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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


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 OF
PREPARING 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<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.
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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 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
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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
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






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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 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





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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.
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Paper presented at the Third International Conference on Nursing Research at the
University of Ibadan, Nigeria, 15
th
to 19
th
, April, 1996.

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