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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 3  |  Page : 408-415

Assessment of the effectiveness of genital infection awareness training provided to women based on the IMB model


Department of Nursing, Faculty of Health Sciences, Ankara Yıldırım Beyazıt University, Ankara, Turkey

Date of Submission03-May-2018
Date of Acceptance10-Nov-2019
Date of Web Publication5-Mar-2020

Correspondence Address:
Dr. O Sinan
Department of Nursing, Faculty of Health Sciences, Ankara Yildirim Beyazit University, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_205_18

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   Abstract 


Background: Genital infections are one of the most common reasons for a hospital visit in the scope of reproductive health problems. The information-motivation-behavioral skills (IMB), therefore, is an appropriate model to provide women with accurate genital hygiene behaviors and develop effective sexual and reproductive health training programs. Aims: This interventional study was conducted to assess the effectiveness of genital infection awareness training provided to women based on the IMB model. Materials and Methods: Study sample consisted of 62 women (nexperimental= 31, ncontrol= 31) who were chosen based on a nonprobability sampling method from vocational courses of Ankara Keçiören municipality. The data collection form developed by the researchers, knowledge evaluation questions (KEQ), and genital hygiene behavior inventory (GHBI) were used to collect data. Data were obtained at training centers and through phone interviews. Another interview was conducted 1 month later and posttest procedures were completed. The Chi-square test, McNemar's, Mann-Whitney U test, and Wilcoxon Signed-Rank tests were used to calculate mean scores. Results: The mean (SD) age was 39.1 (8.4) years for the women in the experimental group and 37.5 (6.7) for the women in the control group (P = 0.481). Pretest knowledge mean scores M (SD)experimental = 15.7 (2.4); and GHBI mean scores M (SD)experimental= 76.9 (11.1) were calculated. Mean scores showed an increase after the training in the experimental group [M (SD)post-test= 19.1 (1.2); M (SD)GHBI= 94.7 (2.6)] (P < 0.001). Conclusion: Based on these findings, it was concluded that the genital infection awareness training provided to women based on the IMB model, improved knowledge and acted as a positive reinforcer for the hygiene behaviors of the women.

Keywords: Genital hygiene training, IMB model, women's health


How to cite this article:
Sinan O, Kaplan S, Sahin S, Peksoy S. Assessment of the effectiveness of genital infection awareness training provided to women based on the IMB model. Niger J Clin Pract 2020;23:408-15

How to cite this URL:
Sinan O, Kaplan S, Sahin S, Peksoy S. Assessment of the effectiveness of genital infection awareness training provided to women based on the IMB model. Niger J Clin Pract [serial online] 2020 [cited 2020 Apr 7];23:408-15. Available from: http://www.njcponline.com/text.asp?2020/23/3/408/280021




   Introduction Top


Childbearing age for women, usually defined as 15–49 years, marks a high-risk period with increased reproductive health issues. Genital infections are one of the most common reasons for a hospital visit in the scope of reproductive health problems.[1] It is stated that at least 75% of women have a history of genital infection worldwide and the incidence of genital infection is 10% to 50% in Turkey.[2] Incorrect genital hygiene practices of women and different physiological characteristics of sensitive female genital organs increase the risk of infection. Thus, it is critical to encourage women to have a gynecologic examination through health training to promote women's health, attach importance to genital hygiene, and raise awareness about early diagnosis, treatment, and follow-up.[3],[4]

The role of healthcare professionals as trainers and consultants gains more importance as more focus is given to maintain and promote health rather than the treatment of problems. Healthcare training and consulting forms an important part of the protection of women's health and reproductive health.[5] The information-motivation-behavioral skills (IMB) is, therefore, an appropriate model to provide women with accurate genital hygiene behaviors and develop effective sexual and reproductive health training programs. The IMB model guides individuals to reduce their health risks, prevent reproductive/sexual health problems, and promote health.[6] The IMB model is based on information, motivation, and behavioral skills. The information involves the topics that should be taught on reproductive/sexual health and information to be provided must be applicable, adaptable, and appropriate for age, sex and developmental period, and sensitive to cultural norms. As part of the motivation, individuals must be motivated to change their risky behaviors and maintain their consistent and healthy behaviors through the information provided. Providing information must be motivating to guide individuals to the desired behavior. The coexistence of information, motivation, and behavioral skills allow the behavior to be practiced.[6]

The studies that used the IMB model are mostly focused on the development of positive health behavior to prevent sexually transmitted diseases (STDs)[7],[8] with no study concentrating on genital infections. Therefore, this study aims to assess the effectiveness of genital infection awareness training provided based on the IMB model.

Questions of the study

Q1. Is there a difference between the mean KEQ scores of the participants in the experimental group and the control group?

Q2. Is there a difference between the mean GHBI scores of the participants in the experimental group and the control group?


   Materials and Methods Top


Type of the study

This is an interventional study to assess the effectiveness of genital infection awareness training provided to women based on the IMB model.

Site and duration of the study

The study was conducted from February to July 2016 in Ankara, Turkey on 62 women who participated in vocational courses of Ankara Keçiören municipality.

Selection of study sample

The sample size was 62 for each group in the power analysis where alpha was 0.05, the beta was 0.95, and the effect size was 0.05. Of the women who presented to Ankara Keçiören municipality from 15/09/2016 to 15/02/2016, were requested to voluntarily courses of the municipality. The experimental group included 31 women who were married, aged 18 years and above, nonpregnant, nonmenopausal, have communication skills, and are willing to take part in the study. The control group included 31 women who have the same characteristics as those in the experimental group and are willing to take part in the study. Power analysis may be required. The experimental group and control group were chosen from different centers to minimize the interaction possibility.

Data collection instruments

The data collection form, knowledge evaluation questions (KEQ), and genital hygiene behavior inventory (GHBI) were used to collect data. The data collection form (DCF) and knowledge evaluation questions (KEQ) were developed based on the literature.[9],[10],[11] The DCF had 11 items on sociodemographic characteristics, a general history of diseases, and certain gynecological characteristics.

Knowledge evaluation questions (KEQ): They were prepared by the researchers based on the literature.[9],[10],[11] The KEQ had a total of 21 items to assess the knowledge of the women on their hygiene habits and behaviors. The KEQ was assessed by an expert. Knowledge levels were determined by applying the KEQ to the participants in the experimental group and control group before and after the training.

Genital hygiene behavior inventory (GHBI): It was developed by Ege and Eryilmaz (2005) with a Cronbach's alpha of 0.86. In our study, Cronbach's alpha value of scale was estimated as 0.79. It had 27 positive and negative items on a 4-point Likert scale. Each inventory item was scored on a scale of 1 to 4, with 1 = never, 2 = sometimes, 3 = frequently, and 4 = always. Items 17, 26, and 27 were negative.[12] Higher GHBI scores denote positive genital hygiene behaviors.

Conduct of the study

Data were obtained at training centers and through phone interviews. Contact details of the women in both groups were obtained to conduct phone follow-up and posttest. The experimental group was first required to complete the data collection form and the GHBI, and then the training on reasons for genital infection and preventive measures was provided according to the IMB model. The questions of the women were answered after the training. For the control group, only the data collection form and GHBI were applied. A phone interview was conducted 1 month later and the GHBI was reapplied to both groups. Before the termination of phone interviews, a consulting service for protection against genital infection was provided to all women. The women who presented genital infection symptoms and may have genital infection according to their data collection forms were also suggested to visit a doctor. Privacy was maintained during the completion of the forms and training, due to the private nature of the matter and the appropriate environment was offered to each woman to complete the data collection form conveniently [Figure 1].
Figure 1: The Flow Diagram of the Study

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Ethical approval

Ethics committee approval was obtained (date: 28/08/2015; number: 94). Legal permission was granted by the Kecioren municipality. Participants were provided with verbal and written information about the purpose of the study and given the opportunity to ask any questions. All women gave their informed consent prior to their inclusion in the study. Moreover, the women were informed that they could withdraw from the study at any stage without any explanation. In accordance with the Declaration of Helsinki, all participants gave written consent which included permission to be interviewed.

Statistical analysis

Data were analyzed using IBM SPSS Statistics (Statistical Package for Social Sciences) version 21.0 (IBM Corp., released in 2012, IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY, USA). The normal distribution of the continuous variables in the study was made by the Shapiro-Wilk test. In statistical analysis, descriptive statistics (number, percentage, average, and standard deviation) and Chi-square tests for categorical variables (Pearson's Chi-square, Yates correction, Fisher's Chi-square test, McNemar) were used. A comparison between groups was performed with the Mann-Whitney U test and Student's t-test. A value of P < 0.05 was considered statistically significant.


   Results Top


This study was completed by 62 women from the experimental group (n = 31) and the control group (n = 31). The mean (SD) age was 39.1 (8.4) years for the women in the experimental group and 37.5 (6.7) for the women in the control group (P = 0.481). The first marriage age was 22.1 (5.0) for the experimental group and 21.2 (4.6) for the control group (P = 0.591). While the women in the experimental group had an average marriage period of 15.8 (11.1) years, it was 14.8 (9.5) for the women in the control group (P = 0.849). Most of the women in the experimental group (54.8%) were high school graduates but the majority of the women in the control group (41.9%) were primary school graduates (P = 0.279). Majority of the women in both groups had no revenue-generating business (experimental = 87.1%; control = 71.0%) (P = 0.119). A large majority of the spouses of the women in both groups had a revenue-generating business (experimental = 93.5%; control = 93.5%) (P = 1.000). Furthermore, majority of the women in both groups stated that their income level was moderate or high (experimental = 77.4%; control = 64.5%) (P = 0.263) [Table 1].
Table 1: Distribution of demographic and related data according to the general characteristics of women

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[Table 2] shows several findings regarding the gynecological characteristics of the women in the experimental and control group. In our study, the frequency of sexual intercourse was stated as two or less in a month by the majority of the women in the experimental group (45.2%) and twice or more in a week by the majority of the women in the control group (38.7%). The rate of women who had a women's health problem was 54.8% in the control group and 35.5% in the experimental group. Regarding these problems, 5 women in the experimental group and 12 women in the control group stated to have vaginal itching, as well as 4 women in the experimental group and 9 women in the control group, stated to have vaginal discharge problems. As for the vaginal discharge characteristics, 1 woman in the experimental group and 5 women in the control group expressed that their vaginal discharge is white and curdled. Besides, 2 women in the experimental group and 1 woman in the control group described their vaginal discharge as greenish yellow with a bad smell. The rate of the women who presented to a healthcare institution due to their gynecological problems was 54.5% in the experimental group and 47.1% in the control group.
Table 2: Distribution of some findings according to gynecological characteristics of the women

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[Table 3] shows the distribution of the answers given by the experimental and control group to the KEQ. The average of the correct answers given by the women in the experimental group to the KEQ was 15.7 (2.4) before the training and 19.1 (1.2) after the training (P < 0.001). The average of the correct answers given by the women in the control group was 15.0 (2.3) before the training and 14.3 (2.5) after the training (P = 0.160). It was determined that percentage of correct answers given by the experimental group to the following questions among 20 items of the KEQ was considerably higher after the training compared to the pretest level: “bathing on a bath stool” (pretest = 67.7%; posttest = 90.3%) (P = 0.016), “vaginal douching” (pretest = 58.1%; posttest = 96.8%) (P < 0.001), “use of soap to clean the perineal area” (pretest = 51.6%; posttest = 90.3%) (P < 0.001), and “liquid intake after the sexual intercourse” (pretest = 32.3%; posttest = 93.5%) (P < 0.001). No statistically significant difference was found between the percentages of correct answers given by the control group to the KEQ before and after the training (P = 0.727).
Table 3: Distribution of the questions in the Knowledge Evaluation Questions according to the experimental and control group

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Distribution of the mean scores obtained from the genital hygiene behavior inventory by the groups is given in [Table 4]. In our study, the mean score obtained from the genital hygiene behavior inventory before the training was 76.9 (11.1) for the women in the experimental group and 73.7 (11.0) for the women in the control group. No statistically significant difference was found between the mean scores obtained by both groups from the genital hygiene behavior inventory before the training (P = 0.234). While there was a statistically significant difference between the mean scores obtained by both groups from the genital hygiene behavior inventory after the training, they were higher in the experimental group [M (SD)experimental = 94.7 (2.6); M (SD)control = 73.6 (2.6)] (P < 0.001).
Table 4: Distribution of scores in the Genital Hygiene Behavior Inventory according to the experimental and control group

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   Discussion Top


Due to the short length of the urethra and close proximity of urethral meatus, vagina, and anus in women, microorganisms can be easily transferred to the urethra and vagina. Thus, urogenital infections are more common in women than in men. Most women experience a gynecologic infection in their lifetime. These infections are not only a source of great discomfort but also may cause permanent damage by affecting the urogenital system adversely.[1],[9]

The frequency of sexual intercourse was stated twice or less in a month by around one in every two women in the experimental group and as twice or more in a week by almost one in every three women in the control group. In Cangol's study, no difference in terms of genital infection was observed when the frequency of sexual intercourse was categorized as once or less in a week and 2–3 times or more in a week. No relation was determined between the frequency of sexual intercourse and the development of genital infection by similar studies conducted in Turkey.[13],[14]

Incorrect and insufficient genital hygiene practices of women cause infections in the genital area. Vagina, urethra, and anus are in close proximity to each other anatomically and they do not pose a disease risk under normal conditions. However, the infection may develop when hygiene is not observed and vaginal microbiota is disrupted. Inappropriate cleaning of the perineal area (e.g. washing from anus to vulva or no washing) may transfer microorganisms from anus to vaginal area.[15] While almost half of the women in the control group stated to have a women's health problem, one of every three women in the experimental group had a women's health problem. The most common problems experienced by the women included vaginal itching (nexperimental = 5; ncontrol = 12) and abnormal vaginal discharge (nexperimental = 4; ncontrol = 9). Almost half of the women (experimental = 54.5%; control = 47.1%) were presented to a healthcare institution due to gynecologic problems. Studies conducted on several segments of the society determined the prevalence of vaginal discharge as 12.1% to 30%.[16],[17],[18] In the study by Ozdemir et al., 25.1% of the students stated to have a history of abnormal vaginal discharge.[19] Karatay and Ozvaris determined that 72.8% of the women had a history of genital infection.[15] In the study by Yagmur, 27% of the women were diagnosed with genital infection.[20] A study by Oner et al. determined that 65.6% of the women had a genital infection.[21] Similarly, Hacialioglu et al. found the incidence of genital infection among women as 71.1%.[22] In our study, 54.8% of the women in the control group and 35.5% of the women in the experimental group stated to have a women's health problem. Our findings are consistent with the literature.

While average of the correct answers given to the KEQ by the women in the experimental and control groups was similar before the training [M (SD)experimental = 15.7 (2.4); M (SD)control = 15.0 (2.3)] (P = 0.137), average of the correct answers increased in the experimental group after the training [M (SD)experimental = 19.1 (1.2); M (SD)control = 14.3 (2.5)] (P < 0.001). It was determined that percentage of correct answers given by the experimental group to the following questions among 20 items of the KEQ was considerably higher after the training compared to the pretest level: “bathing on a bath stool” (pretest = 67.7%; posttest = 90.3%) (P = 0.016), “vaginal douching” (pretest = 58.1%; posttest = 96.8%) (P < 0.001), “use of soap to clean the perineal area” (pretest = 51.6%; posttest = 90.3%) (P < 0.001), and “liquid intake after the sexual intercourse” (pretest = 32.3%; posttest = 93.5%) (P < 0.001). Our study of the genital infection awareness training provided based on the IMB model improved knowledge on the hygiene behaviors of the women. Akin et al. (2006) emphasized that vaginal douching increases the risk of developing major health problems such as bacterial vaginosis (BV), ectopic pregnancy, infertility, low-birth weight, preterm delivery, sexually transmitted diseases (STDs), cervical cancer, and pelvic inflammatory disease (PID).[23] Although vaginal douching causes many negative health problems, it is commonly performed worldwide. It was determined that women usually perform vaginal douching for vaginal cleaning, eliminating the odor after the menstruation and as a contraception method after sexual intercourse.[15],[23],[24] Vaginal douching which is traditionally performed after sexual intercourse in Turkey is also common in other countries as part of feminine hygiene. Studies conducted abroad (except for Muslim countries) revealed that vaginal douching is usually performed for cleaning purposes.[24],[25],[26] However, as the majority of the population in Turkey is Muslim, most of the Turkish women believe that they cannot be considered clean, in religious terms, without washing inside the vagina during ghusl (full ablution). The use of vaginal douching as a family planning method indicates that it is a much more important issue than it is estimated.[15],[24],[27]

Our study regarding the genital infection awareness training provided based on the IMB model was a positive reinforcer for the hygiene behaviors of the women. At the same time, improved information and behavioral changes in genital hygiene are thought to be effective in preventing the common symptoms of genital infections in women. In the study of Karatay and Ozvaris (2006), only 13.2% of the women stated that they were only informed on matters to be considered in case a genital infection develops.[15] Another study revealed that planned genital hygiene behavior training affected the genital hygiene behaviors of women positively.[12] This finding is believed to be important as it demonstrates that training programs to be provided to women on reproductive health and hygiene should be organized and included in education and healthcare system to prevent vaginal infections.

While mean GHBI scores obtained by the women in the experimental and control groups were similar before the training [M (SD)experimental = 76.9 (11.1); M (SD)control = 73.7 (11.0)] (P = 234), mean scores increased in the experimental group after the training [M (SD)experimental = 94.7 (2.6); M (SD)control = 73.6 (2.6)] (P < 0.001). Kavlak et al. determined a statistically significant difference between mean GHBI scores and the knowledge level of pregnant women on genital hygiene.


   Conclusion Top


This study revealed that appropriate genital care is not known sufficiently by women. The women wanted to obtain information on genital hygiene, particularly genital cleaning and symptoms of genital infection, from healthcare professionals. The genital infection awareness training provided based on the IMB model improved knowledge on the hygiene behaviors and was a positive reinforcer for the hygiene behaviors of the women. Several training studies should be conducted on genital hygiene which is very important for women's health. More extensive studies are required to establish the relation between genital hygiene and genitourinary infections. The limitation of the study may include the fact that it was conducted in a single region.

Limitations of the study

Data obtained in this study was limited to self-declarations of women at the Kecioren municipality on the study dates. In our study, women's genital hygiene knowledge levels and behaviors were evaluated with GHBI and data collection form. In future studies, studies based on the IMB model should be conducted with vaginal cytology, swab samples, and pH levels. Thus, the effect of changes in women's hygiene behaviors on cell structure and vaginal pH can be evaluated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Kisa S, Taskin L. Behavioral and socio-demographic risk factors that affect vaginal infections among married women aged 15-49 who applied to a maternal-child health/family planning center in Ankara. Journal of Health and Society 2007;17:69-84.  Back to cited text no. 1
    
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Çankaya S, Dereli YS. Factors associated with Genital Hygiene Behaviours in pregnant and nonpregnant women in Turkey. Int J Hum Sci 2015;12:920-32.  Back to cited text no. 4
    
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Fisher JD, Fisher WA, Williams SS, Malloy TE. Empirical tests of an information-motivation-behavioral skills model of AIDS- preventive behavior with gay men and heterosexual university students. Health Psycol 1994;13:238-50.  Back to cited text no. 7
    
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Kisa S, Taskin L. Validity of the symptomatic approach used by nurses in diagnosing vaginal infections. J Clin Nurs 2009;18:1059-68.  Back to cited text no. 13
    
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Kostu N, Beydag KD. Genital hygiene practices of women who present to a gynecology clinic. Journal of Atatürk University School of Nursing 2009;12:91-7.  Back to cited text no. 14
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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