Journal of Diabetes Mellitus, 2015, 5, 181-189
Published Online August 2015 in SciRes.
How to cite this paper: Vahidi, S., Shahmirzadi, S.E., Shojaeizadeh, D., Haghani, H. and Nikpour, S. (2015) The Effect of an
Educational Program Based on the Health Belief Model on Self-Efficacy among Patients with Type 2 Diabetes Referred to
the Iranian Diabetes Association in 2014. Journal of Diabetes Mellitus, 5, 181-189.
The Effect of an Educational Program Based
on the Health Belief Model on Self-Efficacy
among Patients with Type 2 Diabetes
Referred to the Iranian Diabetes Association
in 2014
Sheida Vahidi1, Sima Esmaeili Shahmirzadi2, Davoud Shojaeizadeh2, Hamid Haghani3,
Soghra Nikpour4*
1Treatment Affairs, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2Department of Health Education & Promotion, School of Public Health, Tehran University of Medical Sciences,
Tehran, Iran
3Department of Biostatistics, School of Management and Information, Iran University of Medical Sciences,
Tehran, Iran
4Center for Nursing Care Research, School of Nursing and Midwifery, Iran University of Medical Sciences,
Tehran, Iran
Email: *
Received 9 July 2015; accepted 3 August 2015; published 6 August 2015
Copyright © 2015 by authors and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
Background: Patient self-efficacy is one of the most important factors in treating and overcoming
disease. Objective: The aim of this study was to evaluate the effect of an educational program
based on the health belief model on self-efficacy among patients with type 2 diabetes referred to
the Iranian Diabetes Association in 2014. Method: A randomized controlled clinical trial was con-
ducted. Eighty patients with type 2 diabetes were selected randomly by the double block sample
method. They were then divided into two groups of intervention and control (40 patients in each
group) by random allocation. Data were collected by a questionnaire based on the Health Belief
Model and self-efficacy. The data were gathered two months after the educational program was
held. The educational program was designed on the basis of data collected in the pre-test phase.
Then, the educational program was executed for the intervention group in 8 sessions (each 30
minutes) using lectures and an educational booklet. Data analysis was done with Chi-square Test,
Pearson’s correlation, Independent samples T-test and paired T-test. The significance level was
Corresponding author.
S. Vahidi et al.
considered at 0.05. Results: Before intervention, no significant difference was detected between
the two groups. However, after intervention all variables were significantly different except for
perceived threat. Moreover, there were significant linear relationships between Self-efficacy and
all Health Belief Model components after the educational intervention in both groups (p < 0.05).
Conclusion: The educational program based on the health belief model increased self-efficacy in
type 2 diabetes mellitus patients.
Self-Efficacy, Health Belief Model, Type 2 Diabetes
1. Introduction
Nowadays, diabetes has become the worlds largest epidemic [1]. Diabetes mellitus is a common chronic dis-
order in the western world. In 2007, an estimated 246 million adults aged 20 - 79 years were diagnosed with di-
abetes, compared to 194 million in 2003 [2]. Recent data from the National Survey of Risk Factors for Non-
Communicable Diseases in Iran reported that 7.7% of Iranian adults had diabetes, half of which had remained
undiagnosed , and that another 16.8% of the Iranian population had impaired fasting glucose. The increasing
prevalence of diabetes among employed adults is an ominous sign for a developing nation; predictions are that
diabetes will be the leading cause of disease burden among Iranians in the future [3]. The health belief model
(HBM) is one of the most widely used models in the public health theoretical framework. It is a useful and ap-
plicable framework for developing and implementing programs to encourage healthy behaviors [4] [5]. Patient
self-efficacy is a key element in the prevention and treatment of disease [4] [6]. Patientsself-care behaviors are
determined by their health beliefs [7]. Although professionals have tried to explain the value of self-care beha-
viors to patients, they are often not achieved by them [8]. On the other hand, studies have shown that patient
self-efficacy and health beliefs are highly correlated with each other.
According to previous studies, all the components of the HBM change significantly after educational inter-
ventions, confirming that HBM constructs cause changes that improve patient behavior in taking care of them-
selves [9] [10]. So the effects of self-efficacy on all HBM components and educational programs are necessary
for improving diabetic self-c are [6]. The heath belief model is a theoretical and conceptual framework that can
be used in a variety of situations. It has served as a successful model in a number of health education programs
[11]. Thus, the main purpose of this study was to find the effect of an educational program based on the HBM-
on self-efficacy among type 2 diabetic patients referred to the Iranian Diabetes Association (IDA) in 2014.
2. Subjects and Methods
2.1. Study Design and Participants
This study was a non-blinded randomized controlled clinical trial. The study population consisted of all patients
with type 2 diabetes referred to the Iranian Diabetes Association in 2014 to control their condition. Inclusion
criteria included; age: 30 - 70 years, having a medical record in the IDA, having not received a formal education
about diabetes, literate individuals, having had no learning disorders, having had a landline phone. Exclusion
criteria included: having a severe mental disorder, having had a history of chronic or severe vision & hearing
problems. Informed consent was obtained from all participants. Participants in both the intervention and control
groups were homogenous in terms of their demographic characteristics.
The sample size was 80, determined by the following sample size formula for comparing the mean in two
groups (test power of 95% and probability error of 0.05) [12] [13]:
( )
( )
Ζ +Ζ
In this randomized controlled trial, 80 patients with diabetes were randomly allocated into Intervention Group
S. Vahidi et al.
or Control Group. Educational classes booklets. In the intervention group were used during one day a week for
30 minutes during the 2-month. The control group has not received the interventional program.
The patients were randomly allocated to two groups of intervention and control groups using 40 red and 40
white cards as follows: For every two individuals, the one with the red card would be assigned to the interven-
tion group, and the immediate next person would be assigned to the control group. The process continued until
all the patients were assigned to the two groups. The participantsresponse rate was 100%, and there was no
sample loss. Data was collected by two means; patientsmedical records and a questionnaire completed upon
interview. Interviews were conducted with the patients before and six months after the training.
2.2. Data Collection Tool
The questionnaire included demographic characteristics, HBM components including; knowledge, perceived
susceptibility-threats-benefits & barrier, cues to action, and data regarding patient self-efficacy. The question-
naire was designed by Health Education academic teachers [14]-[16 ]. Among demographic variableEconomic
situationwas measured by self-report methodhow do you assess your economic situation?
Qualitative and quantitative methods were used to determine the content validity of the tool, as follows. Also
10 of Health Education experts were interviewed to obtain their professional opinion about the questionnaire.
After the experts assessment and consultation with members of the research team were applied necessary change.
In addition, the designed tool was then emailed to a 10 of Health Education experts. Their views about ques-
tionnaire items were assessed based on a three-point Likert scale consisting of Necessary, helpful but not neces-
sary, and not necessary (CVI) and four-point Likert consisting of “relevance”, “clarity”, and “simplicity”. Then
the content validity ratio (CVR) and the content validity index (CVI) were determined. According to the
Lawsche table content validity ratio for 70 items was calculated above 0.62. Questionnaire items had a score of
content validity index over than 0.7. Reliability of the questionnaire was assessed through test-retest method. To
calculate the reliability coefficient, 20 IDA members (type 2 diabetes patients) completed the questionnaire
twice at a two week interval in a pilot study. Cronbachs alpha was calculated for each of the seven domains as
follows: 0.82, 0.89, 0.92, 0. 90 , 0.87, 0.91 and 0.92. The individuals who participated in the pilot study were ex-
cluded from the main study. A five-point Likert scale was used for the answers, ranging from strongly agreeto
strongly disagree. The questionnaire included the following sections; the demographic section (5 questions),
knowledge (14 questions), perceived susceptibility (5 questions), perceived threat (3 questions), perceived bene-
fits (7 questions), perceived barriers (11 questions) and cues to action (10 questions). The self-efficacy dimen-
sion included 20 questions with Likert-type answers, r angin g from 5 to 1. Overall, the questionnaire contained
70 questions. The lowest possible score obtained in the questionnaire was 20, and the highest was 100.
The educational program was designed based on HBM component for promotion of health behaviors among
patient with diabetes. This program was included educational classes and educational booklets. The content of
the booklet was included definitions of diabetes, symp t o m s , risk factors and the benefits of adopting healthy be-
haviors to prevent long-term complications of diabetes, introduce needed resources to get more information such
as Reputable websites Diabetes Control Centers and Clinics. Six months after the intervention, data were again
collected through the questionnaire in both groups. Trained health professionals were completed questionnaires
by face to face interview during one hour for each person. A free visit to the doctor was given to all successful
patients (those whose self-efficacy had improved over the educational course) at the end of the study. Ethical
approval for this study was obtained from the Research Ethic Committee of Iran University of Medical Sciences.
All the patients had signed the informed consent. The participants were free to continue or give up the proce-
dures at any time during the study. They were assured of the confidentiality of their information.
2.3. Statistical Analysis
Finally, data were analyzed using SPSS 18. Data analysis was done by Chi-square Test, Pearsons correlation,
Independent samples T-test and paired T-test. The Significance level was considered as 0.05.
3. Results
A total of 80 patients with type 2 diabetes were involved in this study. Among the 80 patients, the mean age in
the intervention and control groups was 54.87 ± 9.32 and 55.45 ± 8.55 years respectively. 72.5 percent of pa-
tients (58 participants) were married and a large proportion had low income and used diabetes pills. The popula-
S. Vahidi et al.
tion under study was mainly unemployed and had elementary & secondary school education. The results of the
study showed that there was no significant difference between the two groups in terms of: gender, marital status,
and economic status, mode of treatment, health insurance, educational status, employment status, and presence
of people with type 2 diabetes in the family (Table 1).
Table 1. Distribution of demographic variables between the two groups before the educational intervention.
Demographic variables Interventional group Control group
No. % No. %
Gender Male 14 35 12 30
Female 26 65 28 70
Total 40 100 40 100
Chi-square Test p = 0.6
Marital status
Married 29 72.5 30 75
Single 6 15 7 17.5
Widowed 5 12.5 3 7.5
Total 40 100 40 100
Chi-square Test p = 0.7
Economic status
Low 18 45 11 27.5
Balanced 15 37.5 20 50
High 7 17.5 9 22.5
Total 40 100 40 100
Chi-square Test p = 0.2
Mode of treatment
Diet 2 5 3 7.5
Diabetes pill 18 45 19 47.5
Insulin 11 27.5 12 30
Diabetes pill & insulin
9 22.5 6 15
Total 40 100 40 100
Chi-square Test p = 0.8
Health insurance Yes 38 95 36 90
No 2 5 4 10
Total 40 100 40 100
Chi-square Test p = 0.3
Primary school 14 35 18 45
High School 12 30 10 25
Academic 14 35 12 30
Total 40 100 40 100
Chi-square Test p = 0.1
Employment status Employed 7 17.5 9 22.5
Unemployed 33 82.5 31 77.5
Total 40 100 40 100
Chi-square Test p = 0.5
Person with type 2
diabetes in the family
Yes 24 60 27 67.5
No 16 40 13 32.5
Total 40 100 40 100
Chi-square Test p = 0.4
S. Vahidi et al.
Before intervention, no significant difference was detected between the two groups. However, after the inter-
vention all variables were significantly different except for ‘perceived threat’ (p = 0.1) (Table 2). Results
showed that there were significant linear relationships between self-efficacy and all HBM components after the
educational intervention in both groups (p < 0.05) (Table 3).
4. Discussion
Studies conducted on type 2 diabetes patients have yielded different results, depending on the type of education
provided. The Health belief model provides a means to understand the attitude, behaviors and educational needs
of people and can therefore be used as a practical tool to develop effective intervention strategies [17].
The paired T-test showed that there was no significant difference in self-efficacy between the two groups be-
fore the intervention. This means that the patients’ recognition of self-efficacy is about average. Because the
mean age in the two groups was over 45 years, they were more likely to have complications from diabetes and
other illnesses. So their performance in self-care activities was not high, and generally speaking, more efforts
were needed to enhance self-efficacy in diabetes management [18] [19]. In our study, self-efficacy was signifi-
cantly higher in the intervention group after the intervention. These changes may have occurred as a result of
patient participation in the educational course. This finding was similar to the findings of other studies (Moro-
wati sharifabad et al. (2009 ) [20].
Table 2. Comparison of Health belief model components before and after the educational intervention.
Variables Group
Before intervention After intervention
Mean SD Mean SD
Intervention 40 16.94 59.50 17.23
Control 41.27 15.59 44.9 12.19
Paired T-test p = 0.7 p < 0.001
Intervention 9 2.54 12 1.69
Control 9.8 2.35 10.67 2.23
Independent T-test p = 0.1 p = 0.004
Intervention 6.65 3.82 11.52 3.88
Control 7.25 3.95 8.1 3.7
Independent T-test p = 0.4 p = 0.001
Intervention 7.05 3.87 8.92 2.58
Control 7.45 3.61 8.07 3.09
Independent T-test p = 0.6 p = 0.1
Intervention 22 9.32 32.72 9.48
Control 23.52 7.85 24.8 6.5
Independent T-test p = 0.4 p = 0.001
Intervention 14 5.93 20.82 6.03
Control 15.02 5.21 15.8 4.4
Independent T-test p = 0.4 p = 0.001
Cues to action
Intervention 12.3 1.5 14.12 1.8
Control 12.22 1.18 12.37 1.19
Independent T-test p = 0.8 p = 0.001
S. Vahidi et al.
Table 3. Correlation between health belief model components and self-efficacy after the educational intervention.
Group Health belief model components
Pearson’s correlation (r) p-value
p < 0.001
p < 0.001
Perceived susceptibility
p < 0.001
Perceived threat
p < 0.001
p < 0.001
Perceived benefits
p < 0.001
Perceived barriers
Cues to action
The present study showed that before the intervention the participantsmean knowledge score was low, but
after the intervention there was a significant difference between the two groupsknowledge and self-efficacy
scores (Table 2). Pearsons correlation also showed a significant difference between the two groupsself-effi-
cacy and knowledge scores (Table 3). This finding implies that increased self-efficacy may be due to the inter-
vention groups increased level of knowledge (r = 0.7, p < 0.001). This increase may therefore be attributed to
the educational program. These results are consistent with results of two other studies [21] [22]. This finding is
in contrast with Mazloomy et al.s study (2010). In Mazloomy’s study, there was no significant correlation dif-
ference between knowledge and self-efficacy [23]. According to their study, increased knowledge of disease risk
does not necessarily lead to improvement of self-efficacy in diabetes. But in this study, when the mean score of
knowledge increases, self-efficacy of patients increases.
There was no significant difference between the mean scores of perceived susceptibility in the intervention
and control groups before intervention either (Table 2). These results are similar to Zandi et al.s (2007) find-
ings [24]. However, after the intervention there was a significant difference between the two groupsself-effi-
cacy and perceived susceptibility scores. This means that the increased perceived susceptibility following inter-
vention leads to increased self-efficacy in the intervention group (r = 0.85, p = 0.001) (Table 3). These results
are consistent with Mazloomy et al.s study (2010) and findings of a study in Kermanshah which reveal that in-
creased perceived susceptibility in patients helps prevent and control their diabetic foot complications [24] [25].
According to another study conducted in Iran, low perceived susceptibility is one reason why patients do not
care about their health. Our results showed that the participantsmean perceived threat score was low in the in-
tervention and control groups before the intervention. The results are similar to Vickie et al.s results, indicating
that the perceived threat of amputation was low among patients with type 2 diabetes before intervention [10]
[24]. However , according to our findings, there was no significant difference between the two groupsmean
perceived threat scores after the intervention, meaning that the educational program did not affect it (Table 2).
These findings are consistent with Aljasem et al. (2001) and othersstudies [25 ] [ 26]. However, Pearsons r
showed significant differences between perceived threat and self-efficacy in the two groups after intervention
(Table 3). This means that increased perceived threat leads to increased self-efficacy in the intervention group
after training (r = 0.72 , p < 0.001) (Table 3). Self-efficacy and perceived threat may therefore influence the pre-
diction of patient behavior. Therefore, the health belief model can predict and change behavior in patients with
diabetes [6]. The study adds to the literature by demonstrating that strategies undertaken to reduce the risk will
positively influence knowledge and attitudes and hopefully lead to changes in health behaviors. Highlighting the
threat of diabetes and its associated cardiovascular risks may provide a theoretical basis for encouraging patients
toward reducing their health risks [27] [28]. The effect of education on self-efficacy is apparent, so education
can expose the potential ability of capable individuals in taking concrete measures toward self-care [6]. Our re-
sults also indicated a reduction in perceived barriers following the intervention in both groups, which was how-
ever more prominent in the intervention group. Polly (1997) showed a significant relationship between per-
S. Vahidi et al.
ceived severity and barriers with blood sugar control [29]. These results have been repeated in Shamsi et al.s
(2010) study [30]. The contrast between Zandis study and ours could be due to the difference in the type of
study, where no significant difference was found between the two groups after intervention [4] [24]. In our study,
Pearsons r showed significant differences between self-efficacy and perceived barriers in the two groups after
intervention (Table 3). Mazloomi et al. (2010) also showed a significant correlation between preventive beha-
viors and perceived barriers, a finding similar to ours [23].
The results showed that patientsperceived benefits of diabetes care were at a low level in both groups before
the educational intervention. Following the intervention, the perceived benefits had increased by 20.85 scores in
the intervention group, which was 7 times more than in the control group (Table 2). The results were similar to
the findings of other studies by Koch (2002), Sharifirad (2007), Aghamolaie (2005), and Shamsi et al. (2010);
and were contradictory to Zandi et al.s findings (2007) [1 ]-[6]. Pear s ons test demonstrated significant changes
in this part as well (r = 0.2, p = 0.001) (Table 3). The patients who had been exposed to the relevant knowledge
acknowledged the benefits of the behavior [6].
Furthermore, there is an internal cue to action that encourages patients to care for themselves. As an external
cue to action, the contribution of family members in caring for the disease is also very important [23]. The re-
sults of this study showed that participantscues to action were low in both groups before the intervention
(Table 2, p = 0.8). However, after the intervention, there were significantly higher differences between the mean
cues to actionscores of the two groups (Table 2). This shows the effectiveness of the educational program.
Pearsons test demonstrated significant differences between self-efficacy and cues to action after the interven-
tion (r = 0.84 , p = 0.03) (Table 3). This finding was in contrast with Borhani et al.s study (2010) [7], where
promoting patientsgeneral knowledge did not differ between mass media and education delivered by physi-
cians. Furthermore, books, magazines and educational pamphlets had little effect on guiding patients with type 2
diabetes toward health beliefs. The limitations of this study can be mentioned that participants want to subscribe
to the Iranian Diabetes Society as a Non-Government Organization (NGO), so they are different from other pa-
tients in terms of socioeconomic status. Therefore, it seems this result is generalizable to this group of patients.
All the health belief model components changed after the educational intervention in this study, especially
self-efficacy. Generally, the results of this study indicate that the health belief model is a suitable model that can
help change patient behavior. Therefore, it may be applied in programs promoting self-management behavior
among patients with type 2 diabetes. There are several limitations in the present study. In this study patients fol-
low up a short period of time after the education. Therefore, a long term follow-up will be recommended. This
study should be done on a larger sample size. Also participants of the study were members of Diabetes Associa-
tion as Non-Government Organization. These people may differ in terms of social and economic characteristics.
This study should be done in the future among the total population.
The project was supported by a grant from the Vice-Chancellor of Research & Technology of Iran University of
Medical Sciences (grant Number: 3182806). This research is registered in The Iranian Registry of Clinical Trials
(clinical registration number: 138811191693N4). We also thank maleki k Dr. This research paper is made poss-
ible through the help and support from everyone, including patients and the Iranian Diabetes Association.
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