The document describes a study that applied the Health Belief Model to examine factors influencing mothers' use of Oral Rehydration Therapy (ORT) for treating childhood diarrhea. Nurses provided 59 health education sessions to 176 mothers over 3 months. Data was collected before and after the sessions. The results showed that after education, mothers had greater recognition of diarrhea complications, higher awareness of ORT benefits, and were more likely to prepare and use ORT/oral rehydration salts at home for treating childhood diarrhea. The education emphasized the severity of diarrhea, recognition of complications, and skills for preparing ORT solutions.
The document describes a study that applied the Health Belief Model to examine factors influencing mothers' use of Oral Rehydration Therapy (ORT) for treating childhood diarrhea. Nurses provided 59 health education sessions to 176 mothers over 3 months. Data was collected before and after the sessions. The results showed that after education, mothers had greater recognition of diarrhea complications, higher awareness of ORT benefits, and were more likely to prepare and use ORT/oral rehydration salts at home for treating childhood diarrhea. The education emphasized the severity of diarrhea, recognition of complications, and skills for preparing ORT solutions.
The document describes a study that applied the Health Belief Model to examine factors influencing mothers' use of Oral Rehydration Therapy (ORT) for treating childhood diarrhea. Nurses provided 59 health education sessions to 176 mothers over 3 months. Data was collected before and after the sessions. The results showed that after education, mothers had greater recognition of diarrhea complications, higher awareness of ORT benefits, and were more likely to prepare and use ORT/oral rehydration salts at home for treating childhood diarrhea. The education emphasized the severity of diarrhea, recognition of complications, and skills for preparing ORT solutions.
The document describes a study that applied the Health Belief Model to examine factors influencing mothers' use of Oral Rehydration Therapy (ORT) for treating childhood diarrhea. Nurses provided 59 health education sessions to 176 mothers over 3 months. Data was collected before and after the sessions. The results showed that after education, mothers had greater recognition of diarrhea complications, higher awareness of ORT benefits, and were more likely to prepare and use ORT/oral rehydration salts at home for treating childhood diarrhea. The education emphasized the severity of diarrhea, recognition of complications, and skills for preparing ORT solutions.
Download as DOCX, PDF, TXT or read online from Scribd
Download as docx, pdf, or txt
You are on page 1of 15
0
APPLICATION OF THE HEALTH BELIEF MODEL (HBM) IN ORAL
REHYDRATION THERAPY (ORT) EDUCATION PROVIDED BY NURSES
Olaide Bamidele Edet Department of Community Health/Nursing University of Calabar P. 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.
1
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 diarrhea 1 . 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 fact 2 . However, only about 20% of the Worlds families know enough about ORT to be able to use it 3 . 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 centers 4 . 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 strategies 5 . 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 behaviour 6 . 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.
2
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 3 rd to September 8 th , 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 T 1 X
T 2 Educational Input
Pre-test
Post/Exit Interview
3
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 barriers 6, 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). 4
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 dehydration 8,9 . 5
Fig. 1. Level of threat perception by mothers at pre-test
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 OF PREPARING ORT/SSS
Reported use in past year moderate (68%)
6
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 7
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.
8
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<0.05; Table 5). Respondents opinion was due to various reasons, for example, 38.0% said it makes the child strong, 31.3% and it replaced lost fluid, 5.7% said it restores sunken eyes, 4.0% mentioned weight gain. Mixing of SSS requires easy availability of certain materials and ingredients in the home. Table 5 shows that 92.6% of respondents had the required bottles at home, 99.4% had salt, 96.6% had spoon and 94.9% had sugar. Knowledge of how to prepare SSS increased significantly from 70.0% at pre-test to 97.7% at post-test (P<0.05). There was a significant increase in the knowledge of amount of SSS to give from 9.1% at pre-test to 29.1% at post-test. Significant number of respondents, 29.3% understands principles of mixing correctly at post-test. Among the barriers to the adoption of this innovation were: i) Negative opinion of ORT which increased from 4.9% at pre-test to 5.7% at post test, though not statistically significant. iii). Some respondents wrongly expect the ORS to stop/limit the frequency of the childs motion, 17.6% at pre-test and 22.2% at post-test. Also 27.4% of respondents reported that past SSS usage resulted in stopping the diarrhoea, 22.6% stated that it limited the frequency while 19.2% said it did not stop the diarrhoea. Modifying Factors/ Cues to Action The HBM assumes that certain variables such as demographic, socio-psychological and structural might influence ORT usage. 9
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 behaviour 12. 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 10
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 1 st (%) N=176 2 nd (%) N=176 3 rd (%) N=176 4 th (%) N=176 5 th (%) 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
11
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 P<0.05 Malnutrition 0.6 2.3 1.338 p>0.05 * 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<0.05 Bottles Salt Sugar Spoon 92.6 99.4 94.9 96.6 a a a a
Knowledge of how to Prepare SSS 70.1 97.7 7.622 P<0.05 Knowledge of SSS to give 9.1 29.1 4.893 P<0.05 Idea of correct mixing 20.5 69.3 10.60 8 P<0.05 Negative opinion SSS 4.9 5.7 0.335 P<0.05 Wrong expectation 17.6 22.2 1.083 p>0.05
a Not obtained at post-test
12
Table 6: Distribution of Respondents by Knowledge of Modifying Factors at Pre and Post Test Modifying factors/ Cues for action Pre-Test (%) N=176 Post Test (%) N=176 Z Value P Value Teething causes diarrhoea 23 2.3 6.213 P<0.001 Awareness of SSS 93 100 3.398 P<0.05 Knowledge of correct recipe 30 97.7 34.140 P<0.05 ORT skills A 96 Information sources: Health staff Media
84.6 3.1
b b
a Not obtained at pre-test b Not obtained at post-test Perceived Benefit/ Barriers Although satisfaction with ORT improved following the intervention, many constraints still existed. Many mothers were expecting ORT to stop/ limit the frequency of bowel motions, a few children could not tolerate the fluid while some remained weak despite use. In addition knowledge of volume of SSS to give at home during diarrhoea episode was poor. In a review of twenty-four correlational studies, perceived barriers and perceived susceptibility were the components of the HBM model most frequently reported as having an impact on diverse health behaviours 13 . These barriers should therefore not be glossed over by the nurse. Interactive group discussion to clarify opinions, attitudes and values could have helped in removing the barriers 5, 14. Furthermore the application of the HBM in this study has shown that the nurse should emphasize: individual childs susceptibility to diarrhoea, and its consequences, the recognition of these complications and skills in ORT preparation during client teaching sessions on diarrhoea. It is hoped that emphasis on these client factors will facilitate clients gain in ORT knowledge and skills and enhance clients adherence to ORT. The educational approach must therefore go beyond the usual health talk approach by nurses to active interactive discussion approach. 13
REFERENCES 1. Ellitot, K.M., Cutting, W.A.M and Attawell, K. (1990). Editorial, Dialogue on Diarrhoea, 41: 6.
2. Seriki, O. Adekunle, F.A. Gacke, K. and Akarakiri, A. T. F. (1983). Oral Rehydration of Infants 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, WHO Technical 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 Education Monographs, 2:328:352.
7. Brown, L. K., DiClements, R. J. and Reynolds, L. A. (1991). HIV Prevention for adolescents, 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 the treatment of acute diarrhoea 2:4, WHO/CDD/SER/80.2.
9. UNICEF, (1985). Management of diarrhoea, Oral rehydration therapy, A Manual for Nurse UNICEF, Nigeria, I.
10. Maiman, L. A. and Bocker, M. H. (1974). The Health Belief model: Origin and correlates in psychological theory. In: M.H. Bocker (ed), The Health Belief Model and Personal Health Behaviour, Thorofare; N.J., Charles B. Slack, Inc.
11. Rosenstock, I.M., Strecher, V. J. and Bocker, M.H.(1988). Social learning theory and the Health 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 preventive recommendations 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, Health Education 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: some concepts, methods and examples, Health Education Monographs, 2 (supp.) 34-60.
Paper presented at the Third International Conference on Nursing Research at the University of Ibadan, Nigeria, 15 th to 19 th , April, 1996.