Educational WhatsApp-delivered intervention based on social cognitive theory to promote leishmaniosis preventive behavior of health ambassadors: a randomized controlled trial

Abstract

Background

Multidimensional strategies can promote preventive behaviors to prevent cutaneous leishmaniosis. WhatsApp, the popular messenger of Iranians, can be used as a platform to provide health education interventions. This study aimed to investigate the effect of using an educational intervention in WhatsApp based on social cognitive theory (SCT) on the preventive behaviors of health ambassadors.

Methods

A randomized clinical trial was conducted from September 2020 to April 2021 on 220 people living in endemic areas of leishmaniosis in Mashhad Province, Iran. By the cluster method sampling, the samples were randomly divided into two intervention and control groups. The intervention was performed for the intervention group over two weeks. Data were collected using a researcher-made questionnaire based on the constructs of SCT before and after the intervention. SPSS 16 was implemented to test multiple statistical analyses.

Results

Findings from the intervention group compared with the control group showed that the scores of SCT constructs and preventive behaviors were significantly changed (P < 0.001) across time during baseline through follow-up. These changes were not significant in the control group.

Conclusions

The educational intervention based on the SCT model to promote leishmaniosis preventive behaviors is effective. This intervention module can be tested in other targeted populations in endemic areas to prevent and control leishmaniosis.

Trial registration

Iranian Registry of Clinical Trials Registry IRCT20200615047784N1, registered 02/09/2020.

Background

Leishmaniosis is a widespread disease that affects both humans and animals. It is prevalent in various regions around the world, including Africa, the Americas, and Asia. Approximately 350 million people are at risk of contracting leishmaniosis globally [1,2,3]. According to the World Health Organization (WHO), 92 and 83 countries or territories are considered endemic for cutaneous and visceral leishmaniosis, respectively [4]. Approximately one million new cases of cutaneous leishmaniosis occur annually [5]. Most cases of cutaneous leishmaniosis occur in Afghanistan, Brazil, Algeria, Colombia, Saudi Arabia, Pakistan, Syria, and Peru [6]. Iran is one of the most important regions where cutaneous leishmaniosis is observed in two common forms between humans and animals [6].

Although the death rate caused by leishmaniosis is low, this disease can lead to persistent wounds that take a long time to heal. It causes discomfort and significantly impacts the quality of life of individuals affected by the disease [7]. Due to the lack of success in vaccine production to prevent parasitic diseases such as leishmaniosis and their high prevalence, the WHO introduced health education as one of the most important elements of preventing these diseases [8]. Studies have shown that the behavior, knowledge, and attitudes of people are not suitable for the prevention of leishmaniosis [9,10,11].

Educational interventions based on empowering factors, which can be individual, interpersonal, and organizational factors, play a vital role in promoting preventive behaviors and controlling leishmaniosis [12]. Social cognitive theory (SCT) is a behavior change model that explains human behavior based on triangular causality derived from behavioral, environmental, and personal factors [9].

Considering that leishmaniosis is affected by individual, interpersonal, and environmental factors, applying SCT as a theoretical framework for intervention seems logical [13]. This theory emphasizes the dynamic interaction between people, their behavior, and their environment [14].

SCT is an interpersonal theory that emphasizes the dynamic interplay among personal factors, the environment, and behavior. The theory considers the influence of environmental factors, cognitive factors, and behavioral factors on each other, a concept known as reciprocal determinism. Environmental factors are seen as physically external to the person and provide opportunities and social support, including social factors such as family, friends, and observational learning, as well as physical factors such as weather and the availability of certain products [14]. The main constructs of SCT that are relevant to behavior change include behavioral ability (knowledge and skill), outcome expectancy (prediction of possible outcomes of a behavior), outcome evaluation (the value a person places on the possible outcomes of a particular behavior), observational learning, environment (the family or physical or social conditions surrounding the person), self-efficacy (confidence in one’s ability to pursue one’s behavior), and self-control (setting goals and planning for their chosen behaviors) [15].

Training using appropriate and modern methods can be more effective in improving the health community. Web-based educational interventions can be used to promote healthy lifestyles. Among web-based interventions, virtual social networks are considered a potential tool for health education [16]. Studies show that people can easily obtain health information related to a healthy lifestyle through Web-based interventions, such as social media platforms [17, 18].

WhatsApp is indeed one of the most downloaded programs in the world and is also very popular among Iranian users [19]. Interventions using WhatsApp are more attractive because users do not need to learn and adapt to new tools for interventions and install any additional programs on their phones. Additionally, users can freely send feedback and reminders without the need for additional time and effort. This makes it convenient for users to stay engaged with the intervention. A previous pilot randomized controlled trial (RCT) conducted in Malaysia used WhatsApp as an intervention to increase Pap smear performance in postpartum women. The study found that a three-month intervention via WhatsApp increased self-reported performance [20]. Additionally, an intervention in 2017 showed that education through WhatsApp is effective in increasing physical activity and controlling high blood pressure in adults and the elderly [21].

The health ambassador’s project was developed by the health education and promotion department of the Iranian Ministry of Health with a peer education approach. Health ambassadors in this program are people interested in participating in programs to promote physical, mental, social, and spiritual health. They receive voluntary training and use what they have learned to care for their health, family members, and society. They act as an interface between the health care system and the community to develop community health [22, 23]. Employing health ambassadors in health programs can impact the community by improving the effectiveness, quality, and impact of health programs, as well as strengthening the responsibility of families towards the health systems of the national community [24]. According to the mentioned study, education based on the SCT model through virtual social networks, such as WhatsApp Messenger, can empower individuals to make informed decisions and engage in preventive behaviors, ultimately improving the health of society.

Health ambassadors play a crucial role in promoting healthy behaviors by identifying risk factors and educating individuals. They are a key group for improving health literacy and lifestyles. However, existing studies are limited in providing actionable insights for policymakers. This study aimed to investigate the effect of educational intervention based on the Social Cognitive Theory (SCT) model using WhatsApp messenger for health ambassadors. The goal is to enhance their ability to promote healthy behaviors and improve health literacy among their families.

Methods

Study design and participants

This randomized controlled trial was conducted from September 2020 to April 2021 on 110 health ambassadors and 110 of their family members in the rural areas of Mashhad, Iran. The study was conducted and reported according to the Consolidated Standards of Reporting Trials (CONSORT) [25], (Additional file 1).

Based on Monfared’s study [26], the mean difference formula, a confidence interval of 95% (α = 0.05), and a test power of 80% estimated the minimum sample size required for each group to be 47. By accounting a 10% sample dropout rate, 55 individuals selected for each group.

$$\:\varvec{n}=\frac{{\left({\varvec{z}}_{1-\frac{\varvec{\alpha\:}}{2}}+{\varvec{z}}_{1-\varvec{\beta\:}}\right)}^{2}\left({\varvec{\sigma\:}}_{1}^{2}+{\varvec{\sigma\:}}_{2}^{2}\right)}{{({\varvec{\mu\:}}_{2}-{\varvec{\mu\:}}_{1})}^{2}}=\frac{{\left(1.96+0.84\right)}^{2}\left(12.4+7.5\right)}{{(94.5-88.5)}^{2}}=47$$

Randomization and recruitment

One of the five health care service centers of Mashhad city was selected by cluster sampling method. This selected city health center is home to 42 health houses. Within these 42 health centers, a total of 25,848 health ambassadors are actively engaged. To conduct a study, the health houses were categorized based on similar housing conditions, income levels, and access to social and support resources. Subsequently, one health house was randomly assigned to the intervention group and another to the control group. Both selected health houses have more than 55 health ambassadors. From the list of health ambassadors in each health house, 55 health ambassadors were randomly selected based on eligibility criteria. Following this selection, each health ambassador’s role in disseminating information to their families was considered, leading to the selection of a family member from each ambassador’s family. This method ensures that through the training of health ambassadors in the intervention group, indirect training is also provided for their family members. Also, constant follow-up from the researcher was conducted to ensure that none of the samples were excluded from the study.

The inclusion criteria were as follows: Completing the health ambassador form, being over 15 years of age, not having cognitive disorders, having and being able to use a smartphone, participating in training classes, and voluntary agreement to participate in the research. Participants who did not complete the questionnaires and educational sessions were excluded from the study. The study flow is illustrated in Fig. 1.

Fig. 1

CONSORT flow diagram of study sample

Data gathering tool

After presenting and elucidating the study’s goals, the participants proceeded to fill out the questionnaires. Data was collected using a self-administered multidimensional questionnaire like demographic information and items related to SCT constructs, and leishmaniosis preventive behaviors. Demographic items include age, gender, marital status, occupation status, education level, family income level, housing status of ambassadors, and their family members.

The SCT questionnaire included 37 items with 9 constructs, which were evaluated on a Likert scale (strongly agree to completely disagree), except for the awareness construct. The scoring system for the questions in the knowledge section is based on the participants’ responses to each item, with a maximum score of 3 points for a correct answer, 2 points for an “I don’t know” response, and 1 point for no response. The constructs of the SCT questionnaire include awareness (7 items), outcome expectation (5 items), outcome value (3 items), Task self-efficacy (3 items), self-efficacy to overcome obstacles (3 items), environment (3 items), situational understanding (4 items), self-control (4 items) and emotional adaptation (5 items).

The validity and reliability of the SCT questionnaire were measured in the study. The content validity of the questionnaire was assessed using the content validity ratio (CVR) and content validity index (CVI) with the input of 10 health education and health promotion specialists and 1 infectious disease specialist. The calculated CVI was 0.87, and the CVR was 0.89. The reliability of the SCT questionnaire was evaluated by administering the questionnaire to 15 health ambassadors who did not participate in the trial. The reliability was calculated using Cronbach’s alpha coefficient for each construct and overall. The results showed that Cronbach’s alpha coefficients ranged from 0.73 to 0.87 for the different constructs, indicating good reliability of the questionnaire.

The questionnaire related to measuring the health behavior regarding the prevention of leishmaniosis was measured with ten questions on a five-point Likert scale. The total score in this questionnaire was between 10 and 50, and higher scores indicated higher levels of leishmaniosis preventive behavior. Cronbach’s alpha coefficient in our study was 0.76.

Educational intervention

We used the Template for the Intervention Description and Replication checklist to conduct the intervention program [27, 28] (Additional file 2).

The application of SCT for the training of health ambassadors involved several stages: including a review of literature studies (conducting a comprehensive review of literature on SCT and its application in health ambassador training), field studies (to determine the most effective implementation method for the training) and a training model designed by a research team including researchers, health center doctors, and an expert on monitoring diseases and healthcare providers in health centers (to design the pilot training to evaluate the feasibility of the intervention).

After obtaining informed consent, the health ambassadors completed the first stage questionnaire, and their inclusion in the WhatsApp group was confirmed. The method of informing, providing training, and participating in the training process was explained to them. Furthermore, they were provided with the educational materials in print. The control group was enrolled in the waiting list and received standard health care exclusively.

The intervention group received educational interventions based on the principles of SCT. The interventions focused on promoting emotional adaptation, self-control, and self-efficacy in overcoming obstacles in twelve training sessions (Table 1). The interventions were delivered through WhatsApp. They also participated in mobile-based online group discussions for two weeks.

Table 1 Summary of education based on the SCT model constructs

The health ambassadors extended the training they received to their family members. The training materials used were assessed in alignment with the course objectives. The evaluators of the outcomes were distinct from the researchers who administered and oversaw the interventions. The efficacy of the training program was assessed immediately post-intervention and three months later through a re-administration of the questionnaire to both the intervention and control groups.

Data analysis

To analyze the data, the Kolmogorov-Smirnov test was used to check the normality of the variables. Since the data was nonparametric, the following tests were used for different groups: Mann-Whitney tests for independent groups, and Friedman’s test for dependent groups. Demographic variables were analyzed on qualitative variables. The following methods were used: mean and standard deviation for continuous variables, Chi-square test for categorical variables, and frequency and percentage for countable variables. Data analysis was performed in three stages of data collection using IBM SPSS version 26.0. The significance level for the analysis was set at 0.05.

Ethical considerations

This study was approved by the Mashhad Ethics Committee Mashhad University of Medical Sciences, Iran (IR.SUMS.REC.1395.20) and registered in the Iran Clinical Trials Registry [IRCT2015072123279N2 (02/09/2020)]. All participants underwent the informed consent procedure, during which the research objectives were thoroughly elucidated. Their data confidentiality was assured, and participants retained the right to withdraw from the study. The study results were shared with participants upon request.

Results

In the present study, 35% of the participants were male, and 65% were female. The average age of health ambassadors in the intervention group was 32.31 ± 6.61 years, while in the control group, it was 30.78 ± 5.92 years. Most of the participants (202/220, 92%) were married. In addition, most of the participants did not have a university education (200/220, 91%) and most of them were housewives (117/220, 53%). More details of demographic information can be seen in Table 2.

Table 2 Comparison of the demographic variables between the intervention and control groups

The results of the Mann‒Whitney test showed that before the intervention, there was no significant difference between the intervention and control groups in demographic variables, SCT structures, and leishmaniosis preventive behavior (p < 0.001).

The mean and standard deviation of the scores of the constructs of SCT and preventive behavior against leishmaniosis of participating health ambassadors are shown in Table 3.

Table 3 Effect of educational intervention based on SCT on health ambassadors and their family members

Based on the results of the Mann‒Whitney test, the changes in the scores of SCT structures after the intervention and three months after the intervention compared to before the intervention in the intervention group were significant (p < 0.001) (Table 3). The results of Friedman’s test showed statistically significant changes in the scores of SCT constructs during the study. The educational intervention increased the score of these constructs in the intervention group (p < 0.001) (Table 3).

The difference in leishmaniosis preventive behavior change score after the intervention and three months later was found to be significant (p < 0.001). To control for the significant difference in the scores of the constructs of knowledge, outcome expectation, understanding of the situation, environment, and emotional adaptation and behavior at the beginning of the study in the group of health ambassadors, covariance analysis was used. The results of the covariance analysis showed that despite this difference at the beginning, the intervention was effective in increasing the scores of all SCT constructs immediately after the intervention and three months after the intervention. The significance of the interaction effect of time and educational group in all structures in the results of ANCOVA repeated measures showed that the effect of educational intervention on these structures varies over time (before the intervention, immediately after the intervention, follow-up). Additionally, based on the results, changes in the leishmaniosis preventive behavior score were shown during the study (Fig. 2).

Fig. 2

Changes in the preventive behavior of leishmaniosis score during the study

Discussion

This study aimed to investigate the effect of SCT-based educational intervention using WhatsApp on leishmaniosis prevention behaviors among health ambassadors and their family members. The knowledge of the health ambassadors in this study showed improvement, which is consistent with the findings of another study [29]. The educational intervention used in the study helped participants gain a clear understanding of ways to prevent leishmaniosis, which likely influenced them to set specific goals for applying the teachings in their daily lives. By gaining knowledge about health preventive measures, the participants were able to develop a better understanding of the behaviors they needed to adapt to reduce the risk of leishmaniosis transmission. Similar to the results of previous studies, our study showed that educational intervention was effective in improving preventive behaviors and enhancing the participant’s knowledge of the importance of such behaviors in leishmaniosis prevention. Having sufficient and correct information about diseases and ways to prevent them is the most basic step to changing behavior [30, 31].

In our study, the behavioral changes observed in the intervention group can be attributed to the SCT constructs used in the study. This study used virtual discussion groups to identify potential barriers to behavior change. In some studies, it has been shown that there are problems in rural areas, such as the long distance from cities and shopping centers, traditional customs for the prevention and treatment of diseases, which make it difficult to access and use appropriate equipment and facilities for disease control [31, 32].

Self-efficacy is a key component of SCT, which refers to a person’s belief in their own ability to change behavior. In the present study, the educational program implemented in the intervention group focused on several factors that facilitated behavior change through self-efficacy and motivation to change behavior. These factors include: increasing participants’ understanding of the importance of the desired behavior and associated benefits, reducing and removing perceived barriers to adopting the desired behavior, breaking down the desired behavior into smaller, manageable steps, and increasing practical skills, which is consistent with findings from other studies [33, 34]. In the present study, the use of educational strategies based on SCT through group discussion on WhatsApp was able to help the participants in solving problems and promoting self-control and self-efficacy in overcoming obstacles. In our educational intervention, this approach has also helped in promoting behavior change and improving leishmaniosis preventive behavior among health ambassadors and their family members. Improvements in emotional adjustment construct scores were observed during the WhatsApp follow-up. This shows that the intervention not only had a positive effect on the participants’ emotional well-being and adaptation to preventive behavior against leishmaniosis, but also contributed to promote their preventive behavior against leishmaniosis. In another study, the results did not indicate the effectiveness of SCT-based intervention through smartphones in promoting physical activity of participants. Also, these researchers showed that virtual training with face-to-face meetings is more effective than virtual training alone [35].

The research revealed that utilizing WhatsApp for follow-up reminders reinforced the importance of adopting preventive behaviors and assisted participants in carrying out practical activities such as using mosquito nets and spraying plant areas. This suggests that the use of WhatsApp follow-up can be an effective tool in promoting behavior change and improving health outcomes. Similar to the findings of this study, other studies have shown that information transfer and behavior change through online messaging platforms such as WhatsApp and Facebook have been effective. These results indicate that the ease of receiving information through these online platforms is well available and can create appropriate behavior change [36]. On the other hand, in a systematic review study, it was shown that health interventions through mobile phones that have been used to manage diseases such as leishmaniosis and other neglected tropical diseases have not had obvious results and clear methodology [37].

In this research, to strengthen learning, educational materials were provided to the participants in the form of an educational package including pamphlets and tracts and a practical guide to the management of seekers on WhatsApp. In this way, the participants were able to obtain information about the disease vector, sanitary disposal of sewage, net installation, and the method of communication with people and institutions related to the management of leishmaniosis. Also, to encourage and strengthen learning and perform preventive behaviors, insect repellent spray was donated to families by the health ambassadors. These strategies helped the participants to be practically prepared for performing leishmaniosis preventive behaviors and led to the promotion of desirable preventive behaviors. Consistent with these results, other studies also show that behavior change interventions using mobile media messages can be a simple, low-cost and effective approach to behavior change [34, 38].

Strengths and limitations

The study is a cluster randomized controlled trial with a high response rate despite the COVID-19 pandemic. It utilized several important constructs of SCT as an educational intervention, delivered through face-to-face meetings and follow-ups on WhatsApp. This study is one of the few local studies that examine the effects of an intervention on leishmaniosis preventive behavior in health ambassadors. It is also the first to use educational intervention and a follow-up and reminder technique through WhatsApp to improve leishmaniosis preventive behavior. However, there are some limitations to consider. The use of self-report questionnaires may lead to under or over-reporting of outcomes, particularly regarding participants’ self-efficacy. Future studies are encouraged to use objective measures. Additionally, the evaluation of health ambassadors’ behavior in leishmaniosis prevention was conducted over three months, and longer follow-up periods may provide more accurate results. Therefore, it is recommended to continue the training program and its follow-up for a longer duration and evaluate the results over a longer period after the intervention. Finally, future studies should consider a larger sample size. This study was conducted in public health homes, which may have limited the participation of other cultures. It is important to note that the findings may differ among other populations.

Conclusion

The study demonstrates that a health education intervention based on Social Cognitive Theory and WhatsApp group follow-up is effective in increasing participation and improving leishmaniosis preventive behavior in health ambassadors and their families compared to traditional methods. It is recommended to use successful health ambassadors as trainers to support people and empower them in self-care activities, and to utilize video media and social networks in educational programs to enhance the effectiveness of education. The study suggests that this intervention should be evaluated in other populations and can also serve as fundamental data for other intervention studies.