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Self-management Intervention Program Based on the Health Belief Model

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Experimental Study IRANIAN MEDICINE

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Arch Iran Med. April 2019;22(4):168-173
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Self-management Intervention Program Based on the Health

Belief Model (HBM) among Women with Gestational
Diabetes Mellitus: A Quazi-Experimental Study
Bahram Mohebbi, MD1; Azar Tol, PhD, MPH2; Roya Sadeghi, PhD2*; Seideh Fateme Mohtarami, MSc2; Ahmadreza Shamshiri, MD3
1
Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences,
Tehran, Iran
2
Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
3
School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran

Abstract
Background: The Health Belief Model (HBM) as a conceptual framework in health behavior research was applied to improve
self-management. This study aimed to determine the effect of theory-based intervention program among women with gestational
diabetes mellitus (GDM).
Methods: This quazi-experimental study was conducted on 110 women 17–41 years old which were divided randomly into
intervention (n = 55) and control (n = 55) groups. The intervention group received a self-management education for four sessions
lasting 35–40 minutes accompanied with a phone call as a booster. Both intervention and control groups attended a routine GDM
education program at outpatient health centers. A multi-section instrument included demographics, 28 items in HBM (CVI and
CVR were 0.83, 0.87, respectively) and self-management sections. All participants were invited to complete the questionnaire at
baseline and at three and six months after intervention. SPSS version 21 was performed for data analysis using repeated measure
ANOVA and paired t-test. P less than 0.05 was considered statistically significant.
Results: At baseline, demographics and HBM constructs revealed no significant differences between two groups (P > 0.05). After
intervention, perceived susceptibility, severity, barriers, benefits and self-efficacy revealed significant differences in the intervention
group compared with controls (P < 0.001). Self-management and HbA1c indicated significant differences in the intervention group
before and after three and six months (P < 0.001) whereas in the control group no significant differences were revealed (P > 0.05).
Conclusion: Implementing the HBM educational intervention program with focus on benefits of self-management has positive
impact on pregnant women.
Keywords: Gestational Diabetes Mellitus, Heath Belief Model, Intervention, Self-management
Cite this article as: Mohebbi B, Tol A, Sadeghi R, Mohtarami FS, Shamshiri A. Self-management intervention program based on
the health belief model (HBM) among women with gestational diabetes mellitus: a quazi-experimental study. Arch Iran Med.
2019;22(4):168–173.

Received: May 16, 2018, Accepted: February 5, 2019, ePublished: April 1, 2019

Introduction healthy lifestyle behaviors after childbirth to prevent type

Gestational diabetes mellitus (GDM) is one of the key 2 diabetes, but little is known about effective strategies to
public health problems both in developed and developing encourage healthy lifestyle behaviors for women especially
countries.1 GDM is described as any degree of glucose with their new multiple roles and maternal responsibilities.
intolerance with onset or first recognition during Based on the chronic nature of the diabetes and high
pregnancy.2 In the United State of America, 1%–14% cost of disease control, the necessity for adopting self-
of pregnant women are at risk of developing GDM3 and management behavior seems to be crucial.7,8 Studies
the rate is 1.3–18.6% in Iran.1 Women with a history of revealed strong association between promoting healthy
GDM have a 35%–60% chance of developing type 2 lifestyle habits such as weight control, physical activity
diabetes (DM).4 and healthy nutrition to reduce type 2 diabetes risk.9,10
Evidence indicated that risk of adverse outcomes of Self-management interventions framework consisting of
pregnancy including fetal macrosomia among women adopting a low glycemic index diet and increasing activity
with poor diabetes control are common.5 Lack of level seem to be successful in reducing maternal blood
appropriate diabetes control resulted in developing glucose levels and insulin resistance during pregnancy.
diabetes complications, therefore, more considerations Sequentially, maternal blood glucose control is related to
to prevent diabetes were recommended.6 Diagnosis of macrosomia reduction and maternal weight gain.1,7-10
GDM is an opportunity to engage women in performing Health Belief Model (HBM) is one of the most widely

*Corresponding Author: Roya Sadeghi, PhD; Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences,
Tehran, IR Iran. Tel: +98-2188955888, Fax: +98-188989129, E-mail: [email protected]
Intervention Based on Health Belief Model and Gestational Diabetes

used theories in the field to examine the barriers and in health center X were numbered X001, X002, X003,
foundation of a person’s participation in programs which …. Participants in the randomized trial were assigned
focus on prevention of disease and promotion of a healthy 1:1 to the intervention and control arms under restricted
lifestyle.11 The HBM enables to predict behaviors according randomized design after informed consent and collection
to constructs consisting of perceived susceptibility (discuss of baseline data. The allocation sequence was generated
about one’s belief regarding chances of getting a disease and released to the researcher on by another independent
or harmful condition related to a specific behavior), department specializes to generate research random
perceived severity ( discuss about a belief which can be sequence. Researchers, skilled data collectors, statistician
harmful as a result of specific behavior), perceived benefits were different persons. Collected data were entered into
( refer to benefits to risk reduction of getting a disease or the SPSS anonymously using an unconnected person to
harmful condition related to a specific behavior), perceived the study.
barriers (refers to beliefs which can be real or imagined and
their costs regarding new behavior), cues to action (forces Assessment of Outcomes
that make one feel the necessity to take action), and self- All demographic variables were classified according to
efficacy (feel confident in having the ability to perform a participants’ declaration. At baseline, HbA1c extracted
behavior).12 from participants’ medical records. After intervention,
To meet the research goals, the HBM was the selected it was assessed at 3 and 6 months later according to
model to guide self-management among women with study design. HBM constructs, self-management15
GDM to prevent DM after childbirth, thus, this study and HbA1c were considered as primary and secondary
aimed at evaluating self-management intervention based on outcome measures, respectively. In order to design HBM
HBM among women with GDM. Study hypotheses were: questionnaire, literature review using different databases
1) HBM constructs will be improved after intervention based on HBM and GDM concepts were conducted. Then,
compared with the controls; 2) Education based on the preliminary version of questionnaire was prepared.
HBM can improve self-management of the intervention HBM constructs (perceived susceptibility, severity,
group compared with controls; 3) The intervention group barriers and benefits, self-efficacy and cues to action)
compared to control will significantly reduce level of questionnaires were 28 items. Each item was calculated in
HbA1c and obtaining desirable diabetes control and 4) five-point scale (strongly agree 5 to strongly disagree 1)
the self-management intervention program has feasibility for five constructs whereas cues to action was measured
for women with GDM. Regarding lack of theory-based by ‘yes’ or ‘No’ answer scoring yes as “1” and No as “zero”.
studies among women with GDM as a health problem in The higher score indicated improved knowledge and their
areas under supervision of Tehran University of Medical practice-based model. The content validity was confirmed
Sciences (TUMS), Iran, our intervention-based study by 15 experts in Endocrinology, Genecology and Health
focused on exploring the effect of self-management Education and Promotion fields who were all experienced
intervention to promote women’s health in pregnancy. in health care fields. Feedback from the expert panel was
carefully reviewed. Then, 15 experts evaluated the items’
Materials and Methods content validity index (CVI) and content validity ratio
Study Design and Subjects (CVR). Items with a low CVI score (<0.79) and low CVR
This multi-center intervention quazi- experimental study score (<0.49) were removed from the scale.16 The 28 items
was conducted in outpatient health clinics affiliated to remained in the scale. The CVI and Scale CVR were 0.83
TUMS during November 2015 to December 2016. and 0.87, respectively. In order to achieve face validity,
Pregnant women who were newly diagnosed with GDM questionnaire was distributed to 30 pregnant women to
without history of any type of diabetes and expressed an assess the degree of difficulty and clarity of questions.
interest in study participation were included. Pregnant According to this pilot study, the questionnaire was
women with absence more than two educational sessions slightly modified. These participants and all information
were excluded. Eligible women aged 17 to 41 years old were omitted from the study. Reliability was tested using
were randomly assigned to either the intervention or test-retest reliability scale which assured the sameness of
control groups. A sample size of 110 women would be results in each measure by different subjects at different
required to confirm a minimum significant increase in times.17 To perform test-retest to assess stability, a sample
self-management behavior, a power of 80% with a 0.05 of 30 pregnant women was selected and Cronbach’s alphas
two-sided significant level.13,14 calculated for each construct ranged between 0.81-0.89;
perceived susceptibility (0.84), severity (0.81), barriers
Randomization (0.88), benefits (0.81), self-efficacy (0.85) and cues to
Randomization was performed alphabetically coded (A, B, action (0.87). The total Cronbach’s alpha was 0.89. Some
C, D, …) and a participant attached to each health center examples of items based on HBM constructs are presented
was given numerical codes (As an example, participants in Table 1.

Arch Iran Med, Volume 22, Issue 4, April 2019 169

Mohebbi et al

Table 1. Examples of Items Based on HBM Constructs Regarding Self-management

HBM Constructs Items

1. Getting a screening test for GDM is a good investment for my health.
Perceived benefits 2. Self-Monitoring of my blood sugar can save my life.
3. Getting diabetes control doesn’t need lots of time.

1. Getting diabetes control only gives me problems.

Perceived barriers 2. I don’t have enough time to adhere to my doctor's advice.
3. Getting diabetes control is time consuming.

1. I believe that I can adhere to a healthy diet for GDM prevention.

Perceived self-efficacy 2. I believe that I can manage my stress during pregnancy.
3. I believe that I should make regular visits to my physician.

1. Because of GDM, my baby is at risk of birth defects.

Perceived susceptibility 2. I am at risk of diabetes if I don’t have self-monitoring.
3. I am at risk of miscarriage and stillbirth if I cannot control of my blood sugar.

1. GDM, without monitoring and control, can lead to diabetes.

Perceived severity 2. GDM may lead to diabetes which make can make a women's life difficult.
3. Non-adherence of GDM treatment regimen can lead to diabetes and serious complications.

1. Because I listened to radio and television about managing GDM.

Perceived cues to action 2. Because I understood risks of diabetes from internet.
3. Because my physician told me about risks of GDM complications.

The secondary outcomes were HbA1c (index of diabetes as small booster were conducted which served as a quick
control) and diabetes self-management instrument. reference to education and reminder to study participants.
Validity and reliability of 35-items Likert self-management The content of educational programs included basic
instrument was confirmed in Iranian version according to information regarding GDM facts, figures and self-
Tol et al study.15 At the baseline, 16 Socio-demographic management based on HBM constructs like perceived
and health related questions, HBM questionnaire and self- susceptibility and severity of gestational diabetes, barriers
management instrument were completed by all participants and benefits of self-management and perceived self-
in both groups. Both intervention and control group have efficacy and self-management using incorporating cues
attended the routine health clinic-based education. In to actions. Strategies such as setting achievable goals and
addition, participants in the intervention group received use of motivational interviewing to increase self-efficacy
self-management educational program based on HBM. were also used in educational sessions. This approach
allowed women to enable, motivate, and empower to have
Educational Intervention self-management and take care of their health. During
The self-management education program was presented educational sessions, teaching methods were used such
in four sessions lasting 35-40 minutes for each during as lectures, power point presentation, role playing, group
a month. Moreover, phone calls as small booster were discussion on two specific topics entitled “healthy diet and
conducted which served as a quick reference to education healthy lifestyle”. Ways of social support from family were
and reminder to study participants. The content of considered offering empathy, concern, encouragement,
educational programs included basic information or caring to the women. Moreover, self- monitoring of
regarding GDM facts, figures and self-management blood glucose used as a way to teach participants about
based on HBM constructs like perceived susceptibility their disease using pictures and simple instructions. At the
and severity of gestational diabetes, barriers and benefits end of each session, the educator reviewed the important
of self-management and perceived self-efficacy and topics of the session and women were encouraged to ask
self-management using incorporating cues to actions. their questions and answered accordingly.
Strategies such as setting achievable goals and use of Women in the control group attended only the routine
motivational interviewing to increase self-efficacy were clinic-based education. Three and 6 months after the
also used in educational sessions. This approach allowed educational intervention, post‑tests were implemented
women to enable, motivate, and empower to have self- both in intervention and control group, so, they were
management and take care of their health. During invited to complete the questionnaire.
educational sessions, teaching methods were used such
as lectures, power point The self-management education Statistical Methods
program was presented in four sessions lasting 35-40 Kolmogorov-Smirnov test was utilized to assess the
minutes for each during a month. Moreover, phone calls normality of data distribution. Descriptive analysis was

170 Arch Iran Med, Volume 22, Issue 4, April 2019

Intervention Based on Health Belief Model and Gestational Diabetes

applied to summarize the subject’s variables. Crosstabs, engage on healthy behavior but think over the best path
frequencies and descriptive statistics were used in data to be healthier by choosing best action; that are weight
analysis. Repeated measured was used to data analysis. of balance between perceived barriers and benefits under
Level of significance was considered as P < 0.05. Data basic assumption that people are motivated for their health.
analysis performed using the Statistical Package for Social This study estimated improvement of self-management
Science version 21(IBM Corp, Armonk, NY, USA). and HbA1c of participants who received education
intervention based on the concepts of HBM compared to
Results those who just attended the routine education classes.
In this quazi-experimental study, 110 pregnant women The overall results of this study indicated that both
with GDM participated producing a response rate 100% groups of participants had a low to moderate knowledge
(n = 110). Based on Baruch study, there were two reasons related to perceived susceptibility and severity (perceived
for low responses rate might be considered including threaten) score about GDM, food choices and nutrition
lack of access to all participants and deficit to collect habits, physical activity during pregnancy and GDM self-
questionnaires and follow up the participants.18 Because of management. The educational intervention offered key
provided regular prenatal care in studied health centered points to change health behaviors by presenting suggestions
we had a chance to get access to all participants. of eating healthy, weight control and incorporating
The mean age of the participants in intervention and physical activity in daily activity. This finding suggests
control groups was 30.7 ± 6.53 and 30.78 ± 6.79 years that the educational intervention program given to the
respectively. Body mass index in intervention and control intervention group was beneficial in increasing the diabetes
groups was 27.84 ± 2.87 and 27.63 ± 4.42, respectively. knowledge based on Model constructs. Furthermore, it
Demographic characteristics tested by crosstabs, is important to note that post-tests data was obtained 3
independent t test in 2 groups by random allocation. More and 6 months after the initial educational sessions. This
than two-thirds (63.6%) of participants in the intervention issue revealed that participants were able to keep sessions
and control group had positive history of type 2 diabetes. information over an extended period of time. Moreover,
Concerning educational status, majority of women who based on the nature and methodology of current study
completed high school in the intervention and control which assessed the related variable about participants
group (74.55 % and 65.46%), respectively. The majority (subjective values and clinical indices) two times after
of participants were housewives in both intervention intervention (3 and 6 months later) revealed that HBM
and control groups (74.5% and 70.9%), respectively. based intervention compared to routine education of
There were no significant differences between two groups health centers has appropriate effectiveness which was
regarding demographic variables (P > 0.05) (Table 2). similar to Bastani study.19
Table 3 presented the significant statistical association It is obvious that women principally during pregnancy
between model constructs within and between intervention period need to receive more support and care; and women
groups after educational program (P < 0.001). Also, 3 and with especial attention like GD situation need extra
6 months after intervention, were modified in intervention attention to pass this time safely using adhering healthy
group (P < 0.001), but there were no significant changes in lifestyle as Hussain study indicated.20 In this study, it is
control group (P > 0.05). highlighted that younger pregnant women due to low
information are more susceptible to experience pregnancy
Discussion disadvantages such as GDM; this finding was in the line of
According to HBM, someone that perceived susceptibility another Iranian study findings.21
and severity of ill-health condition gets the force to According to Bandura definition about self-efficacy

Table 2. Selected Socio-demographic Characteristics of Intervention and Control Groups at Baseline

Intervention Control
Demographic Characteristics P
No. % No. %
Illiterate 5 9.09 9 10.90
High school 21 38.18 21 38.18
Level of education 0.276
Diploma 20 36.37 12 27.28
University 9 16.36 13 23.64
Yes 35 63.6 35 63.6
Family history 1.00
No 20 36.4 20 36.4
Poor 4 7.3 2 3.6
Economic status Moderate 27 49.1 23 41.8 0.432
Privileged 24 43.6 30 54.6
HbA1c (%) Mean ± SD 9.34 ± 1.62 8.82 ± 2.14 0.151

Arch Iran Med, Volume 22, Issue 4, April 2019 171

Mohebbi et al

Table 3. Score of HBM Constructs Among Participants

Six Months after Three Months after
Baseline
Model constructs P Intervention P Intervention P Group
Mean ± SD Mean ± SD Mean ± SD
77.27 ± 9.8 <0.001 69.63 ± 9.22 55.09 ± 6.27 Intervention
Perceived susceptibility <0.001 0.06
56.18 ± 6.8 55.26 ± 6.79 51.64 ± 8.05 Control
76.36 ± 10.2 67.54 ± 10.84 57.0 ± 7.67 Intervention
Perceived severity <0.001 <0.001 0.05
57.55 ± 7.69 57.36 ± 7.63 49.54 ± 8.48 Control
-28.26 ± 8.68 -19.46 ± 8.86 60.45 ± 7.02 Intervention
Perceived barriers <0.001 <0.001 0.06
1.09 ± 3.14 0.82 ± 2.84 51.91 ± 10.21 Control
80.73 ± 10.69 72.72 ± 10.66 63.18 ± 3.65 Intervention
Perceived benefits <0.001 <0.001 0.07
63.27 ± 3.56 63.73 ± 3.32 53.91 ± 8.96 Control
78.81 ± 8.86 69.73 ± 9.4 56.27 ± 10.68 Intervention
Self-efficacy <0.001 <0.001 0.09
57.45 ± 11.08 56.79 ± 10.81 47.0 ± 9.75 Control
Cues to action 85.10 ± 15.83 72.17 ± 17.48 46.35 ± 15.39 Intervention
<0.001 <0.001 0.75
48.76 ± 19.02 47.87 ± 19.57 41.13 ± 18.35 Control
84.18 ± 8.77 73.75 ± 8.7 60.31 ± 8.08 Intervention
Self-Management <0.001 <0.001 0.05
62. 6 ± 9.35 61.96 ± 7.92 47.2 ± 9.38 Control
6.97 ± 2.21 7.372 ± 2.13 9.34 ± 1.62 Intervention
HbA1c <0.001 <0.001 0.151
9.18 ± 1.64 9.26 ± 1.62 8.82 ± 2.14 Control
Intervention group: n = 55, Control group: n = 55.

concept, “is an individual ‘s belief that he/she is capable recommended.

of performing specific tasks to obtain certain goals and is a Due to GDM theory-based study, this research can
strong predictor of health behaviors”.22,23 Study participants guide further large studies in this field. The limitations
reported a high self-efficacy in 3- and 6-months post- of the study were due to lack of studies designed based
tests indicating they became confident that they could on HBM and self-management accompany with diabetes
perform health behaviors, which might have been related control and self-reporting the questionnaire by women
to education strategies, health care providers and close with GDM.
relationship between patient-heath care providers during In conclusions, our findings suggesting this theory
prenatal care. based self-management intervention can improve healthy
In this study, self-efficacy was the significant predictor for behaviors and diabetes control among women with GDM.
adopting healthy lifestyle behaviors for pregnant women In order to increase healthy lifestyle behaviors in women
with GDM, which is consistent with previous studies in with GDM, interventions with focus on reinforcing
literature supports such as Kalhor et al study that indicated self-efficacy, increasing their perceived threaten, barriers
that running intervention programs using educational and reduction, better diabetes control can lead to better self-
consulting strategies can lead to better self-management management regarding to GDM. It seems that theory-
and health improvement among pregnant women with based educational intervention focusing on diabetes risk
low self-efficacy.24 On the other hand, patient with more in GDM women, improving perceived self-efficacy to
self-efficacy experience adopting more self-management adopt healthy behaviors, identifying common barriers
behaviors which can be reachable with effective patient– to healthy lifestyle behaviors should be provided to both
provider communications.25 patients. Tailoring theory-based intervention program
As Tol study et al reported that adopting self- based on pregnant women’s need aimed at empowering
management behaviors can result in empowerment and target groups might be the way forward. This important
based on the nature of diabetes, the better empowering the achievement highlighted the importance of considering
better diabetes control. This study indicated that better skill entrance of target groups in this study. Evidence
self- management behaviors accompanied with better of this study can provide for the development of future
HbA1c. 26 GDM education and intervention programs.
Based on Matris et al successful treatments for GDM
have better health outcomes for women with GDM and Authors’ Contribution
BM, AT and RS contributed in study design and manuscript
their babies.27
drafting. SFM writing the proposal, participated in data collection.
The study results addressed that implementation of ASH participated in data analysis, commented on the analysis. All
educational intervention program based on HBM caused authors revised subsequent drafts of manuscript. RS supervised the
a significant modification in HbA1c and self-management study.
score. Based on the nature of GDM and the important
Conflict of Interest Disclosures
role of family to have a safe pregnancy termination, The authors have no conflicts of interest.
implementation of family-based intervention programs is

172 Arch Iran Med, Volume 22, Issue 4, April 2019

 Intervention Based on Health Belief Model and Gestational Diabetes

Ethical Statement Health Promotion. 3rd ed. United State: Jones and Bartlett
All study protocols were approved by the TUMS Educational Learning; 2017.
Board and received Ethical Number (IR.TUMS.REC.1394.982) 13. Jalilian F, Zinat Motlagh F, Solhi M, Gharibnavaz H.
and Iranian Registry of Clinical Trials code on 19 October 2015 Effectiveness of self-management promotion educational
(identifier: IRCT2016072612460N10). To ensure ethical issue, prior program among diabetic patients based on health belief
to requirement and data collection, the purpose of the study was model. J Educ Health Promot. 2014;3:14. doi: 10.4103/2277-
discussed and explained for both groups. Privacy and confidentiality 9531.127580.
issues were also explained and kept for both groups. There was any 14. Khiyali Z, Manoochri M, Khani Jeihooni A, Babaei
cost to participants involved to the study. All participants signed Heydarabadi A, Mobasheri F. Educational intervention on
written informed consent. preventive behaviors on gestational diabetes in pregnant
women: application of Health Belief Model. Int J Pediatr.
Acknowledgement 2017;5(5):4821-31. doi: 10.22038/ijp.2016.7750
The authors enthusiastically thank all the personnel of health centers 15. Tol A, Mohajeri Tehrani MR, Mahmoodi G, Alhani F,
of South Health Networks affiliated to TUMS for their cooperation. Shojaeezadeh D, Eslami A, et al. Development of a valid and
We would also like to thank educational chancellor of TUMS for reliable diabetes self-management instrument: an iranian
partialy funding as a part of MSPH thesis. version. Journal of Diabetes and Metabolic Disorders. 2011;
10:18-24.
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