An educational program based on the PRECEDE-PROCEED model for promoting behavior related to low back health was successfully developed and implemented via two methods, in-person and social media. Evaluation of the program showed that all components improved over the 3-month follow-up for both delivery types and over the 6-month follow-up for the social media intervention, while two components improved over the 6-month follow-up for the in-person intervention (enabling factors and behavior).
Our educational program was in line with previous literature, which acknowledged that the use of community-based participatory research models to guide intervention development can contribute to more engaging and effective health behavior interventions [29–32]. A fundamental assumption of the PRECEDE-PROCEED model is the active participation of its intended audience, that is that the participants will take an active part in defining their own problems, establishing their goals and developing their solutions . This is supported by a systematic review which advocated for the use of social or behavioral theories in the prevention of musculoskeletal injuries . Steinmetz et al., showed interventions based on the Theory of Planned Behavior on average, were successful in changing variables such as attitude and behavior . The results of Ebadifard' et al’s., study indicated the effectiveness of an in-person educational intervention based on a PRECEDE-PROCEED model combined with self-management theory improved self-care behaviors in patients .
In our study, nurses’ knowledge and attitude towards LBP increased over the 3-month period for both interventions. Nurses are knowledgeable regarding health-promoting activities such as physical activity, stress management, and maintaining healthy relationships. However, this knowledge may not translate into nurses’ own self-care or health behavior . Our result was supported by Janssens’ study which showed an increase in knowledge and attitude of the care staff following a healthcare program . As well as, this finding supported through other studies. In these studies, improved knowledge and attitude (pain management, self-care, lifestyle, mental health, oral health) was achieved following educational intervention delivered by in-person and web-based [37–43]. Similarly the result of McNamara’ study et al., showed the acute pain educational program intervention improved nurses' knowledge and attitudes towards pain assessment and management over the 6 weeks . At the 6-month follow-up, nurses’ knowledge and attitude in the in-person and attitude in the social media group was reduced. Schaller et al. compared two educational methods in physical activity (movement coaching; phone and web and low-intensity control; using two oral presentations). They found that at 6-month follow-up there were no statistically significant between-group differences in physical activity . It seems face-to-face education or a booklet is not sufficient for enhancement of knowledge. There is a need to use an educational method can be used at any time and place and a social media delivery can be more effective in the long-term.
The educational program led to increasing self-efficacy over 3-months. maintenance at 6 months was more effective with the program being delivered via social media. In a study by George et al, the findings suggested the use of two types of in-person education (Dedicated Education Unit and Traditional Clinical Education) had a significant increase in self-efficacy scores post clinical education in both groups . Also Thompson’ study support the effect of social media intervention to improve self-efficacy. Thompson showed that the online intervention in nursing students were associated with a statistically significant increase in self-efficacy on bullying behavior . At 6-months follow-up, self-efficacy decreased among the in-person group. It seems that using a program with easy access will help to maintain self-efficacy. However, in-person group did not have access to educational materials after the intervention ended.
In our study, there was a moderate positive correlation between self-efficacy and behavior. Higher self-efficacy score indicated increased health behavior. These results were supported by Fida' study et al, who found self-efficacy was an important protective factor against negative behavior in the workplace . Self-efficacy can potentiate an effect on learning new behavior. Indeed, self-efficacy is defined as one’s perceived capability for learning or performing actions at designed levels . Self-efficacy is hypothesized to influence behaviors and environments and in turn be affected by them [49, 50]. People with higher levels of self-efficacy tend to choose more challenging tasks, persist in personal behaviors when encountering difficulties, confront adversities with courage, and have higher levels of confidence . Self-efficacy is extensively applied in health behavior-related fields, on patients suffering from chronic pain, and workplace incivility and burnout in nursing [48, 52]. A systematic review demonstrates that interventions that modify attitudes, norms, and self-efficacy are effective in promoting health behavior change . Likewise self-efficacy can enhance self-care behavior in patients .
Irvine demonstrated that a theoretically based stand-alone mobile-web intervention that tailors content to users’ preferences and interests can be an effective tool in self-management of low back pain and health behavior . Zachary' study discovered the effect of an E-learning module in addition to attitudes, confidence and knowledge, on clinical skills chronic low back pain in older adults .
Nursing leaders can be concerned with improving participation in health-promoting behaviors not only because it is a workplace health issue, but because it is potentially a financial and patient safety issue. Fortunately, we saw an increase in the enabling factors over the 3 and 6 months’ follow-up in both of groups. This suggests that management factors and hospital policies can play a major role in the adoption and promotion of health behaviors. Leaders and managers can provide the environment for exercise facilities and comfortable spaces for managing workplace stress. Ross’ study supports the results of our study. The results provided strategies in the nursing workplace to improve the health of staff nurses by increasing health-promoting behaviors . The social relationship between colleagues, reward, and satisfaction from the outcome of adopting the behavior, and the role of colleagues are effective factors in improving health behaviors. The effect of these factors has observed over the 3-months follow-up in both groups. But over the 6-months follow-up decreased in the in-person group. We provided the certification to participate in the intervention as a reward. After the intervention, we encouraged participants to maintain the behavior through the website and recalled the role of colleagues in promoting the behavior. Perhaps because of the lack of interaction at the end of in-person education, the role of the reinforcing factors was diminished and individuals had not acted as incentives for one another.
The result showed behavior score was improved over 3-month after the intervention. This is in line with the findings of Maghbouli et al., from the effect of an educational intervention in healthy behaviors of the nursing students to prevent LBP . Even a qualitative study also noted interactive websites for people with chronic pain lead to improved health literacy, self-efficacy, empowerment, improvements in physical exercise and overall quality of life . However, in our study the social media intervention was more successful in improving behavior than in-person intervention over the 6-month follow-up. Literature showed the mobile-web program (FitBack) in adults performed better on behavior of self-management of low back pain, and worksite outcomes at 4-month follow-up. Further, indicated greater improvement at 4-month follow-up on patient activation, constructs of the theory of planned behavior, and attitudes toward pain .