Journal of Preventive Medicine

Introduction
The novel coronavirus disease (COVID-19) is a type of acute respiratory syndrome and its cause is a virus from the beta coronavirus family. The speed of this virus is very high. It is mainly spread between humans by cough and sneeze of an infected person, contact with an infected person, or touching contaminated surfaces and then touching the mouth, nose, and eyes. Symptoms of this disease include fever, cough and shortness of breath, muscle pain, sore throat, and in new cases, diarrhea and vomiting and gastrointestinal symptoms. The mortality rate is estimated at 1-5%, but it varies according to age and other health conditions; older people and those with immune system deficiencies experience severe COVID-19. Education plays an essential role in preventing this infectious disease. Educational interventions based on theories have a higher chance of success than simple educational interventions. One of the appropriate models in the field of teaching preventive behaviors against COVID-19 is Pender’s health promotion model (HPM). This model is a comprehensive and predictive model for promoting health behaviors. This model has the following constructs: Perceived benefits, perceived barriers, perceived self-efficacy, activity-related affect, situational influences, interpersonal influences, commitment to plan of action, immediate competing demands, and health-promoting behavior. This study aims to investigate the effect of an HPM-based intervention on preventive behaviors against COVID-19.

Methods
This semi-experimental study was conducted on 200 people over 18 years of age referred to two comprehensive health service centers of Lar County (Khalili Azad and Zamani comprehensive health centers), who had active health records in the SIB system. Sampling was done by simple random sampling method. They were randomly divided into two groups of intervention and control. The data collection tool was a researcher-made questionnaire consisting of 3 sections: Demographic form, a questionnaire based on the HPM constructs, and a questionnaire on preventive behaviors against COVID-19. The opinions a of panel of experts (five faculty professors) were used for determining the validity of this questionnaire. Cronbach’s α was used to calculate the internal consistency of the questionnaire and the test re-test method was used to calculate the test re-test reliability. Due to the fact that the study coincided with the outbreak of COVID-19 and for compliance with the health protocols, the intervention was conducted in 5 sessions online on WhatsApp. The post-test assessment was conducted after two months of educational intervention. Descriptive and inferential statistics were used to analyze the data.

Results
Most of the participants were in the age range of 26-40 years; 50% were male and 50% were female. The highest percentage of education was related to university education with 43% in overall (49% in the intervention group and 37% in the control group). Most of the participants were self-employed (34.5% in overall, 46% in the intervention group, and 23% in the control group). The results of the independent t-test showed a statistically significant difference between the intervention and control groups in all HPM constructs (P<0.05). Also, the results of the paired t-test showed that the mean score of all HPM constructs, except for the importance of perceived health and perceived health status, significantly increased in the intervention group after the intervention compared to the pre-test phase. The results of the analysis of covariance showed that after adjusting the effect of the pre-test score for all constructs, there was a statistically significant difference in the scores after the intervention in both groups (P<0.001). The mean scores of perceived barriers and immediate competing demands were significantly reduced in the intervention group. According to the chi-square test, a statistically significant difference was observed between the two groups in commitment to the plan of action.

Conclusion
In this study, after the educational program, the scores of perceived benefits, perceived self-efficacy, perceived control, guide for action, interpersonal influences, situational influences, activity-related affect, and preventive behaviors increased significantly while the scores of perceived barriers and immediate competing demands were significantly reduced. This indicates the effectiveness of the HPM-based educational intervention in promoting preventive behaviors against COVID-19. Therefore, it seems that educational program based on HPM in the field of preventive behaviors against respiratory diseases such as COVID-19 and influenza can have beneficial results.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Hormozgan University of Medical Sciences (No.: IR.HUMS.REC.1400.410).

Funding
This study financially supported by the Hormozgan University of Medical Sciences.

Authors' contributions
Study design: Fatemeh Adeli, Teamur Aghamolaei and Zahra Hosseini; Data collection: Fatemeh Adeli; Statistical analysis: Shokroallah Mohseni; Drafting the manuscript: Fatemeh Adeli; Review and editing: Teamur Aghamolaei and Zahra Hosseini. 

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
This project has been carried out in cooperation with Hormozgan University of Medical Science and Larestan University of Medical Sciences and Lar City Health Network. Their support is appreciated.


References

1. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. 2020 ;382(8):727-33. [DOI:10.1056/NEJMoa2001017] [PMID] [PMCID]
2. Jahanpeyma P, Shamsi A, Nejad Rahim R, Aghazadeh Sarhangipour K. [Knowledge of the COVID-19 virus, from diagnosis to prevention and treatment: A narrative review (Persian)]. J Mil Caring Sci. 2020; 7(3):289-300. [DOI:10.29252/mcs.7.3.289]
3. Reynolds M. What is coronavirus and how close is it to becoming a pandemic? Wired UK ISSN. 2020; 1357-0978. [Link]
4. Sahu KK, Lal A, Mishra AK. COVID-2019 and pregnancy: A plea for transparent reporting of all cases. Acta Obstet Gynecol Scand. 2020; 99(7):951. [DOI:10.1111/aogs.13850] [PMID] [PMCID]
5. World Health Organization (WHO). COVID-19 weekly epidemiological update [Internet]. 2022 [Updated 2022 October 26]. Available from: [Link]
6. Delshad Noghabi A, Yoshany N, Mohammadzadeh F, Javanbakht S. [Predictors of COVID-19 preventive behaviors in Iranian population over 15 years old: An application of health belief model (Persian)]. J Mazandaran Univ Med Sci. 2020; 30(191):13-21. [Link]
7. Abbaspour A, Jalili Z, Shojaeizadeh D. [Study the effect of education based on the theory of planned behavior in the prevention of AIDS among addicts (Persian)]. Iran J Health Educ Health Promot. 2021; 9(2):201-11. [DOI:10.52547/ijhehp.9.2.201]
8. Tonkaboni ND, Peyman N, Khandehroo M. [Application of health theories and models of health education and promotion in nutritional interventions for pregnant women in Iran: A systematic review (Persian)]. J Educ Community Health. 2021; 8(1):65-71. [DOI:10.52547/jech.8.1.65]
9. Sabooteh S, Feizi A, Shekarchizadeh P, Shahnazi H, Mostafavi F. Designing and evaluation of E-health educational intervention on students' physical activity: An application of Pender's health promotion model. BMC Public Health. 2021; 21(1):657. [DOI:10.1186/s12889-021-10641-y] [PMID] [PMCID]
10. Morowatisharifabad Ma, Shirazi KK. Determinants of oral health behaviors among preuniversity (12th-grade) students in Yazd (Iran): An application of the health promotion model. Fam Community Health. 2007; 30(4):342-50. [DOI:10.1097/01.FCH.0000290546.33328.76] [PMID]
11. Dwi Windasari N, Mishbahatul Marah Has E, Pradanie R. Determinants of healthy lifestyle among adolescent girls based on pender’s health promotion model. Eur J Mol Clin Med. 2020; 7(5):735-40. [Link]
12. Pouresmali A, Alizadehgoradel J, Molaei B, Vanderhasselt MA, Fathi D. Self-care behavior prevention of COVID-19 in the general population based on Pender health promotion model. 2021; [Unpublished]. [DOI:10.21203/rs.3.rs-139049/v1]
13. Mansourizadeh M, Anoosheh M, KazemNejad A. [The effect of physical activity program based on pender health promotion model on type 2 diabetic middle-aged women’s mental health (Persian)]. Iran J Health Educ Health Promot. 2018; 6(2):159-67. [DOI:10.30699/acadpub.ijhehp.6.2.159]
14. Khani F, Pashaeypoor S, Nikpeyma N, Kazemnejad A. Effect of lifestyle education based on Pender model on health-promoting behaviors in HIV positive individuals: A randomized clinical trial study. Nurs Pract Today. 2020;7(1):45-52. [DOI:10.18502/npt.v7i1.2299]
15. Naserpoor F, Zamani-Alavijeh F, Shahri P, Saki Malehi A. Effect of education based on Penders health promotion model on nutrition behavior of adolescent girls. J Res Health. 2018; 8(5):394-402. [DOI:10.29252/jrh.8.5.394]
16. Elgzar WT, Al-Qahtani AM, Elfeki NK, Ibrahim HA. COVID-19 outbreak: Effect of an educational intervention based on health belief model on nursing students’ awareness and health beliefs at Najran University, Kingdom of Saudi Arabia. Afr J Reprod Health. 2020;24(2):78-86. [Link]
17. Seo JH, Kim HK. [Factors affecting the health promoting behaviors of office male workers during the COVID-19 pandemic: Using pender’s health promotion model (Korean)]. J Korean Acad Soc Nurs Educ. 2021; 27(4):412-22. [DOI:10.5977/jkasne.2021.27.4.412]
18. Asadzandi M, Sekarifard M, Ebadi A, Morovvati Sharif Abad M, Salari M. [Effects of anger management training based on Health Promotion Model on soldiers engaged in risky behavior (Persian)]. Iran J Psychiatr Nurs. 2015; 2(4):68-79. [Link]
19. Mirzaee Z, Zare M, Zende Talab HR, Behnam Vashani H. [The effect of education based on Pender model on the quality of school life of female high school students (Persian)]. Navid No. 2021; 24(79):14-26. [DOI:10.22038/NNJ.2021.57691.1289]
20. Khafaie M, Mahjoob B, Mojadam M. [Evaluation of preventive behaviors of corona virus (COVID 2019) among family health ambassadors of Ahvaz Jundishapur university of medical sciences in 2020 using the health belief model (Persian)]. Jundishapur Sci Med J. 2021; 20(2):150-61. [DOI:10.32598/JSMJ.20.2.7]
21. Mohammadipour F, Izadi Tameh A, Sepahvand F, Naderifar M. [The impact of an educational intervention based on Pender’s health promotion model on the lifestyle of patients with type II diabetes (Persian)]. J Diabetes Nurs. 2015; 2(4):25-35. [Link]
22. EL Sayed HA, Sarhan AE. Effect of health belief model-based educational intervention on COVID-19 preventive behaviors among pregnant women. Tanta Sci Nurs J. 2022; 24(1):308-38. [DOI:10.21608/tsnj.2022.221607]
23. El Sayed SLM, Salama AM, Badawy AS. Effect of educational intervention based on the health belief model on preventive behavior of maternity nurses towards COVID-19 and its vaccination. Tanta Sci Nurs J. 2022; 24(1):329-46. [DOI:10.21608/TSNJ.2022.218014]
24. Hashemi M, Sadeghi R, Shamsi M. [An investigation of educational intervention impact on pregnant women for promote preventive behaviors of influenza H1N1: Using health belief model (Persian)]. Koomesh. 2017; 19(3):603-10. [Link]
25. Bahmanpour K, Nouri R, Nadrian H, Salehi B. [Determinants of oral health behavior among high school students in Marivan County, Iran based on the pender’s health promotion model (Persian)]. J Sch Public Health Inst Public Health Res. 2011; 9(2):93-106. [Link]
26. Aghamolaei T, Eftekhar H, Mohammad K. [Application of health belief model to behavior change of diabetic patients (Persian)]. Payesh. 2005; 4(4):61-71. [Link]
27. Sadeghi R, Mazloomy S, Hashemi M, Rezaeian M. [The effects of an educational intervention based on the health belief model to enhance HIV-preventive behaviors among male barbers in Sirjan (Persian)]. J Rafsanjan Univ Med Sci. 2016; 15(3):235-46. [Lin