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George TJ, Batra K. Effect of a community-based multicomponent intervention on cervical cancer behavior among women - A randomized controlled trial. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2022; 11:329. [PMID: 36568008 PMCID: PMC9768704 DOI: 10.4103/jehp.jehp_1742_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/06/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Cervical cancer is the leading cause of death worldwide, especially in developing countries. More than one-fifth of newly diagnosed cervical cancer cases are occurring in India. Cervical cancer is a highly preventable and curable cancer compared with other types of cancer, if detected at an early stage. The present study has been carried out to assess whether a community-based, multicomponent, nurse-led intervention program improves cervical cancer screening behavior of women. MATERIALS AND METHODS An experimental randomized controlled trial was carried out by recruiting 419 women in the age group of 30-60 years (246 in the experimental group and 173 in the control group) residing in a selected rural community (selected tribal settlements) of Idukki district of Kerala, India, using multistage cluster sampling. The intervention comprising small group education followed by reinforcement session, telephonic reminders, navigation and guidance for Pap smear, and follow-up visit by the investigator was administered to the experimental group, and the control group did not receive any intervention. Knowledge, attitude, and screening behavior of women related to prevention of cervical cancer were assessed before and twice after the intervention. RESULTS The experimental and control groups were homogenous in all baseline sociodemographic variables. The community-based intervention program was effective in improving knowledge (P < 0.001), attitude (P < 0.001), and screening behavior (P < 0.001) of women regarding the prevention of cervical cancer. A significant moderate positive correlation was found between knowledge and screening behavior (r = 0.408). Significant association was found between knowledge, attitude, and practice regarding prevention of cervical cancer with education, age at the time of marriage, and number of pregnancies. CONCLUSION The community-based, multicomponent, nurse-led intervention program was effective in improving cervical cancer screening behavior among women. Repeated motivation and reinforcement are needed to bring behavioral change and to increase uptake of screening services among rural women.
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Affiliation(s)
- T Jisa George
- College of Nursing, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Kiran Batra
- Department of Medical Surgical Nursing, Silver Oaks College of Nursing, Mohali, Punjab, India
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2
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Schliemann D, Tan MM, Hoe WMK, Mohan D, Taib NA, Donnelly M, Su TT. mHealth Interventions to Improve Cancer Screening and Early Detection: Scoping Review of Reviews. J Med Internet Res 2022; 24:e36316. [PMID: 35969450 PMCID: PMC9425170 DOI: 10.2196/36316] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Cancer screening provision in resource-constrained settings tends to be opportunistic, and uptake tends to be low, leading to delayed presentation and treatment and poor survival. OBJECTIVE The aim of this study was to identify, review, map, and summarize findings from different types of literature reviews on the use of mobile health (mHealth) technologies to improve the uptake of cancer screening. METHODS The review methodology was guided by the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Ovid MEDLINE, PyscINFO, and Embase were searched from inception to May 2021. The eligible criteria included reviews that focused on studies of interventions that used mobile phone devices to promote and deliver cancer screening and described the effectiveness or implementation of mHealth intervention outcomes. Key data fields such as study aims, types of cancer, mHealth formats, and outcomes were extracted, and the data were analyzed to address the objective of the review. RESULTS Our initial search identified 1981 titles, of which 12 (0.61%) reviews met the inclusion criteria (systematic reviews: n=6, 50%; scoping reviews: n=4, 33%; rapid reviews: n=1, 8%; narrative reviews: n=1, 8%). Most (57/67, 85%) of the interventions targeted breast and cervical cancer awareness and screening uptake. The most commonly used mHealth technologies for increasing cancer screening uptake were SMS text messages and telephone calls. Overall, mHealth interventions increased knowledge about screening and had high acceptance among participants. The likelihood of achieving improved uptake-related outcomes increased when interventions used >1 mode of communication (telephone reminders, physical invitation letters, and educational pamphlets) together with mHealth. CONCLUSIONS mHealth interventions increase cancer screening uptake, although multiple modes used in combination seem to be more effective.
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Affiliation(s)
- Désirée Schliemann
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
| | - Min Min Tan
- South East Asia Community Observatory (SEACO), Monash University Malaysia, Subang Jaya, Malaysia.,Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia
| | - Wilfred Mok Kok Hoe
- South East Asia Community Observatory (SEACO), Monash University Malaysia, Subang Jaya, Malaysia.,Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia
| | - Devi Mohan
- Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia
| | - Nur Aishah Taib
- Department of Surgery, Faculty of Medicine, University Malaya Cancer Research Institute, University of Malaya, Kuala Lumpur, Malaysia
| | - Michael Donnelly
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
| | - Tin Tin Su
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom.,South East Asia Community Observatory (SEACO), Monash University Malaysia, Subang Jaya, Malaysia.,Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia
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3
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Khani Jeihooni A, Jormand H, Harsini PA. The effect of educational program based on beliefs, subjective norms and perceived behavior control on doing pap-smear test in sample of Iranian women. BMC WOMENS HEALTH 2021; 21:290. [PMID: 34362375 PMCID: PMC8348997 DOI: 10.1186/s12905-021-01419-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 07/06/2021] [Indexed: 12/24/2022]
Abstract
Objective Cervical cancer is considered treatable as long as it is detected early and managed effectively. Pap smear test is a screening tool that plays an important role in the early detection, prevention and can prevent any early cervical cell changes from becoming cancer. This study aims to survey the effect of educational programs based on beliefs, subjective norms, and perceived behavior control on doing the pap-smear test in a sample of Iranian women. Materials and methods This experimental interventional study was performed on 300 women admitted to Fasa City, Fars Province, Iran health centers in 2018–2019. A questionnaire consisting of demographic information, knowledge, Health Belief Model, and Theory of Planned Behavior constructs were used to measure on doing of Pap smear test in women before and after 6 months’ educational intervention. Results The results revealed that 6 months after the intervention, 108 women (72%) in the experimental group and only 9 women (6%) in the control group received the Pap smear test.
Conclusions The current research results revealed that education based on the combination of the health Belief model and theory of planned behavior might be promoting participation and an increasing rate of receiving Pap smear tests in women. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-021-01419-w.
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Affiliation(s)
- Ali Khani Jeihooni
- Nutrition Research Center, Department of Public Health, School of Health , Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Hanieh Jormand
- Department of Health Education and Promotion, School of Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Pooyan Afzali Harsini
- Department of Public Health, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Ruco A, Dossa F, Tinmouth J, Llovet D, Jacobson J, Kishibe T, Baxter N. Social Media and mHealth Technology for Cancer Screening: Systematic Review and Meta-analysis. J Med Internet Res 2021; 23:e26759. [PMID: 34328423 PMCID: PMC8367160 DOI: 10.2196/26759] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/15/2021] [Accepted: 06/21/2021] [Indexed: 02/07/2023] Open
Abstract
Background Cancer is a leading cause of death, and although screening can reduce cancer morbidity and mortality, participation in screening remains suboptimal. Objective This systematic review and meta-analysis aims to evaluate the effectiveness of social media and mobile health (mHealth) interventions for cancer screening. Methods We searched for randomized controlled trials and quasi-experimental studies of social media and mHealth interventions promoting cancer screening (breast, cervical, colorectal, lung, and prostate cancers) in adults in MEDLINE, Embase, PsycINFO, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, and Communication & Mass Media Complete from January 1, 2000, to July 17, 2020. Two independent reviewers screened the titles, abstracts, and full-text articles and completed the risk of bias assessments. We pooled odds ratios for screening participation using the Mantel-Haenszel method in a random-effects model. Results We screened 18,008 records identifying 39 studies (35 mHealth and 4 social media). The types of interventions included peer support (n=1), education or awareness (n=6), reminders (n=13), or mixed (n=19). The overall pooled odds ratio was 1.49 (95% CI 1.31-1.70), with similar effect sizes across cancer types. Conclusions Screening programs should consider mHealth interventions because of their promising role in promoting cancer screening participation. Given the limited number of studies identified, further research is needed for social media interventions. Trial Registration PROSPERO International Prospective Register of Systematic Reviews CRD42019139615; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=139615 International Registered Report Identifier (IRRID) RR2-10.1136/bmjopen-2019-035411
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Affiliation(s)
- Arlinda Ruco
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Fahima Dossa
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jill Tinmouth
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Prevention & Cancer Control, Ontario Health (Cancer Care Ontario), Toronto, ON, Canada.,Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Diego Llovet
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Prevention & Cancer Control, Ontario Health (Cancer Care Ontario), Toronto, ON, Canada
| | - Jenna Jacobson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Ted Rogers School of Management, Ryerson University, Toronto, ON, Canada
| | - Teruko Kishibe
- Library Services, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Nancy Baxter
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
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Zhang D, Advani S, Waller J, Cupertino AP, Hurtado-de-Mendoza A, Chicaiza A, Rohloff PJ, Akinyemiju TF, Gharzouzi E, Huchko MJ, Barnoya J, Braithwaite D. Mobile Technologies and Cervical Cancer Screening in Low- and Middle-Income Countries: A Systematic Review. JCO Glob Oncol 2021; 6:617-627. [PMID: 32302236 PMCID: PMC7193780 DOI: 10.1200/jgo.19.00201] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Cervical cancer screening is not well implemented in many low- and middle-income countries (LMICs). Mobile health (mHealth) refers to utilization of mobile technologies in health promotion and disease management. We aimed to qualitatively synthesize published articles reporting the impact of mHealth on cervical cancer screening–related health behaviors. METHODS Three reviewers independently reviewed articles with the following criteria: the exposure or intervention of interest was mHealth, including messages or educational information sent via mobile telephone or e-mail; the comparison was people not using mHealth technology to receive screening-related information, and studies comparing multiple different mHealth interventional strategies were also eligible; the primary outcome was cervical cancer screening uptake, and secondary outcomes included awareness, intention, and knowledge of screening; appropriate research designs included randomized controlled trials and quasi-experimental or observational research; and the study was conducted in an LMIC. RESULTS Of the 8 selected studies, 5 treated mobile telephone or message reminders as the exposure or intervention, and 3 compared the effects of different messages on screening uptake. The outcomes were diverse, including screening uptake (n = 4); health beliefs regarding the Papanicolaou (Pap) test (n = 1); knowledge of, attitude toward, and adherence to colpocytologic examination (n = 1); interest in receiving messages about Pap test results or appointment (n = 1); and return for Pap test reports (n = 1). CONCLUSION Overall, our systematic review suggests that mobile technologies, particularly telephone reminders or messages, lead to increased Pap test uptake; additional work is needed to unequivocally verify whether mhealth interventions can improve knowledge regarding cervical cancer. Our study will inform mHealth-based interventions for cervical cancer screening promotion in LMICs.
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Affiliation(s)
- Dongyu Zhang
- Department of Oncology, Georgetown University School of Medicine, Washington, DC
| | - Shailesh Advani
- Department of Oncology, Georgetown University School of Medicine, Washington, DC.,Social Epidemiology Research Unit, Social Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD
| | - Jo Waller
- Department of Behavioural Science and Health, University College London, London, United Kingdom
| | - Ana-Paula Cupertino
- Latino Cancer Disparities Center, John Theurer Cancer Center, Hackensack, NJ
| | | | - Anthony Chicaiza
- Department of Oncology, Georgetown University School of Medicine, Washington, DC
| | - Peter J Rohloff
- Center for Research in Indigenous Health, Wuqu' Kawoq, Tecpán, Guatemala.,Division of Global Health Equity, Brigham & Women's Hospital, Boston, MA
| | - Tomi F Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | | | - Megan J Huchko
- Duke Global Health Institute, Duke University, Durham, NC
| | - Joaquin Barnoya
- Unidad de Cirugia Cardiovascular de Guatemala, Guatemala City, Guatemala
| | - Dejana Braithwaite
- Department of Oncology, Georgetown University School of Medicine, Washington, DC
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Rossman AH, Reid HW, Pieters MM, Mizelle C, von Isenburg M, Ramanujam N, Huchko MJ, Vasudevan L. Digital Health Strategies for Cervical Cancer Control in Low- and Middle-Income Countries: Systematic Review of Current Implementations and Gaps in Research. J Med Internet Res 2021; 23:e23350. [PMID: 34042592 PMCID: PMC8193495 DOI: 10.2196/23350] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 01/01/2021] [Accepted: 01/13/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Nearly 90% of deaths due to cervical cancer occur in low- and middle-income countries (LMICs). In recent years, many digital health strategies have been implemented in LMICs to ameliorate patient-, provider-, and health system-level challenges in cervical cancer control. However, there are limited efforts to systematically review the effectiveness and current landscape of digital health strategies for cervical cancer control in LMICs. OBJECTIVE We aim to conduct a systematic review of digital health strategies for cervical cancer control in LMICs to assess their effectiveness, describe the range of strategies used, and summarize challenges in their implementation. METHODS A systematic search was conducted to identify publications describing digital health strategies for cervical cancer control in LMICs from 5 academic databases and Google Scholar. The review excluded digital strategies associated with improving vaccination coverage against human papillomavirus. Titles and abstracts were screened, and full texts were reviewed for eligibility. A structured data extraction template was used to summarize the information from the included studies. The risk of bias and data reporting guidelines for mobile health were assessed for each study. A meta-analysis of effectiveness was planned along with a narrative review of digital health strategies, implementation challenges, and opportunities for future research. RESULTS In the 27 included studies, interventions for cervical cancer control focused on secondary prevention (ie, screening and treatment of precancerous lesions) and digital health strategies to facilitate patient education, digital cervicography, health worker training, and data quality. Most of the included studies were conducted in sub-Saharan Africa, with fewer studies in other LMIC settings in Asia or South America. A low risk of bias was found in 2 studies, and a moderate risk of bias was found in 4 studies, while the remaining 21 studies had a high risk of bias. A meta-analysis of effectiveness was not conducted because of insufficient studies with robust study designs and matched outcomes or interventions. CONCLUSIONS Current evidence on the effectiveness of digital health strategies for cervical cancer control is limited and, in most cases, is associated with a high risk of bias. Further studies are recommended to expand the investigation of digital health strategies for cervical cancer using robust study designs, explore other LMIC settings with a high burden of cervical cancer (eg, South America), and test a greater diversity of digital strategies.
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Affiliation(s)
- Andrea H Rossman
- Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC, United States
| | | | | | | | | | - Nimmi Ramanujam
- Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC, United States
- Duke Global Health Institute, Durham, NC, United States
| | - Megan J Huchko
- Duke Global Health Institute, Durham, NC, United States
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, United States
| | - Lavanya Vasudevan
- Duke Global Health Institute, Durham, NC, United States
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC, United States
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Eghbal SB, Karimy M, Kasmaei P, Roshan ZA, Valipour R, Attari SM. Evaluating the effect of an educational program on increasing cervical cancer screening behavior among rural women in Guilan, Iran. BMC WOMENS HEALTH 2020; 20:149. [PMID: 32689993 PMCID: PMC7372794 DOI: 10.1186/s12905-020-01020-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/14/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Cervical cancer is one of the major health problems and the third prevalent cancer in women all around the world. As a simple, inexpensive, and with no side-effects, Pap test is a reliable way to screen cervical cancer. This study aimed to investigate, the effects of educational intervention based on the Health Belief Model (HBM) on doing Pap smear tests among the rural women of the north of Iran. METHODS In a quasi-experimental study, 160 rural women were randomly divided into control and experimental groups to experience a three-session intervention. The experimental group received the usual educational programs of rural health center and educational programs based on the HBM constructs through personal consultation, asking/answering questions, and an educational pamphlet. The control group, received the usual educational programs of rural health center. The post-test data were collected 2 months after the intervention and analyzed in SPSS-18. RESULTS Before the intervention, there was no significant difference between the control and experimental groups regarding the mean score of knowledge, performance and constructs of the HBM. After the intervention, however, there was a significant difference in the mean scores of knowledge performance and all constructs of the HBM in two groups (p < 0.001). Rate of doing the Pap smear test in the experimental group increased from 18.7 to 78.7% in the intervention group. CONCLUSION These findings support the effectiveness of cervical cancer prevention programs based on the HBM. Therefore, conducting similar programs in other regions is recommended.
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Affiliation(s)
- Sedighe Bab Eghbal
- Reproductive Health Research Center, Department of Obstetrics and Gynecology, Al-Zahra Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Mahmood Karimy
- Department of public health, faculty of health, Social Determinants of Health Research Center, Saveh University of medical sciences, Saveh, Iran
| | - Parisa Kasmaei
- Department of Health Education and Promotion, Research Center of Health and Environment, School of Health, Guilan University of Medical Sciences, Rasht, Iran.
| | - Zahra Atrkar Roshan
- Department of Social Medicine, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Roghieh Valipour
- Department of public health, Mazandaran Training & Education Organization, Babol, Iran
| | - Seyedeh Maryam Attari
- Reproductive Health Research Center, Department of Obstetrics and Gynecology, Al-Zahra Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
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Rafieyan-Kopaei Z, Fathian-Dastgerdi Z, Tarrahi MJ, Zamani-Alavijeh F. Effectiveness of message-framing intervention on complementary feeding related behaviors among mothers with infants aged 4-8 months: a 3-arm randomized controlled trial. Ital J Pediatr 2019; 45:158. [PMID: 31801605 PMCID: PMC6894219 DOI: 10.1186/s13052-019-0749-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 11/19/2019] [Indexed: 11/29/2022] Open
Abstract
Objective Complementary feeding from the age of 6 months along with breastfeeding is essential for the health of infants. The effect of educational interventions on preventing the early or late onset of complementary feeding and correcting other relevant behaviors depends on the framing of educational messages. This study aimed to compare different types of message framing on maternal behaviors in complementary feeding of infants. Materials and methods This randomized controlled trial was performed on 96 mothers in three groups of 32 subjects with four-month-old infants in Isfahan (central Iran) during May–September 2018. Data were collected through self-report using a valid researcher-made questionnaire including demographic factors, knowledge, attitude, self-efficacy, and the complementary feeding related behaviors of mothers. For 4 months, the mothers received gain-framed messages in the GF group and loss-framed messages in the LF group from two different channels. The control group only received routine education. Data analysis was performed in SPSS20 using paired t-test, ANOVA, and Chi-square at the significance level of below 0.05. Results In this study, all three groups were matched in terms of demographic characteristics and mean scores of attitude, knowledge, and self-efficacy regarding the complementary feeding of their infants. Following the intervention, the mean knowledge score increased in all three groups and was more favorable in the intervention groups compared to the control group. However, no difference was observed between the GF and LF groups regarding their knowledge. In addition, the GF and LF groups were similar in terms of self-efficacy and behavior of mothers concerning the appropriate onset of complementary feeding. Meanwhile, the mean scores of attitude and behavior of mothers regarding the timely onset, diversity, and appropriateness of continuing complementary feeding were higher in the LF group compared with the GF group. Conclusion Framing messages changes the attitude and knowledge and improves behaviors related to complementary feeding. The interesting point is the different impacts of different types of framing on psychological and behavioral variables. In general, loss-framed messages have more effects on the attitude and certain parts of maternal behaviors. Trial registration IRCT, IRCT20180901040919N1. Registered 29 October 2018, https://en.irct.ir/trial/33782
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Affiliation(s)
- Ziba Rafieyan-Kopaei
- Health Education and Health Promotion. Student Research Committee, School of Heath, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zohreh Fathian-Dastgerdi
- Department of Health Education and Promotion, School of Health, Isfahan University of Medical Sciences, Hezar Jarib, Avenue, Postal Code, Isfahan, 81676-36954, Iran
| | - Mohammad Javad Tarrahi
- Department of Epidemiology and Biostatistics, School of Heath, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fereshteh Zamani-Alavijeh
- Department of Health Education and Promotion, School of Health, Isfahan University of Medical Sciences, Hezar Jarib, Avenue, Postal Code, Isfahan, 81676-36954, Iran.
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