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Volume 11, Issue 5 (2023)
Health Educ Health Promot 2023, 11(5): 723-731 |
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Received: 2024/01/19 | Accepted: 2024/04/4 | Published: 2025/05/15
Received: 2024/01/19 | Accepted: 2024/04/4 | Published: 2025/05/15
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Impact of a Blended Educational Intervention on COVID-19 Preventive Behavior in Teachers. Health Educ Health Promot 2023; 11 (5) :723-731
URL: http://hehp.modares.ac.ir/article-4-73501-en.html
URL: http://hehp.modares.ac.ir/article-4-73501-en.html
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Introduction
Since its emergence in December 2019, Coronavirus disease (COVID-19) has spread globally and become a global concern. COVID-19, which is spread by droplets and direct contact from human to human and is known to cause emergent respiratory infections and ranges from colds to acute severe respiratory syndrome, has imposed a global burden on health and the economy that has never been seen before. It has resulted in more than 1.4 million deaths in 220 countries or territories as of November 29, 2020 [1]. While it appears that the whole world is looking forward to the arrival of safe behavior, the adherence to COVID-19 prevention by the general public remains uncertain [2].
In the Eastern Mediterranean region, Iran has the highest incidence and mortality of COVID-19 [3-5]. On February 19, 2020, the first case of death from COVID-19 was reported in Iran, and the infection spread rapidly [6, 7]. As of January 26, 2020, 1,183,182 definite cases and 54,308 deaths due to COVID-19 have been reported in Iran [8]. The main ways of transmitting coronavirus are by inhaling the infected person’s respiratory droplets and being in close contact with the infected person or their secretions [9]. Even though several types of vaccines protect against COVID-19, the best way to avoid infection is to avoid exposure to this virus [10, 11]. Implementation of the community-based knowledge recommended by the World Health Organization (WHO) for prevention is crucial [12]. COVID-19 preventive behaviors include using a face mask, washing hands frequently with soap and water, covering the mouth and nose with a handkerchief when coughing and sneezing, avoiding touching eyes, mouth, and nose with a sitting hand, avoiding close contact with infected people, and maintaining social distance [11].
Undoubtedly, the COVID-19 epidemic has affected everyone, including teachers, and caused many challenges [13, 14]. In a study in the United States, teachers rated the negative impact of COVID-19 on themselves as moderate [15]. It is important to protect older teachers with an underlying illness because they are a high-risk group for COVID-19 [13, 15]. Teachers should be trained on how to deal with COVID-19 and properly implement health guidelines for the high incidence and mortality of COVID-19 in Iran and the lack of specific treatment. Primary prevention increases knowledge based on scientific evidence creates the proper attitude, and creates COVID-19 preventive behaviors among people, especially teachers. Therefore, considering teachers’ health because of their relationship with many students and having an effective role in them and their parents’ mindsets seems essential; The meaning of the phrase prevention is better than cure sheds light on the path.
The Health Belief Model (HBM) is a psychosocial model for behavioral change. It is more often used to describe the relationship between health beliefs and health behaviors. HBM assumes that individuals’ participation in prevention, early detection, and treatment measures for a specific health problem is depended on their perception that they are at risk of this condition, even if they do not exhibit symptoms (perceived susceptibility). They recognize that COVID-19 is a significant health problem with serious consequences (perceived severity); They believe in the benefits of suggested preventive measures (perceived benefits) and recognize that the benefits outweigh the common barriers associated with these measures (perceived barriers). Furthermore, they believe they have the motivation and ability to engage in a healthy lifestyle [16].
According to the above, teachers’ health beliefs, behaviors, and knowledge about preventive behaviors are important. Changing the health beliefs regarding the infectious disease epidemic may deeply root the importance of self-efficacy in healthy behavior regarding COVID-19. The educational intervention content leveled them up with the latest updates about COVID-19's way of transmission, signs and symptoms, and preventive behaviors.
Therefore, promoting preventive behavior-related COVID-19 with an appropriate educational method is important. Individual enabling factors such as level of literacy, socio-economic status, age, etc. as well as access-limiting situations such as the COVID-19 pandemic and lockdowns affect educational method selection. Furthermore, choosing the proper training method in line with using a fit change behavior conceptual framework is as important too. The present study was one of the first studies that approached behavior change in the early waves of the COVID-19 pandemic in Iran. Understanding the cognitive factors affecting corona-preventing behaviors in the early waves due to the high perceived fear and sensitivity in people required the design of a curriculum based on the theory and framework of behavior change. On the other hand, in terms of facilitating educational programs by providing training both in online and offline ways blended learning was designed. The current study aimed to investigate the effect of an educational intervention based on the HBM about COVID-19 on teachers' knowledge, health beliefs, and behaviors.
Materials and Methods
Study design
This randomized controlled trial was conducted on elementary school teachers of Karaj City, Iran, in 2021. Comprehensive sampling was followed to include all below 60 female teachers who were residents of Karaj, Alborz Province, Iran (140 teachers). The cluster sampling method was used for sampling. First, two districts were randomly selected from the four districts affiliated with the Karaj Education Organization (districts 3 and 4). Then, one of these two areas was assigned to the intervention group (district 3) and the other to the control group (area 4) by lottery method. Then, from each of these two districts, 12 primary schools were randomly selected by an externally trained researcher (Figure 1). Teachers from selected schools were invited to participate in this study, taking into account the inclusion and exclusion criteria, set by the teachers of these schools during a telephone or in-person call after a brief description of the subject of the study and its objectives. Written and online consent was obtained from them.
![src=./files/hehp/images/HTML_Publish/73501/f1.png]()
Figure 1. Consort diagram
Data collection tools
Data were collected using a validated questionnaire [17]. It has two sections: Part I: Socio-demographic data, designed to collect data such as age, educational level, residence, work experience, and history of COVID-19. Part II: Assessment of teacher’s knowledge regarding COVID-19: Researchers developed it after reviewing current literature. It included the COVID-19 definition, signs and symptoms, mode of transmission, and World Health Organization recommendations. Part III: Health belief model scale; To assess teacher’s beliefs regarding COVID-19. Researchers developed it after reviewing current literature to examine perceived susceptibility (8 items), perceived severity (5 items), perceived benefits (5 items), perceived barriers (6 items), cues to action (4 items) and self-efficacy (11 items). In each item, the teachers have to choose one of five alternatives: Strongly agree=5, agree=4, indifference=3, don't agree=2, and strongly don't agree=1. Part IV: Assessment of teachers’ behavior regarding COVID-19: Teachers’ likelihood to engage in healthy behaviors regarding COVID-19. In this item, the teachers have to choose one of five alternatives: Always=5, often=4, sometimes=3, rarely=2, and never=1. The researchers developed the instrument, and then it was tested for face, content, and construct validity by 15 experts in health education, health care providers, and nursing fields. Instrument reliability was conducted using Cronbach's Alpha coefficient test (r=0.78) and Intra-Class Correlation (ICC=0.75). A pilot study was carried out on 20% of the participants. The pilot study's goal is to determine the instruments' clarity and validity. Based on the findings of the pilot study, no instrument modifications were made.
Procedure
The content of the BEHTA intervention was not individually tailored to each participant, as all participants were homogenous in terms of socio-cultural status. Therefore, the educational contents generally included: 1) Basic health information about the coronaviruses and global timeline of COVID-19, including statistical facts such as COVID-19 prevalence and mortality, when the COVID-19 test will be performed; 2) Introducing the correct ways of implementing COVID-19 preventive behaviors such as wearing a face mask, frequent hand washing, and maintaining social distance; 3) Information about accessibility and availability of local healthcare centers regarding COVID-19 testing and care; 4) Information on how to prevent coronavirus spreading by disinfecting surfaces; 5) Stories, myths, misunderstandings, pseudo-knowledge that describe teachers' overcoming socio-cultural barriers to preventive behaviors regarding COVID-19; 6) When a person should be visited by a doctor; 7) The benefits of obeying preventive behaviors correctly (Table 1).
Table 1. Educational content for BEHTA
![src=./files/hehp/images/HTML_Publish/73501/t1-1.png]()
![src=./files/hehp/images/HTML_Publish/73501/t1-2.png]()
The educational intervention was designed and conducted based on the HBM through four sequential phases:
Assessment phase: Assessment of teachers' knowledge, health beliefs and behavior regarding COVID-19 through using the developed tools as an online pretest. The results of the pre-test were analyzed to reveal teachers' training needs for COVID-19.
Planning phase: According to the results of the needs assessment and in light of the relevant literature, the investigators designed an educational intervention in the form of a blended educational program, and then it was independently evaluated by external peer reviewers. The educational intervention emphasized the areas of teacher’s knowledge and health beliefs about COVID-19.
Educational phase: Because of closures in Iranian schools at the time of the COVID-19 pandemic, all the educational intervention was conducted via three online platforms. Our intervention is named BEHTA, abbreviated for Behavior Education Health Teachers Awareness. Actually, the BEHTA intervention was designed as a blended education. In other words, BEHTA’s educational content was delivered through a specifically designed website available at www.behta-tmu.ir, holding virtual and group discussion classes via an online platform called Big Blue Bottom (BBB) supported by Tarbiat Modares University, and using a popular social network messenger (such as WhatsApp) for multimedia messages. Teachers in the intervention group were provided with educational content by accessing the BEHTA website (Behta-tmu.ir) with a password. To increase their knowledge regarding COVID-19, they were allowed to receive all the contents of the website just for two weeks. After this period, access was denied and they had to take part in an online class to share their experiences, beliefs, and attitudes regarding COVID-19 in a group discussion. Accordingly, each Wednesday at 10:00 a.m., four 45-minute online class discussions were moderated by two mentors identified as a healthcare provider and a nurse affiliated with health centers in Tehran. Participants also agreed to receive multimedia messages each day for four weeks at 8:00 a.m. They also, received a reminder notification for the online class participation through their social media (such as WhatsApp) one hour before the class would begin. To enhance participants’ adherence to the BEHTA intervention program, we bought internet service for their smartphones. The subjects were committed to refusing to check educational content and messages about the COVID-19 pandemic received by other platforms during the performance of the study.
Evaluation phase: A follow-up test was conducted immediately and 12 weeks after the one-month intervention using the same pre-test tools for intervention groups. It was an online questionnaire, and the results were collected using the self-report method.
In this study, the control group did not receive intervention. The subjects of the control group participated in the pre and post-test with basic and ordinary information, achievable through mass media such as television, newspapers, and social networks. Therefore, an online post-test was provided to the control group immediately after completing the questionnaire and 12 weeks later, using the same questionnaire in the pre-test stage. Due to the usefulness of the planned education, the interventions were provided to the control group, after evaluation of the findings.
Data analysis
After data collection was completed, it was entered into SPSS 16 software to perform the required analysis. Descriptive statistics such as frequency, percentage, and mean±SD were used to describe the data. Differences between the intervention and control groups were tested using Chi-square, Fisher exact, and independent t-test.
Findings
There was no significant difference (t=0.306; df=138; p=0.76) between the mean age of the intervention (44.74±8.50) and the control (44.33±7.48) groups. Also, there was no significant difference (t=1.949; df=138; p=0.053) between the mean job experience of the intervention (20.99±8.56) and the control (17.96±9.78) groups. There were no statistically significant differences between intervention and control groups concerning their demographic characteristic (Table 2).
Table 2. Comparing the sociodemographic characteristics frequency (the numbers in parentheses are percentages) between the intervention (n=70) and control (n=70) groups
![src=./files/hehp/images/HTML_Publish/73501/2.png]()
There were no statistically significant differences between the intervention and control groups in all areas of knowledge assessed before the intervention. On the contrary, immediately and 12 weeks after the intervention, significant differences were observed between the intervention and control groups in knowledge (Table 3).
Table 3. Comparing the knowledge score regarding COVID-19 mean between the intervention (n=70) and control (n=70) groups before, immediately and 12 weeks after the intervention
![src=./files/hehp/images/HTML_Publish/73501/3.png]()
Before the intervention, there were no statistically significant differences between the intervention and control group concerning perceived susceptibility, perceived severity, perceived barriers, perceived benefits, cues to action, self-efficacy, and total health beliefs (p<0.05). Immediately and 12 weeks after the intervention, there were statistically significant differences between intervention and control groups in all elements of the health belief model and the total health beliefs score (p<0.05; Table 4).
Table 4. Comparing the Health Belief Model (HBM) constructs scores mean between the intervention (n=70) and control (n=70) groups before, immediately and 12 weeks after the intervention
![src=./files/hehp/images/HTML_Publish/73501/4.png]()
Since its emergence in December 2019, Coronavirus disease (COVID-19) has spread globally and become a global concern. COVID-19, which is spread by droplets and direct contact from human to human and is known to cause emergent respiratory infections and ranges from colds to acute severe respiratory syndrome, has imposed a global burden on health and the economy that has never been seen before. It has resulted in more than 1.4 million deaths in 220 countries or territories as of November 29, 2020 [1]. While it appears that the whole world is looking forward to the arrival of safe behavior, the adherence to COVID-19 prevention by the general public remains uncertain [2].
In the Eastern Mediterranean region, Iran has the highest incidence and mortality of COVID-19 [3-5]. On February 19, 2020, the first case of death from COVID-19 was reported in Iran, and the infection spread rapidly [6, 7]. As of January 26, 2020, 1,183,182 definite cases and 54,308 deaths due to COVID-19 have been reported in Iran [8]. The main ways of transmitting coronavirus are by inhaling the infected person’s respiratory droplets and being in close contact with the infected person or their secretions [9]. Even though several types of vaccines protect against COVID-19, the best way to avoid infection is to avoid exposure to this virus [10, 11]. Implementation of the community-based knowledge recommended by the World Health Organization (WHO) for prevention is crucial [12]. COVID-19 preventive behaviors include using a face mask, washing hands frequently with soap and water, covering the mouth and nose with a handkerchief when coughing and sneezing, avoiding touching eyes, mouth, and nose with a sitting hand, avoiding close contact with infected people, and maintaining social distance [11].
Undoubtedly, the COVID-19 epidemic has affected everyone, including teachers, and caused many challenges [13, 14]. In a study in the United States, teachers rated the negative impact of COVID-19 on themselves as moderate [15]. It is important to protect older teachers with an underlying illness because they are a high-risk group for COVID-19 [13, 15]. Teachers should be trained on how to deal with COVID-19 and properly implement health guidelines for the high incidence and mortality of COVID-19 in Iran and the lack of specific treatment. Primary prevention increases knowledge based on scientific evidence creates the proper attitude, and creates COVID-19 preventive behaviors among people, especially teachers. Therefore, considering teachers’ health because of their relationship with many students and having an effective role in them and their parents’ mindsets seems essential; The meaning of the phrase prevention is better than cure sheds light on the path.
The Health Belief Model (HBM) is a psychosocial model for behavioral change. It is more often used to describe the relationship between health beliefs and health behaviors. HBM assumes that individuals’ participation in prevention, early detection, and treatment measures for a specific health problem is depended on their perception that they are at risk of this condition, even if they do not exhibit symptoms (perceived susceptibility). They recognize that COVID-19 is a significant health problem with serious consequences (perceived severity); They believe in the benefits of suggested preventive measures (perceived benefits) and recognize that the benefits outweigh the common barriers associated with these measures (perceived barriers). Furthermore, they believe they have the motivation and ability to engage in a healthy lifestyle [16].
According to the above, teachers’ health beliefs, behaviors, and knowledge about preventive behaviors are important. Changing the health beliefs regarding the infectious disease epidemic may deeply root the importance of self-efficacy in healthy behavior regarding COVID-19. The educational intervention content leveled them up with the latest updates about COVID-19's way of transmission, signs and symptoms, and preventive behaviors.
Therefore, promoting preventive behavior-related COVID-19 with an appropriate educational method is important. Individual enabling factors such as level of literacy, socio-economic status, age, etc. as well as access-limiting situations such as the COVID-19 pandemic and lockdowns affect educational method selection. Furthermore, choosing the proper training method in line with using a fit change behavior conceptual framework is as important too. The present study was one of the first studies that approached behavior change in the early waves of the COVID-19 pandemic in Iran. Understanding the cognitive factors affecting corona-preventing behaviors in the early waves due to the high perceived fear and sensitivity in people required the design of a curriculum based on the theory and framework of behavior change. On the other hand, in terms of facilitating educational programs by providing training both in online and offline ways blended learning was designed. The current study aimed to investigate the effect of an educational intervention based on the HBM about COVID-19 on teachers' knowledge, health beliefs, and behaviors.
Materials and Methods
Study design
This randomized controlled trial was conducted on elementary school teachers of Karaj City, Iran, in 2021. Comprehensive sampling was followed to include all below 60 female teachers who were residents of Karaj, Alborz Province, Iran (140 teachers). The cluster sampling method was used for sampling. First, two districts were randomly selected from the four districts affiliated with the Karaj Education Organization (districts 3 and 4). Then, one of these two areas was assigned to the intervention group (district 3) and the other to the control group (area 4) by lottery method. Then, from each of these two districts, 12 primary schools were randomly selected by an externally trained researcher (Figure 1). Teachers from selected schools were invited to participate in this study, taking into account the inclusion and exclusion criteria, set by the teachers of these schools during a telephone or in-person call after a brief description of the subject of the study and its objectives. Written and online consent was obtained from them.
Figure 1. Consort diagram
Data collection tools
Data were collected using a validated questionnaire [17]. It has two sections: Part I: Socio-demographic data, designed to collect data such as age, educational level, residence, work experience, and history of COVID-19. Part II: Assessment of teacher’s knowledge regarding COVID-19: Researchers developed it after reviewing current literature. It included the COVID-19 definition, signs and symptoms, mode of transmission, and World Health Organization recommendations. Part III: Health belief model scale; To assess teacher’s beliefs regarding COVID-19. Researchers developed it after reviewing current literature to examine perceived susceptibility (8 items), perceived severity (5 items), perceived benefits (5 items), perceived barriers (6 items), cues to action (4 items) and self-efficacy (11 items). In each item, the teachers have to choose one of five alternatives: Strongly agree=5, agree=4, indifference=3, don't agree=2, and strongly don't agree=1. Part IV: Assessment of teachers’ behavior regarding COVID-19: Teachers’ likelihood to engage in healthy behaviors regarding COVID-19. In this item, the teachers have to choose one of five alternatives: Always=5, often=4, sometimes=3, rarely=2, and never=1. The researchers developed the instrument, and then it was tested for face, content, and construct validity by 15 experts in health education, health care providers, and nursing fields. Instrument reliability was conducted using Cronbach's Alpha coefficient test (r=0.78) and Intra-Class Correlation (ICC=0.75). A pilot study was carried out on 20% of the participants. The pilot study's goal is to determine the instruments' clarity and validity. Based on the findings of the pilot study, no instrument modifications were made.
Procedure
The content of the BEHTA intervention was not individually tailored to each participant, as all participants were homogenous in terms of socio-cultural status. Therefore, the educational contents generally included: 1) Basic health information about the coronaviruses and global timeline of COVID-19, including statistical facts such as COVID-19 prevalence and mortality, when the COVID-19 test will be performed; 2) Introducing the correct ways of implementing COVID-19 preventive behaviors such as wearing a face mask, frequent hand washing, and maintaining social distance; 3) Information about accessibility and availability of local healthcare centers regarding COVID-19 testing and care; 4) Information on how to prevent coronavirus spreading by disinfecting surfaces; 5) Stories, myths, misunderstandings, pseudo-knowledge that describe teachers' overcoming socio-cultural barriers to preventive behaviors regarding COVID-19; 6) When a person should be visited by a doctor; 7) The benefits of obeying preventive behaviors correctly (Table 1).
Table 1. Educational content for BEHTA
The educational intervention was designed and conducted based on the HBM through four sequential phases:
Assessment phase: Assessment of teachers' knowledge, health beliefs and behavior regarding COVID-19 through using the developed tools as an online pretest. The results of the pre-test were analyzed to reveal teachers' training needs for COVID-19.
Planning phase: According to the results of the needs assessment and in light of the relevant literature, the investigators designed an educational intervention in the form of a blended educational program, and then it was independently evaluated by external peer reviewers. The educational intervention emphasized the areas of teacher’s knowledge and health beliefs about COVID-19.
Educational phase: Because of closures in Iranian schools at the time of the COVID-19 pandemic, all the educational intervention was conducted via three online platforms. Our intervention is named BEHTA, abbreviated for Behavior Education Health Teachers Awareness. Actually, the BEHTA intervention was designed as a blended education. In other words, BEHTA’s educational content was delivered through a specifically designed website available at www.behta-tmu.ir, holding virtual and group discussion classes via an online platform called Big Blue Bottom (BBB) supported by Tarbiat Modares University, and using a popular social network messenger (such as WhatsApp) for multimedia messages. Teachers in the intervention group were provided with educational content by accessing the BEHTA website (Behta-tmu.ir) with a password. To increase their knowledge regarding COVID-19, they were allowed to receive all the contents of the website just for two weeks. After this period, access was denied and they had to take part in an online class to share their experiences, beliefs, and attitudes regarding COVID-19 in a group discussion. Accordingly, each Wednesday at 10:00 a.m., four 45-minute online class discussions were moderated by two mentors identified as a healthcare provider and a nurse affiliated with health centers in Tehran. Participants also agreed to receive multimedia messages each day for four weeks at 8:00 a.m. They also, received a reminder notification for the online class participation through their social media (such as WhatsApp) one hour before the class would begin. To enhance participants’ adherence to the BEHTA intervention program, we bought internet service for their smartphones. The subjects were committed to refusing to check educational content and messages about the COVID-19 pandemic received by other platforms during the performance of the study.
Evaluation phase: A follow-up test was conducted immediately and 12 weeks after the one-month intervention using the same pre-test tools for intervention groups. It was an online questionnaire, and the results were collected using the self-report method.
In this study, the control group did not receive intervention. The subjects of the control group participated in the pre and post-test with basic and ordinary information, achievable through mass media such as television, newspapers, and social networks. Therefore, an online post-test was provided to the control group immediately after completing the questionnaire and 12 weeks later, using the same questionnaire in the pre-test stage. Due to the usefulness of the planned education, the interventions were provided to the control group, after evaluation of the findings.
Data analysis
After data collection was completed, it was entered into SPSS 16 software to perform the required analysis. Descriptive statistics such as frequency, percentage, and mean±SD were used to describe the data. Differences between the intervention and control groups were tested using Chi-square, Fisher exact, and independent t-test.
Findings
There was no significant difference (t=0.306; df=138; p=0.76) between the mean age of the intervention (44.74±8.50) and the control (44.33±7.48) groups. Also, there was no significant difference (t=1.949; df=138; p=0.053) between the mean job experience of the intervention (20.99±8.56) and the control (17.96±9.78) groups. There were no statistically significant differences between intervention and control groups concerning their demographic characteristic (Table 2).
Table 2. Comparing the sociodemographic characteristics frequency (the numbers in parentheses are percentages) between the intervention (n=70) and control (n=70) groups
There were no statistically significant differences between the intervention and control groups in all areas of knowledge assessed before the intervention. On the contrary, immediately and 12 weeks after the intervention, significant differences were observed between the intervention and control groups in knowledge (Table 3).
Table 3. Comparing the knowledge score regarding COVID-19 mean between the intervention (n=70) and control (n=70) groups before, immediately and 12 weeks after the intervention
Before the intervention, there were no statistically significant differences between the intervention and control group concerning perceived susceptibility, perceived severity, perceived barriers, perceived benefits, cues to action, self-efficacy, and total health beliefs (p<0.05). Immediately and 12 weeks after the intervention, there were statistically significant differences between intervention and control groups in all elements of the health belief model and the total health beliefs score (p<0.05; Table 4).
Table 4. Comparing the Health Belief Model (HBM) constructs scores mean between the intervention (n=70) and control (n=70) groups before, immediately and 12 weeks after the intervention