programme.

The instruments used for data collection were a pre-test questionnaire and an

observation checklist. The instruments had four major sub-sections. Sub-section A was used

in obtaining information on mother and child demographic data. Sub-section B elicited

information on mothers knowledge, attitude and practices in regards to diarrhea before and

T1X T2

Educational

Input

Pre-test Post/Exit

Interview


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after the educational session. Sub-section C elicited information on mothers, feelings/

thoughts about care received at the unit. Open ended questions were used to elicit accurate

and full responses from respondents. Sub-section D contained the checklist on ORT skills.

Observation was carried out on daily basis by the researcher using the checklist to

ascertain that education was actually given and to document the type and extent of education

provided. It was also used to document the skills displayed by mother during return

demonstrated at post-test.

The checklist on educational process recorded the following observation; i) Delivery

of information related to the educational programme, ii) the methods of disseminating

information, iii), the materials used, iv) the time frame, and v) the procedure of evaluating

participants.

Analysis

Frequency tables were run out on the demographic profile and socio-behavioural data.

Z test was used to verify the statistical association between variables. Significance was fixed

at 0.05 level. Calculation was done by using a scientific calculator and Epistat Statistical

programme.

Comparison tables were developed to compare the results of the pre and post-test on

four factors of the HBM that account for variation in health behaviour: perceived

susceptibility, perceived severity, perceived benefits and perceived barriers6, 7, 11.

. The effect

of cultural modifiers such as belief about causes of diarrhea which has implication for

susceptibility, as well as that of structural modifiers like awareness of SSS, correct knowledge

of SSS recipe were examined. Also examined were cues to action such as recognition of

symptoms/complications of diarrhea, source of information about ORT (Figs. 1 and 2).


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Results

Study Population

A total of 219 mothers and their 219 children who attended the ORT unit over a three

months period were included in the study, 43 (19.6%) could not be interviewed for reasons

such as language barrier, unwillingness to participate in the study, non participation in the

educational session due to babys condition.Almost all mothers (96.0%) were married, 2.8%

were never married and 1.1% were divorced. Respondents were predominantly (71.0%)

Muslims, while 29.0% were Christians. Concerning educational status 41.0% had no formal

education, 37.0% had primary education and 22.0% had post-primary education. Most

(79.5%) of the mothers were unskilled while 20.5% were semi-skilled (Table 1).

As shown in Table 1, majority (85%) of the ORT patients, were between 0 and 23

months of age out of which 56.8% were males and 43.2% were females. Most (65.3%) of the

clients, were mildly dehydrated, 17% were moderately dehydrated while only 17.6% were not

dehydrated. Oral dehydration solution was administered to the ORT patients based on the

childrens weight and level of dehydration8,9.


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Fig. 1. Level of threat perception by mothers at pre-test

MODIFYING FACTORS

1. Cultural: believe teething causes diarrhoea (23%)

2. Structural: awareness of SSS high (93%),

Knowledge of SSS recipe was low (30%)

PERCEPTION

OF DIARRHOEA

COMPLICATIONS

1. Susceptibility

- teething is common hence it could be

inferred that mothers believe

diarrhoea is common

2. Seriousness

- believe leads to dehydration (19.2%)

- believe leads to malnutrition (0.6%)-but dont know if consider these are

serious

- believe leads to death 52.3%

BENEFITS/ CONSTRAINTS FOR

RECOMMENDED ACTION

1. Benefits

Bottle (92.6%)

- Availability of salt (99.4%)Sugar (94.9%)

Spoon (96.6%)

- Positive opinion of SSS (20.1%)

2. Constraints

- low knowledge of how to mix (70%)

- some negative opinion (49%)

- SSS expected to stop diarrhoea (56%)

LEVEL OF

THREAT OF DIARRHOEA

COMPLICATIONS

Moderate

CUES TO ACTION

Recognize complications (94.6%)

Have heard of ORT before from

health staff (84.6%) & 3.1% from the

mass media.

LIKELIHOOD OF TAKING

RECOMMENDED ACTION OFPREPARING ORT/SSS

Reported use in past year moderate (68%)


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Table 1: Characteristics of Mothers/ Caretakers of ORT Patients

Material/ Caretakers

Variable

Characteristics Proportion of the sample

%

(n= 176)

Age (yrs) 20-34

< 20

81.5

7.4

Martial status Married

Never married

Divorced

96.0

2.8

1.1

Religion Muslim

Christians

71.0

29.0

Educational status

Non formal

Primary

Education

> Primary

Education

41.0

37.0

22.0

Occupational

Status

Unskilled

Semi-skilled

79.5

20.5

Educational Process

The educational session took place in an informal group setting. The venue was a

waiting area at the end of the Children Out-patient Department. The area was comfortable

and ensured privacy. Seating in form of three long benches with back rest was provided

for the mothers.

The education was given by a nurse with training in health education. The

following facilities and equipments were also available; conveniences, hand washing

basin, 2 buckets of sterile water, cups and spoons, one beer bottle and 2 coke bottles.

Fifty-nine educational sessions of 25 minutes duration each, with a mean of 8.4

minutes per person were held. Table 2 illustrates the methods/ materials employed during

the session. In 100% of the session lecture-discussion method was used. Information was


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reinforced by the use of songs in 86.4% of the session. Visual aids were used in 98.3% of

the session. Displays of photographs, real objects, models, posters were used for

illustration and for teaching ORT skills. In 77.9% of the session there was demonstration

of ORT skills. Majority (70%) of the attendees performed return demonstration. Feedback

was in the form of a 2-3 minutes question and answer period at the end of each of the

sessions.

Table 2: Educational Methods Utilized at the University College Hospital Oral

Dehydration Therapy Unit

Methods* Sessions

No. %

N=59

Lecture-discussion 59 (100.00)

Visual Aid 58 (98.3)

Song 51 (86.4)

Demonstration 47 (79.7)

Return Demonstration 47 (79.7)* Multiple responses allowed

Perception of Susceptibility/ Severity

The health belief model states that an individual will use ORT to avoid dehydration

if she feels threatened. Disease threat is composed of the two factors stated above namely

perceived susceptibility and severity. In this study the issue of susceptibility and severity

relates to the complications of diarrhoea.

As shown in Table 6 some mothers (23.3%) mentioned teething, which is normal

growth process as a cause of diarrhoea. Table 3 shows the order to severity of various

childhood health problems as perceived by mothers. Majority (89.9%) of the respondents

named diarrhoea as one of the five conditions considered serious, though only 28.4%

named it as the first. Also, 88.6% considered diarrhoea more serious than malaria.


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Table 4 shows that death was listed by 52.3% of respondents at pre-test while

61.9% did at post-test. This increase was not statistically significant. Although the session

did not emphasize malnutrition, some (2.4%) mothers mentioned it at post-test compared

to only one at pre-test.

Perceived Benefits/ Barriers to ORT Usage

Twenty point one percent of respondents had a positive opinion of ORT at pre-test

which increased significantly to 98.3% at post-test (p


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All the respondents were females with majority (1.5%) in the 20-34 age group,

7.4% were under 20 years of age (Table 2). The respondents occupation and religious

background have no consistent influence on their ability to acquire ORT knowledge and

skills. In addition, the educational level of mothers did not affect gain in knowledge of

causes and management of diarrhoea. There was no association between mothers

educational level and ability to perform ORT skills. At pre-test 23% of respondents

mentioned teething as a cause of diarrhoea which significantly reduced to 2.3% at post-

test. The post-test shows an insignificant increase in the number of mothers who

mentioned dirty feeling utensils and fly contamination of utensils as causes of diarrhoea.

Other causes of diarrhoea mentioned were overfeeding, hot stomach, watery food,

and cough. Awareness of SSS was high (93%) at pre-test and significantly increased to

100% at post-test. Respondent knowledge of correct SSS recipe was low (30%) at pre- test

but significantly increased to 97.7% at post-test. Majority (96%) of respondents have also

developed appropriate ORT skills. Knowledge of ORT through the health team was high

84.6% while through the media it was only 3.1%

Discussion

Perceived Susceptibility, Severity and Modifiers

In a prospective study carried out to evaluate the efficacy of the HBM, it was

reported that perceived severity had the largest beneficial impact on behaviour12. In this

study, prior to the educational intervention, about half of the mothers indicated that

diarrhoea leads to death while fewer mentioned other dangers like dehydration and

malnutrition. Following the intervention this number increased slightly. However,

majority of the mothers ranked diarrhoea more serious than other childhood health

conditions. It is however, not known if they attribute death to dehydration, or consider

malnutrition serious or consider their children personally susceptible to these dangers.

Hence while mothers moderately perceive diarrhoea a serious condition, perception of


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susceptibility is not known. It is not known if mothers perceive their children susceptible

to either the complication of diarrhoea or to future episodes of diarrhoea. Since perception

of susceptibility to diarrhoea is closely linked with mothers beliefs about its causes,

educational efforts should be directed at influencing deep rooted maternal beliefs about

causes of diarrhoea like teething, hot stomach, cough, watery food, newly introduced food

in order to tackle the issue of susceptibility.

Also, since many mothers already consider diarrhoea a serious problem, more

efforts should directed at making them realize that every child with diarrhoea would

become dehydrated and malnourished without prompt treatment. Efforts should also be

made to raise mothers knowledge in specific areas, for example educating mothers that

dirty utensils and fly contamination of utensils are not causes of diarrhoea.

Table 3: Mother Perception of the Seriousness of Five Childhood Health Conditions

in Order of Priority

Health

condition

1st (%)

N=176

2n (%)

N=176

3r (%)

N=176

4t (%)

N=176

5t (%)

N=176

Total % of

Responses

Diarrhoea 28.4 26.7 20.4 10.8 3.4 89.7

Fever* 19.3 22.7 12.5 11.4 7.0 72.7

Cough 14.2 13.1 13.6 13.6 5.7 60.2

Measles 12.0 4.5 8.0 4.5 8.5 37.5

Malaria 12.0 3.4 7.4 8.0 4.5 35.2

* As reported by respondents


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Table 4: Distribution of Respondents by Knowledge of Dangers of Diarrhoea

Dangers of

Diarrhoea

Pre- Test

n=176

(%)

Post-test n=176

(%)

Z

Value

P

Value

Death 52.3 61.9 1.745 p>0.05

Dehydration 19.2 33.2 8.48 P0.05

* Multiple responses allowed

Table 5: Distribution of Respondents by Perceived Benefits/ Barriers to SSS Use

Benefits/Barriers Pre Post Z Value P Value

Positive opinion of ORT 20.1 98.3 24.668 P


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Table 6: Distribution of Respondents by Knowledge of Modifying Factors at Pre and

PostTest

Modifying factors/ Cues for

action

Pre-Test (%)

N=176

PostTest

(%) N=176

Z Value P Value

Teething causes diarrhoea 23 2.3 6.213 P


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REFERENCES

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2. Seriki, O. Adekunle, F.A. Gacke, K. and Akarakiri, A. T. F. (1983). Oral Rehydration ofInfants and children with diarrhoea, Tropical Doctor, 13 (3): 120-123.

3. Grant, J. P. (1986). The State of the Worlds Children UNICEF, New York.4. World Health Organisation (1986). Report of a WHO study group: Regulatory

mechanisms for nursing training and practice, meeting primary health care needs, WHOTechnical Report Series, No. 738, Geneva

5. Green, L. W., Krouter, M., Deeds, S. and Partudge, K. (1980). Health Education Planning.A Diagnostic Approach, Mayfield Publishing Company, California.

6. Rosenstock, L. M. (1974). Historical origins of the Health Relief Model, Health EducationMonographs, 2:328:352.

7. Brown, L. K., DiClements, R. J. and Reynolds, L. A. (1991). HIV Prevention foradolescents, Utility of the Health Relief Model, AIDS Education and Prevention, 3 (1) 50-59.

8. World Health Organisation (1980). Control of diarrhoea diseases. A Manual for thetreatment of acute diarrhoea 2:4, WHO/CDD/SER/80.2.

9. UNICEF, (1985). Management of diarrhoea, Oral rehydration therapy, A Manual forNurse UNICEF, Nigeria, I.

10.Maiman, L. A. and Bocker, M. H. (1974). The Health Belief model: Origin and correlatesin psychological theory. In: M.H. Bocker (ed), The Health Belief Model and PersonalHealth Behaviour, Thorofare; N.J., Charles B. Slack, Inc.

11.Rosenstock, I.M., Strecher, V. J. and Bocker, M.H.(1988). Social learning theory and theHealth Belief Model, Health Education Quarterly, 15, 175-183.

12.Montgomery, S. B., Joseph, J.C., Bocker, M.H., Ostrow, D.G., Kessler, R.C and Kirescht,J.P.(1989). The Health Belief Model in understanding compliance with preventiverecommendations for AIDs. How useful? AIDS Education and prevention, 1, 303:323.

13.Janz, N. K and Bocjer, M. H. (1984). The Health Belief Model: A decade later, HealthEducation Quarterly, 11, 1-47, 14. A decade later, Health Education Quarterly, 11, 1-47,14.

14.Green, L.W.(1974). Towards cost-benefit evaluations of Health education planning: someconcepts, methods and examples, Health Education Monographs, 2 (supp.) 34-60.

Paper presented at the Third International Conference on Nursing Research at theUniversity of Ibadan, Nigeria, 15

thto 19

th, April, 1996.


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Application of HBM