Nurses' Knowledge and Attitudes towards Health Promotion At Al-Hussein Medical City in Kerbela

Selman Hussain Faris A. Lecture/ College of Nursing/ University of Kerbala Selmanhf2005@yahoo.com ةصلاخلا فدھلا : و فراعم مییقت ىلإ ةساردلا فدھت فقاوم يف ةحصلا زیزعت وحن نیضرمملا ءلابرك يف ةیبطلا نیسحلا ةنیدم . ةیجھنملا : نم ةرتفلل اھئارجإ مت ةیفصو ةسارد ٢٥ / ٣ / ٢٠١٤ ىلإ ٣٠ / ٦ / ٢٠١٤ و فراعم مییقتل فقاوم ةحصلا زیزعت وحن نیضرمملا يف ءلابرك يف ةیبطلا نیسحلا ةنیدم ، نم ةنیعلا تنوكت ١٢٠ ةضرممو ضرمم . ءازجأ ةثلاث نم ةساردلا ةنابتسا تنوكتو ، ءزجلا يوتحیو ةیفارغومیدلا تامولعملا نمضت لولأا ) ٥ ( تارقف ، نمضت يناثلا ءزجلاو ةحصلا زیزعت لوح نیضرمملا تامولعم يوتحیو ) ١٤ ( ةرقف ، ا نمضت ثلاثلا ءزجلاو تاھاجت ةحصلا زیزعت لوح نیضرمملا ىلع توتحاو ) ١٦ ( ةرقف ، ةقیرطب تانایبلا تعمجو ةرشابملا ةلباقملا . عساتلا رادصلإا ةیئاصحلإا ةبیقحلا مادختسا متو ، يللادتسلااو يفصولا ءاصحلإا قیبطت للاخ نم تانایبلا لیلحت متو اھلیلحتو تانایبلا لاخدلإ رشع . جئاتنلا : اتنلا ترھظأ دقو نیضرمملا يثلث نم رثكأ نأ جئ (68.3%) يبیردت جمانرب يأ يف اوكراشی مل ةحصلا زیزعت لوح . ةرورضب ةقلعتملا رواحملا ءانثتساب ةحصلا زیزعت تانوكم بلغا لوح ةیفاك فراعم مھیدل نیضرمملا مظعم ناو ریثأت اھل ةنمسلاب ةباصلإا ناو ءاندبلل مظتنم لكشب ةیضایرلا نیرامتلا دامتعا ةحصلا ىلع ءيس تاریثأتلاب ةقلعتملا فراعملا امأ نیضرمملا ىدل ةیفاك ریغ يھف ةحصلا ىلع ةنمسلل ةیبلسلا . ةحصلا زیزعت لوح ةیباجیا فقاوم مھیدل ةنیعلا دارفأ مظعم ناو . تاجاتنتسلاا : ةحصلا زیزعت لوح نیضرمملل ةصصخملا ةیبیردتلا جماربلا يف ةلق كلانھ نأ ةساردلا تجتنتسا . يف ضافخنا كلانھ ناو يف ءيس ریثأت اھل ةنمسلاب ةباصلإا ناو ءاندبلل مظتنم لكشب ةیضایرلا نیرامتلا دامتعا ةرورض لوح نیضرمملا فراعم ىوتسم اونسو يمیلعتلا ىوتسملا نأ نع لاضف ةحصلا فراعملا ىوتسم يف اباجیإ رثؤت ةیبیردتلا جماربلا يف نیضرمملا كارتشاو ةربخلا ت . ةحصلا زیزعت وحن نیضرمملا فقاوم يف اباجی ارثؤت ةیبیردتلا جماربلا نأ امك . تایصوتلا : ةساردلا تصوأ لعتملا مھتامولعم ةدایزل تایفشتسملا يف نیلماعلا نیضرمملل يبیردت جمانرب ذیفنتو میظنتب ةحصلا زیزعتب ةق . حم يف تانیعلا نم ربكا ددع لمشت ىرخأ ةسارد ءارجإ ىلع لمعلا و ا قارعلا يف ىرخأ تاظف . Abstract Objectives: to assess nurses’ knowledge and attitudes toward health promotion at Al-Hussein medical city in Kerbela. Methodology: A descriptive study was carried out during the period from March 25 through June 30, 2014 to assess the nurses’ knowledge and attitudes toward health promotion at Al-Hussein medical city in Kerbela on a sample of 120 nurses. A questionnaire was used in the study, which contain information about the demographic data of the nurses (5 items) & selected questions about their knowledge (14 items) and attitudes regarding health promotion (16 items). Data were analyzed through a descriptive, and inferential statistics (t-test and correlational statistics) using the SPSS, version 19. Results: it was found that more than two thirds of nurses (68.3%) were no participate in training courses about health promotion .The study revealed that most of the nurses have adequate knowledge regarding majority aspects of health promotion except in the aspect of (Regular exercise is highly recommended for the obese, and obesity is always bad for health) were they have inadequate knowledge. Also, most of the nurses have positive attitude toward health promotion. Conclusions: the present study concluded that there is a shortage in the training courses about health promotion for nurses; there is a lack of knowledge level about the importance of regular exercise for the obese; and, "obesity is always bad for health". In addition to the education level, years of experience and training have a positive effect on the level of nurses' knowledge. As well as training courses affect positively on nurses' attitudes toward health promotion. Recommendations: the study recommended education program should be designed and implemented to nurses who were working in the hospital to increase their knowledge concerning health promotion. Also to carryout additional studies with larger sample in other Iraqi governorates.


INTRODUCTION
Heath promotion involves the activities that help people change their lifestyle in order to move toward a state of optimal health (1) .To improve the health of patients the nurses have the potential by placing emphasis upon the promotion of health within their clinical practice, alongside the traditional practice of caring for the patient's illness (2) .
The chronic diseases of lifestyle were responsible for 28.9% of all deaths of all Iraq (except Kurdistan region).Also the proportion of inpatient for chronic diseases represent 11.9/per 1000 population of all Iraq for the year 2012.Whereas the proportion of inpatient for chronic diseases represent 9.4 /per 1000 population of all Karbala for same year (3) .The causes of any of these diseases has yet to be understood, behavioral factors such as unhealthy diet and excessive energy intake; physical inactivity; and tobacco use (4) .These causes are expressed through the intermediate risk factors of high blood pressure, abnormal blood lipids (particularly low density lipoprotein LDL cholesterol), raised glucose levels, and overweight (body mass and obesity (body mass index ≥30 kg/m)..index≥25 kg/m2).The relationship between the major modifiable risk factors and the main chronic diseases is similar in all regions of the world (5) .Common, modifiable risk factors underlie the major chronic diseases.These risk factors explain the vast majority of chronic disease deaths at all ages, in men and women, and in all parts of the world.They include: unhealthy diet; physical inactivity; tobacco use.Each year at least: 4.9 million people die as a result of tobacco use; 2.6 million people die as a result of being overweight or obese; 4.4 million people die as a result of raised total cholesterol levels; 7.1 million people die as a result of raised blood pressure in all regions of the world.In Hospital, a major proportion of admission are related to patients suffering one or more chronic diseases.These patients require support to cope with their disease and to achieve some changes in lifestyle (1) .
However, health promotion activities should not be opportunistic but planned as an integral part of hospital care (6) .Achieving this not only requires clear standards to guide the overall organization of hospitals towards supporting and promoting health promotion activities but a recognition that health promotion is central to the work of healthcare personnel (7) .In other words, health promotion must be viewed as a legitimate role for clinicians, including nurses (8) .
In health promotion, the role of the nurse has expanded over time.Health promotion in nursing is a continual, active process necessary to achieve and maintain the condition of wellness (1) .There is a lack of studies in Iraq relevant to health promotion among nurses, and there is a need for exploring the knowledge, attitudes of secondary care nurses regarding health promotion.Therefore, the objectives of this study were to assess (1) nurses' knowledge about health promotion, (2) nurses' attitudes towards health promotion of specific lifestyles, (3) the relationships between nurses' knowledge about health promotion and their demographic characteristics, and(4) the relationships between nurses' attitudes about health promotion and their demographic characteristics.

METHODOLOGY
A descriptive study was conducted to assess the nurses' knowledge and attitudes toward health promotion at Al-Hussein medical city in Kerbela during the period from March 25 th through June 30 th , 2014 on a sample of 120 nurses.The tool of this study was adapted from a study by Aldossary et al. (2012), and Haddad and Umlauf (1998) when the researchers conducted the systematic survey of knowledge and attitudes toward health promotion in Saudi Arabia (9) and in Jordon (10) .Several statements of this questionnaire were modified and developed to increase the validity of this instrument and to be more appropriate for achieving the aims of the present study.
The study instrument consisted of (3) parts as the following: Demographic data which include nurses' gender, age, educational level, jobs experience, number of training courses.Nurses' knowledge on health promotion which is comprised of (14 items).section one is related to information about cigarette smoking (4 items), section two is related to physical exercise (6 items), section three is related to the control of body weight (4 items).Nurses' attitudes which is comprised of (16 items): section one is related to constraints (2 items), section two is related responsibilities (6 items), section three is related to perception of clients responses (8 items).The overall number of the items included in the nurses' knowledge and attitudes assessment tool were (30) items.The items concerning nurses' knowledge were measured on a three levels Likert scale; Agree, not sure, and disagree and rated as 3, 2, and 1, respectively with a cut-off point=2.The items concerning nurses' attitudes were measured on a two levels scale; Agree, and disagree, and rated as 2, and 1, respectively with a cut-off point=1.5.Reverse scored scale was applied on items 6,7,9,10,11,12,13,15 of total distribution of nurses' attitudes concerning the health promotion.Cut-off-point was calculated as 1+2+3/3=2.RS= cut-off-point/no. of scoring*100, 2/3*100=66.66 which is considered low limit of acceptance.Assessment of nurses' knowledge was based on: Mean score for knowledge items equal to 2 or more is considered as an adequate (2 to 2.4 considered as a moderate and, 2.5 to 3 considered as an high knowledge).Mean score for knowledge items below 2 is considered as an inadequate (poor knowledge).Data analysis included descriptive, and inferential statistics (t-test and correlational statistics) using the Statistical Package for the Social Sciences for Windows (SPSS, version 19 Table (1) indicates that 75.8 % of the total subjects were males while 24.2 % were females.Most of the sample were between (20-39) years old (87.5% of them) in the age range of 24 to 59 years (M age 31.6 yr., SD=7.1).45% of the study have diploma in nursing.The table also shows that the majority (65%) that the study sample had 1-10 years' experience with a mean of 7.2 years (SD=7.2).Relative to the subjects' training, more than two third of nurses have no training and they accounted 68.3%.Table (2) shows the knowledge of nurses regarding health promotion, it revealed that 92.5% of nurses knew that passive smoking is always harmful, 35% smoking is associated with chronic obstruction pulmonary disease, 26.6% emphasized that regular exercise is highly recommended for the obese, 85.8% exercise three times or more per week on regular basis is better than exercise less often, 80%"distribution of body fats has a role in determining the risk for some diseases", 78.3% does not knew that obesity is always bad for health.Table 4 shows nurses' views about health promotion.It revealed that 59.1% of nurses agreed with the statement that they have enough time to carry out health promotion effectively, 53.3% of nurses that they have the necessary skills to promote health.Nearly all (98.3%) of the nurses agreed that the staff nurse should be a health advocate, insisting that preventive health is put on the political agenda, and 88.6% agreed that the nurse should take more responsibility for promotion of health.While, only 5.8% of nurses agreed that they should only provide health promotion counseling if that has been requested by the physician, and 15.8% of nurses agreed that they patient is totally responsible to promote his/her health.On the other hand, 50.8% of nurses disagreed that the clients find health promotion dull and boring, and 82.5% of nurses agreed that they find health promotion dull and boring.66.7% of nurses disagreed that they the evidence relating diet to health is too uncertain and contradictory for me to advise my patients on what to eat.77.5% of nurses disagreed that they nurses should not interfere with client's life by telling him/her to stop smoking, lose weight, or do more exercise.72.5% of nurses agreed that they the client's lifestyle is conditioned by their culture and environment; there's not much a professional can do to change them, and 83.3 % agreed that helping patient to understand how health-related behaviors interfere with health is an important part of the staff nurse's duty.This table shows that there is a significant association between nurses' knowledge and their educational level, jobs experience and, training concerning health promotion , and no significant association between nurses' knowledge and their other demographic characteristics that presented in this table at P≤ 0.05.Table (5) reveals that there is a significant association between nurses' attitudes concerning health promotion and their course.And no significant association between nurses' attitudes and their other demographic characteristics that presented in this table at P≤ 0.05.

DISCUSSION:
The study showed that most of the nurses (75.8%) were males and (24.2%) were females (Table1).The current result agreed with the study which was conducted by Al-Sai'di (2008) who found that 58% of nurses were males (11) .The study revealed that the majority 87.5% of the nurses were of age group (20-39) years old, which was agreed (12) The study showed that 45% of the nurses have diploma in nursing.While the minority (15%) of the nurses had bachelor degree in nursing (Table 1).This result inconsistent with Phipps, et al. (2003) which indicated that the majority (64.0%) had bachelor degree in nursing (13) .
The study showed that the majority (65%) of nurses have (1-10) years old of experience (Table 1).This result disagree with study conducted by Al-Sai'di (2008) which revealed that (22%) of nurses have (6-10) years old of employ in a nursing field (11) .
The study revealed that most nurses (68.3%) had no course about health promotion which was inconsistent with the result of Al-Ftlawy (2001) who found that (100%) of nurses didn't attend any training session (14) While, (31.7%) of the study sample had trained about health promotion.This result was disagreeing with Nihmatolla, (2005) who reported that (95%) of the nurses staff had no training session after graduation (15) .Also, this study revealed that most of the nurses have adequate knowledge regarding majorities aspects of health promotion except in the aspect of (Regular exercise is highly recommended for the obese and, Obesity is always bad for health) were they have inadequate knowledge.In the present study it was found that the curriculum focused on behavioral change as opposed to health promotion addressing socio-economic issues.However the capability of health promotion depends on the knowledge and skills offered by the education (16) .Table (4) presents the relationship between nurses' knowledge about health promotion and their demographic characteristics.It shows that there was non-significant relationship between nurses' knowledge and their gender at P≤ 0.05.This result was supported by the study of Peltzer (2001) who represented that there was no significant relationship between nurses' knowledge and their age (17) .Other results of this table show that there was non-significant relationship between nurses' knowledge and their age (0.328) at P≤ 0.05.This result was agree with the study of Pawl (2007)Who represented that there was no significant relationship between nurses' knowledge and their age (13) .
There were the relationship between nurses' knowledge and their level of education .It shows that there was a significant relationship between nurses' knowledge and their level of education at P≤ 0.05.This result was supported by Al-Mansory (2005) which reported that many authorities in education emphasized that the level of education has positive effect on the quality and quantity of knowledge and skills acquired by the recipient of education (18) .Education has a significant impact on the competencies and knowledge of nurses (19) .Table (4) indicated that the relationship between nurses' knowledge and their years of experience .It shows that there have a significant relationship between nurses' knowledge and years of experience at P≤ 0.05.Because most people make a rough assessment about whether they are at risk.This seems to be influenced by personal experience. (20).This finding was disagreed with Peltzer (2001) who stated that there was no significant association between nurses' knowledge about health promotion and clinical experience (16) Other results obtained from this table indicated that there was a significant relationship between nurses' knowledge and training at P≤ 0.05.Assaf (2004) mentioned that the health personnel must be trained to meet the community's health needs and become competent in their jobs.Systems of continuing education that allow practicing health professionals to improve their knowledge, skills and attitudes are crucial for achieving this target (21) Also, the results obtained from this table shows that most of the samples have positive attitude toward health promotion.The findings show that 40.9% of the nurses disagreed with the statement of the nurse have enough time to carry out health promotion effectively, Many studies have reported that workloads can limit the health promotion practices of nurses (22,23) Nearly all (98.3%) of the subjects agreed that nurses should act as health advocates by insisting that preventive health should be put on the political agenda.On the subject of personal responsibility, about 78.3% agreed that the nurses are more appropriate people to get involved in health promotion.This finding disagree to the result obtained from a study who stated that the participants considered nurses to have the necessary skills to promote health as well as being the most appropriate healthcare personnel to get involved in health promotion (9) .There seemed to be a conflict between the nurses' own perception on health education as not dull and boring (82.5%) and the nurses' perception that clients find health education dull and boring (49.2%).The finding was supported by the perceived between lifestyles and culture and environment (72.5%).Few (22.5%) of the nurses believed that nurses should not interfere with client's lives by telling them to stop smoking, lose weight, or do more exercise.This finding was agreed with the study of South African nurses (4.7%) and the study of Jordanian nurses (8.6%) (10) .This may indicated that nurses feel the responsibility for health promotion but are at the same time aware of the possible resentment of patients, which may be more appropriately addressed by using a health rather than a risk or disease approach of health promotion.
Regarding the relationship between nurses' attitudes about health promotion and their demographic characteristics, the results of the present study in table (5) shows that there was non-significant relationship between nurses' attitudes and their gender at P≤ 0.05.Other results of this table show that there was non-significant between nurses' attitudes and their age at P≤ 0.05.
Table (5) presents the relationship between nurses' attitudes and their level of education .It shows that there was non-significant relationship between nurses' knowledge and their level of education at P≤ 0.05.Likewise, it shows that there was non-significant relationship between nurses' attitudes and years of experience at P≤ 0.05.Also, this table indicates that there was a significant relationship between nurses' attitudes and training at P≤ 0.05.New attitudes are learned in complex patterns that can promote a new performance .Attitudes toward what is appropriate to learn and who should teach may require alterations in the nurse's approach (24) .

CONCLUSIONS:
The present study concluded that there is a shortage in the training courses about health promotion for nurses; there is a lack of knowledge level about the importance of regular exercise for the obese; and, "obesity is always bad for health".In addition to the education level, years of experience and training have a positive effect on the level of nurses' knowledge.As well as training courses effect positively on nurses' attitudes toward health promotion.

RECOMMENDATIONS
The present study recommends to an education program should be designed and implemented to the nurses who were working in the hospital to increase their knowledge concerning health promotion and importance of increasing nurses' graduate in hospital.In addition to carrying out additional studies on a larger sample in other Iraqi governorate.