Efficacy of Health Belief Model-Based Training in Changing the Beliefs about Substance use

: Background: Substance use problems are associated with capitalizes health retro gradation, weakness and death due to impacts and exceed.


INTRODUCTION
Substance use disorders and intemperance represent universal public health problem of substantial socioeconomic inclusion (1) . Many clinical studies signalize that there is an association between substance use and personality troubles with guide that personality pathology may affect both the etiology and course of substance use troubles (2) . Substance uses problems are associated with capitalize health retro gradation, weakness and death due to impacts and exceed (3) . There is growing concern about the effects of conflict and wars on substance use in Iraq (4) . Students are among the groups with higher drug risk abuse because they don't know the illegal drugs' outcomes yet have no right convictions about them (5) Substance use causes clinical, practical and significant sickness such as health problems, inability and defeat to meet responsibilities at work, school, house and university (6,7) .Substance use and consequently its abuse is a common phenomenon seen among young adults.
In a survey conducted in 2010, it was found that approximately five percent of the young adult population (230 million) tried an illicit drug at least once. Of these, (27 million) were found to have "high-risk" substance use which posed a threat to their health, caused both psychological and social problems. Substance use disorders have caused about 300,000 deaths in 2015.Among these, alcohol use disorders, opioid use disorders, amphetamine use disorders and cocaine use disorders correspond to "137,500, 122,100, 12,200 and 11,000 respectively". Not only is alcohol use widespread in itself, it is also extremely prevalent because of its possible co-morbidity with most other disorders (8) . According to reports of the Iraqi Ministry of Health in 2017, the number of smokers in Iraq was (31%) male, (4%) female. On the other hand, according to the statistics of the (9) , the number of alcoholics is (6.8%) for men, and (0.6%) for female. While, the number of drug addicts (illegal drug) in Iraq was around (7.2%). Health Belief Model this theory has been developed significantly and is considered the first theories that concern the behavior and beliefs of individuals (10) . The stated model was developed in the 1950s by some of United States (US) public health researchers with the purpose of improving the usefulness of health educations programs (11) . The health belief model was considered among the earliest theories of health psychology as a social cognition model, which focuses on increasing health security motives by adopting a healthy lifestyle (12) . The HBM has six construct that clarify or predict why individuals would take steps to avoid, monitor or test for a disease, including perceived susceptibility, perceived seriousness, perceived benefits, perceived barriers, cue to action and self-efficacy (13) .

AIM OF THE STUDY
The aim of this study is to identify the efficacy of Health Belief Model-based training in changing the beliefs about substance use among university students in Mosul City.

METHODOLOGY
The research design for this study was an experimental, randomized controlled trial design (14) . To determine the efficacy of the HBM in changing the belief that about substance use among university students in Mosul City. The study is carried out in Iraq. In University of Mosul is a public university situated in Mosul. A probability (simple random sample) of (N=80) undergraduate student in different specialties would be selected. Data were gathered in 1st of October / 2019 till 12 of May / 2020 using a questionnaire method. A sampling pool consisted of 80 students distributed at four college in Mosul University included (Political Science, Engineering, Sciences, and Nursing Colleges). The sample will be randomly assigned into experimental and control groups of (40) undergraduate student for each group. The instrument consists of two parts; part I: involved, to describe the student's sociodemographic characteristic such as (age, gender, grade, college, socioeconomic status) the part II: involved the using scale to measure students' beliefs towards of substance use. This instrument developed from more than one source and includes (15,16,17,18, and 19) .This scale to developed on the rule of health belief model and included (6) major subscales and (3) secondary; (1): "the perceived susceptibility subscale", (2): "the perceived severity subscale", (3): "the perceived benefits subscale", (4): "the perceived barrier subscale", (5): "the perceived cue to action", (6): "the perceived self-efficacy subscale". These secondary components include (7):"the perceived motivation subscale", (8): "the perceived behavioral control subscale" and (9): "the perceived behavioral intentions subscale" to changes in the student's beliefs about substance use. The overall scale consisted of 48 items measured in 5 points Likert scale distributed among the nine subscales to gauge the changes in HBM among students behavior.
The response for these items ranged between (1) strongly disagrees and (5) strongly agree, with a higher score indicating higher agreement of the beliefs. Data were analyzed by using Statistical Package for Social Science (SPSS) for Windows Version 25: We calculated mean, standard deviation, frequency and percentage to describing the participants of the study. Pearson chi-square and t-test were used to explore the homogeneity of characteristics between experimental and control groups at baseline test (T1). A mixed design analysis of variance (ANOVA) was used to measure changes in the health belief model concepts over three times (T1, T2, and T3) among groups. Finally, the Pearson correlation coefficient was used to calculate the liner correlation among health belief model concepts.   Table 2 showed that there were no significant differences in participant's beliefs, Motivation, Behavioral Control and Intensions at baseline (pre-test).  subject's factor (group with two levels: intervention and non-intervention and one with in subject factor (time of testing with three levels: pre-test, post 1, post 2).  Table 4 showed the post-hoc procedure by using Bonferroni corrections test was conducted to determine where the differences among changed beliefs and variables exactly lie. This test revealed that the score of the changed beliefs and variables differed significantly among experimental group participants over times (p< 0.05).  Tables (1) were consistent with the study (20) who found that no significant association has been shown between the difference in knowledge scores and certain sociodemographic variables such as gender, age, and education of parents, occupational status of fathers and house ownership.

DISCUSSION
This study agree with (21,22) ,This study indicated that life expectancy in university students between 21-24 years old age and body mass index were (21.16) consider normal body weight. This study disagreement with Nasir et .al. 2020) who found the majority of the   (23) . Table (2) showed that there were no significant differences in participant's beliefs, Motivation, Behavioral Control and Intensions at baseline (pre-test). This implies the homogeneity of beliefs, Motivation, Behavioral Control and intention between experimental and control group. This study consistent with (24) in Iran also showed that there was no significant difference at the baseline attitude between students and they had a relatively negative attitude toward substances abuse. These findings of the study is in line with the results of other studies by (25) who found there was no significant difference between the mean score of the HBM constructs (P > 0.05) before the program application. The visual observation for Table 3 shows that the Mean scores and the Standard Deviations for the variables under the study were changed among participant's over times. To determine the significance of this changes in the mean scores and if our health education session based on health belief model was successful in promoting enhancement among participant beliefs, a mixed design analysis of variance (ANOVA) was calculated. For this analysis (ANOVA) there was one between subject's factor (group with two levels: intervention and non-intervention and one with in subject factor (time of testing with three levels: pre-test, post 1, post 2). All effects were reported as significant at P < 0.05. This test showed that the changes among variables mean scores are a result of time, not of condition (group) or interaction between time of test and types of groups. Specifically, there was a significant main effect of time on participants perceived susceptibility, F (1, 78) = 25.416, P < .000, perceived severity, F (1, 78) = 11.970, P < .000, perceived benefits in changing the belief related to substance use, F (1, 78) = 7. 877, P < .000,Cue to action, F (1, 78) = 15.842, P < .000, perceived self-efficacy to change in behaviors F (1,78) = 7.006, p =.000,motivation behavioral, F (1, 78) = 17.318, P <.000,behavioural control, F (1, 78) = 13.893, P <.000, and behavioral intentions to adapt behaviors in the futures F (1, 78) = 10.722, P < .000 (Table 3). However, this was one belief for which no statistically significant effect was identified.
These beliefs was related to the perceived barrier to substance use F (2, 94) = 1.958, p = 0.147 (Table 3). This study consistent with (26) in Iraq showed that the changes among beliefs mean scores is a result of time, not of condition (group) or interaction between time of test and types of groups. Specifically, there was significant main effect of time on participants perceived seriousness, perceived susceptibility, and perceived benefit. Table 4, showed, the post-hoc procedure by using Bonferroni corrections test was conducted to determine where the differences among changed beliefs and variables exactly lie. This test revealed that the score of the changed beliefs and variables differed significantly among experimental group participants over times (p< 0.05) ( Table 4). The transitions period from (pre-test) to (post-test2) and from (post-test1) to (post-test 2) revealed that there was a continuous stable enhancement upon participant's beliefs (Table 4). Concerning the control group, the post-hoc procedures signaled the fluctuation of the beliefs mean score over times. However, no exact improvement or stable continuous significant changes in the score of variables were observed (Table 4). Therefore, we can conclude that the substance use health education sessions elicit statistically significant improvement upon participants in changing to substance use related beliefs and intentions over times.

CONCLUSION
This study concluded that designing an HBM-based study could affect students' understanding and their behaviors in the field of substance abuse. Considering the positive correlation between construct of HBM, particularly in "perceived benefits and perceived severity" related to students beliefs. These beliefs implied a significant correlation with each other and with the attention to the prevention of addiction.

RECOMMENDATIONS
This study recommended there is a need to conduct future studies based on the Health Belief Model on large number of the Iraqi population with the goal of changing People's behavior the direction of addiction.