Study design and sampling
This interventional study was conducted at Shahid Beheshti University of Medical Sciences (Tehran, Iran) from October 2015 to June 2016.
In this study, using the sample size formula (see Formula 1 in the Supplementary Files) and with an attrition rate of 10%, finally 110 women (55 subjects in the experimental and 55 in the control group) were considered. The random sampling method (clustering and simple random sampling) was used in this study. In order to choose from four faculties (faculties) of Shahid Beheshti University of Medical Sciences, four faculties were randomly selected and from these four faculties, two faculties were assigned as intervention group and 2 were considered as control group. Random sampling method was used to select samples from each cluster.
Inclusion & Exclusion Criteria
Being under 50 years of age, having satisfaction to participate in the study, and not having serious diseases, including gastrointestinal diseases were the inclusion criteria. Also, not willing to continue with the study, not completing the questionnaire in full, and not attending in more than two educational sessions were the exclusion criteria.
Measures
The data collection tool was a researcher-made questionnaire that to design it, the available tools, literature review and expert view were used. This tool consisted of following parts:
Part one: Demographic questions about age, gender, educational level, and economic status.
Part two: Constructs of the health belief model, which includes knowledge, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy, behavioral intent, and behavior (Table 1).
Table 1: Description of study instrument
Construct
|
No. of Items (Format)
|
Scoring (Range)
|
1) Knowledge; refers to a theoretical or practical understanding of a subject
|
11 items
(true-false-don’t know)
|
‘Correct’ response=2,
‘don’t know’ response=1, ‘incorrect’ response=0
(0-22)
|
2)Perceived Susceptibility; refers to subjective assessment of risk of developing a health problem
|
4 items/ 5-point Likert Scale
(strongly disagree to strongly agree)
|
Strongly disagree=1, disagree=2, no idea=3, agree=4, strongly agree=5
(4-20)
|
3) Perceived severity: Perceived severity refers to the subjective assessment of severity of a health problem and its potential consequences.
|
6 items/5-point Likert Scale
(strongly disagree to strongly agree)
|
Strongly disagree=1, disagree=2, no idea=3, agree=4, strongly agree=5
(6-30)
|
4) Perceived benefits: Health-related behaviors are also influenced by the perceived benefits of taking an action.
|
7 items/5-point Likert Scale
(strongly disagree to strongly agree)
|
Strongly disagree=1, disagree=2, no idea=3, agree=4, strongly agree=5
(7-35)
|
5) Perceived barriers: Health-related behaviors are also a function of perceived barriers to taking action.
|
9 items/5 point Likert Scale
(strongly disagree- strongly agree)
|
Strongly disagree=1, disagree=2, no idea=3, agree=4, strongly agree=5
(9-45)
|
6) Behavioral intention; refers to a person's perceived probability or "subjective probability” that he or she will engage in a given behavior.
|
5 items/5-point Likert Scale
(strongly disagree to strongly agree)
|
Strongly disagree=1, disagree=2, no idea=3, agree=4, strongly agree=5
(5-25)
|
7) Behavior; refers preventative behaviors associated with colorectal cancer.
|
5 items/5-point Likert Scale
(Always to never)
|
Always=5, often=4, sometimes=3, rarely=2, never=1
|
Validity and Reliability
The validity of the tool was ensured by face / content validity and its reliability was tested by test-retest and internal consistency (Cronbach's alpha). For face validity, a survey was done on 4-5 employees about the difficulty in understanding the words and phrases, the probability of misunderstanding the phrases, and lack of clarity in the meaning of the words. Some modifications were made to the tool’s questions. To determine the content validity of the questionnaire, two gastroenterologists, five health education and health promotion specialists, and one related expert were asked to complete the questionnaire. The initial questionnaire had 52 questions. The constructs of knowledge had eleven questions, perceived susceptibility constructs had four questions, perceived severity constructs had six questions, perceived benefits constructs had seven questions, perceived barriers structure had nine questions, perceived self-efficacy constructs had five questions, and the constructs of intention and behavior had five questions each. Internal consistency was used to determine the reliability of HBM structures. The Cronbach's alpha coefficient was 0.72 for all structures and was statistically acceptable. The re-test was used to ensure the reliability of the awareness variable. In this way, 15 employees completed the questionnaire twice and the ICC = 0.70 was obtained.
Intervention
Both intervention and control groups were pre-tested using the questionnaire. The analysis of educational needs determined the educational methods (educational package), and the number of educational sessions was obtained by the pre-test results. The content of each session was determined according to the samples’ learning power. Assurance about the matching of content materials with the samples’ learning power was obtained by pre-testing (pamphlets, SMS, etc) 10 employees who were not part of the study.
Educational intervention based on educational text massages: Over the course of ten days, ten text messages were sent to the employees in the intervention group at 8am, most of which had been prepared according to the educational objectives of the constructs of knowledge, perceived susceptibility, perceived benefits, perceived barriers and perceived self-efficacy.
Educational pamphlets: Two pamphlets were given to the employees during two separate sessions, along with simultaneous provision of individual counseling. There was a possibility of questioning and answering any ambiguity regarding the content of pamphlets. The first pamphlet contained sections on the signs and symptoms of colorectal cancer and the risk factors of this cancer, and the second pamphlet contained sections on methods of preventing this cancer.
Educational packages in the office automation system: Educational packages were uploaded on the staff automation system for ten days and the employees were asked to study it during the working hours.
The intervention was conducted one month and follow-up two months after the intervention. The educational contents were taken from the trusted sources of the Ministry of Health, complemented by what the staff needed to know about promoting nutritional behaviors related to the prevention of colorectal cancer. The education varied in form across the model constructs. For perceived susceptibility, the facts and figures of the incident rate of colorectal cancer were presented in the class, and for perceived severity, images of colorectal cancer problems were used. Also, for perceived barriers, educational materials were used to somehow incite the individuals to analyze the cost of optimal behavior against the costs of risks, time, etc involved in unhealthy behavior. The educational content used for perceived benefits intended to raise awareness on the usefulness of health promoting behaviors to reduce the risk of illness or to understand the benefits of healthy behaviors. In Figure 2, the research process is presented in general.
Ethical Considerations
At first, a permission was obtained from the university to conduct the study and attend the healthcare center. The samples were assured about the confidentiality of their specifications and information. They were also told that, their information will only be used for the purpose of this study and the data collection. The participants were allowed to enter and leave the study at any time. Suitable conditions were provided for a proper understanding of questions and responses for the subjects. After the end of the intervention period, the control group was also trained using the slides that were used to train the intervention group. An informed consent was obtained from the participants.
Data Analysis
Data were analyzed by SPSS software. Kolmogorov Smirnov test was used to check the normality of the data. To assess the effectiveness of intervention on variables of knowledge, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy, behavioral intention and behavior in the intervention and control groups. Two groups were evaluated in two stages, pre-test and post-test. Data were analyzed using SPSS-18 software, analysis of Covariance (ANCOVA) and independent t-test (intergroup comparisons). In this study, the confidence level of 95% and the significance level of 0.05 were considered.