The Effect of the Instructional Program of Health-related Behaviour on Socio-demographic Variables for Patients with Chronic Diseases

Ahmed D. Salman*, Zahid J. Mohammed

Department of the Community Health Nursing, College of Nursing, University of Baghdad, Bagdad city, Iraq

*Corresponding Author’s Email: ahmed.abd2206p@conursing.uobaghdad.edu.iq

ABSTRACT

Background: The current study, a continuation of a previous study, explores the relationship between sociodemographic factors and health behaviours among chronic disease patients in Diwaniyah City, Iraq. Objectives: To evaluate the effect of the instructional program of health- related behaviour on socio-demographic variables for patients with chronic diseases. Methods: A quasi-experimental study was conducted on 222 chronic disease patients using a structured questionnaire. Data analysis included descriptive and inferential statistics. Results: The findings revealed significant associations between sociodemographic variables and health behaviours. Education level and income were positively correlated with healthier behaviours, while age and gender influenced specific health behaviours. Conclusion: The present study emphasises the need for targeted health promotion programs that consider sociodemographic variables to improve health outcomes among chronic disease patients.

Keywords: Chronic Disease; Health Behaviours; Sociodemographic Variables

INTRODUCTION

Sociodemographic factors influence health behaviours among chronic disease patients (Maccido, 2024). The Health Promotion Model explains individuals' health-promoting behaviours (Pender, Murdaugh & Parsons, 2015). Secondary theories explain the influence of social and environmental factors on health behaviours (Ajzen, 1991). The Health Promotion Model can help understand the factors influencing health behaviours (McLeroy et al., 1988). This research aims to investigate the influence of sociodemographic factors on health behaviours and explore strategies to improve them (Oster & Chaves, 2023). Higher education and income are correlated with healthier lifestyle behaviours (Sallis, Owen & Fisher, 2015; Kardan et al., 2024). Older adults are less likely to engage in physical activity compared to younger individuals (Ali & Qassim, 2023; Khleel & Mohammed, 2021).

Health education programs should be tailored to address the specific needs of various populations (CDC, 2019). Chronic diseases pose a significant global health burden (WHO, 2013; Su et al., 2023). Adopting healthy behaviours can improve health outcomes and quality of life for individuals with chronic diseases (Garvey, 2023). Regular physical activity, a balanced diet, and stress management are essential for a healthy lifestyle (Khemka et al., 2023; Alkasab & Aziz, 2023). Sociodemographic factors influence health behaviours, with age, gender, education, and income playing significant roles (Mousa & Mansour, 2020; Hussain & Mohammed, 2021; Al Omari et al., 2024). Education level is a significant predictor of health-related behaviours (Benjamin et al., 2019; Al-Mayahi, Al-Jubouri, & Jaafar, 2023; Shinjar, Bakey & Khudur, 2018; Al-Ganmi et al., 2018). Income level, marital status, social support networks, environmental factors, and cultural beliefs influence health behaviours, and understanding these factors is crucial for designing effective and culturally tailored health interventions (Ahmed, Naji & Younis, 2023; Athbi & Hassan, 2019). The study aims to assess the effect of the Instructional program of health-related behaviour on socio-demographic variables for patients with chronic diseases.

Hypotheses

Null Hypothesis (H0): The instructional program of health-related behaviour has no significant effect on the health-related behaviours of patients with chronic diseases, regardless of their socio-demographic variables.

Alternative Hypothesis (H1): The instructional program of health-related behaviour has a significant positive effect on the health-related behaviours of patients with chronic diseases, influenced by their socio-demographic variables.

METHODOLOGY

Design

A quasi-experimental design was conducted to fulfil the purpose of the study.

Settings

The study was conducted in Diwaniyah City, Iraq, within healthcare facilities that cater to chronic disease patients.

Subjects

The study subjects comprised a purposive sample of 222 adult male and female patients with chronic diseases, equally divided into study and control groups. All studied patients were selected according to the following criteria:

Inclusion Criteria

Adults aged 18 and older with chronic diseases who can read, write, and consent to participate.

Exclusion Criteria

Patients with acute illnesses, chronic mental health disorders, or those who decline participation or are absent from the program.

Sample Size Calculation

A G-Power analysis determined a sample size of 222 patients with chronic diseases, equally divided into study and control groups, selected using non-probability purposive sampling.

Tools of Data Collection

A structured interview questionnaire to assess sociodemographic characteristics. The Health Promotion Lifestyle Profile II (HPLP II) assesses health-related behaviours (Pender, Murdaugh & Parsons, 2015).

A pretest-posttest design will be used to evaluate the impact of a five-session health promotion program on health-related behaviours in the study group, with follow-up assessments at one and two months. Sociodemographic data and HPLP II will be collected from both groups, analysed using descriptive and inferential statistics, and compared between the three phases. The study was conducted from August 1 to November 1, 2024.

Statistical Analysis

All statistical analyses were conducted using a significance level of 0.01 (two-tailed), corresponding to a 99% confidence level. Paired sample t-tests were utilised to examine test- retest reliability, while independent samples t-tests were employed to evaluate differences between study and control groups for continuous variables such as age and BMI. For categorical variables, including gender and marital status, the Chi-square test was applied to assess group equivalency and successful randomisation. A p-value > 0.05 was interpreted as indicative of no statistically significant difference between groups.

Mean scores (M) were calculated for each domain of health behaviour, including Health Responsibility (HR), Physical Activity (PA), Nutrition (N), Spiritual Growth (SG), Interpersonal Relationships (IR) and Stress Management (SM). These scores collectively contributed to an overall health score, representing a general index of individual health behaviour.

Correlation analyses were conducted to determine the strength and direction of relationships between sociodemographic variables and health-related behaviours. Pearson's correlation coefficients (r) were interpreted based on the following classification for both positive and negative correlations are very weak- 0.00–0.20, weak- 0.21–0.40, moderate- 0.41–0.60, good- 0.61–0.80 and excellent- 0.81–1.00.

Significant correlations were defined as those with p-values < 0.01 (two-tailed), indicating statistical significance at the 99% confidence level. Effect sizes for the paired sample t-tests were calculated using Cohen's d, with interpretation thresholds sets are small- 0.2, medium- 0.5 and large- 0.8.

These analyses were used to evaluate the consistency of measurements over time (test-retest reliability), differences between experimental and control groups and associations between health behaviours and demographic factors.

Nursing Implications

Nurses play a vital role in chronic disease management, providing holistic care, education, support, and collaboration to improve patient outcomes.

Content Validity

Five community health nursing experts evaluated the tools for comprehensiveness, applicability, clarity, relevance, and comprehension to conduct content validity. No changes were made when needed.

Pilot Study

Ten percent of patients in the sample participated in a pilot study to make sure the questions were clear, the instruments were applicable, and the time required to complete them was adequate. No ambiguous statements or questions were present, and no changes were made. Pilot study was included in the study.

Field Work

Fieldwork was conducted in healthcare facilities in Diwaniyah City, where data collection took place over the specified study period.

Implementation of the instructional program included four phases (assessment phase, planning phase, implementation phase, and evaluation phase)

Assessment Phase

The researcher initially established a friendly relationship with the patients by having brief talks with them. Every patient was interviewed before the program was conducted to gather the patients' data utilising tool and Tool II was used to assess the patients' health-related behaviour.

Planning Phase

In response to the patients' practical demands, knowledge gaps and health-related behaviour among chronic disease patients, the goals, priorities, and expected results were defined based on the results of the preceding phase. For the patients under study, the researchers designed five sessions—two theoretical and three practical.

The Instructional Program

They created and updated an instructional program. It featured presentations on chronic disease, both theoretical and clinical.

The general and specific objectives of instructional program sessions

At the end of the instructional program sessions, the chronic disease patients were expected to acquire knowledge and practices.

Some specific objectives of the instructional program are to provide participants with a comprehensive understanding of chronic diseases. It aims to identify the causes and risk factors of chronic disease and recognise their common signs and symptoms. The program also focuses on identifying potential complications that may arise from chronic diseases and understanding the diagnosis of these conditions. Furthermore, it will discuss the available management and treatment options, as well as strategies for prevention. Lastly, the program will guide individuals to properly prepare for exercise and follow appropriate dietary practices to support overall health and well-being in the context of chronic disease management.

Implementation phase

After assessing the level of knowledge and practice among chronic disease patients, the investigator conducted the pretest by using knowledge and practice assessment tools. The investigator obtained consent from the selected samples before the study, and their data were also collected.

This study aimed to evaluate the effect of the instructional program of health-related behaviour on socio-demographic variables for patients with chronic diseases and was aimed at improving patients’ knowledge and practice of health-related behaviour among chronic disease patients through five sessions, including two theoretical and three practical sessions for about 30-45 minutes each. The researchers began every session by gathering input regarding the preceding one, and they concluded each one with a recap. From 9 a.m. to 12 p.m., three days a week, the researchers were accessible in the study settings. The previously indicated study techniques were used for one-on-one interviews with each patient.

Following a review of the relevant literature based on an assessment of the actual needs of the patients under study, a simplified booklet was used as supportive material and provided to patients in Arabic. It covered all items regarding the knowledge and practice of chronic disease. A variety of instructional techniques, including lectures, brainstorming sessions, small-group discussions, visuals, demonstrations, and re-demonstration in the education setting. A variety of instructional tools were employed, including flipcharts, PowerPoint, figures, handouts, and animated films explaining chronic disease.

The instructional program's theoretical and practical sessions were done as follows:

The first session (theoretical) began with the researchers introducing themselves, wishing the patients happy participation in the study, and outlining the goals of the instructional program. The following topics were reviewed in the first session: definition, causes, risk factors, signs and symptoms, and complications related to chronic disease. The topics discussed in the second (theoretical) session included the diagnosis, prevention, and treatment of chronic disease. In the third session (practical), this course covered the administration, therapy, and avoidance of problems associated with chronic disease. In the fourth session, which was practical, patients were clinically demonstrated and re-demonstrated how to prepare for performing exercises and health-related behaviour of diet. These exercises were created by the researcher in response to the patient's lack of knowledge and practices. Finally, fifth session (practical) began with gathering data regarding the preceding sessions and addressing any queries regarding chronic disease, exercise types and frequencies, lifestyle modifications, and healthy diet. After giving out the post-test to each participant's patients, the researcher expressed gratitude for their participation in the study

Evaluation phase

This phase aimed to evaluate the effect of the instructional program of health-related behaviour on socio-demographic variables for patients with chronic diseases. This was done by giving a post-test with similar tools to the pretest one month and two months later.

Ethical Consideration

The researchers obtained ethical approval from the Al Diwaniyah Health Directorate, Iraq, with reference number 227 on 2nd June 2024.Informed consent was obtained from all participants prior to their inclusion in the study. Participants were assured of their right to withdraw from the study at any time without any repercussions. Confidentiality and anonymity were maintained throughout the research process, ensuring that personal information was securely stored and only accessible to the research team.

RESULTS

Table 1: Frequency Distribution of the Sociodemographic Characteristics of the Study and Control Groups (N222)

f –Frequency, % Percentage; IQD-Iraqi Dinar

Table 1 presents the frequency distribution of sociodemographic characteristics of the study and control groups, including age, sex, education level, marital status, occupation, work hours, place of residence, and monthly family income. The data indicates a balanced representation of participants across various demographics, which is essential for understanding the influence of these factors on health behaviours.

Type CDs HTN DM CVD Stroke RF IBS Eczema Disk prolapse Morbidity Total

HTN: Hypertension, DM: Diabetes Mellitus, CVD: Cardiovascular Disease, RF: Respiratory Failure, IBS: Irritable Bowel Syndrome

Figure 1: Distribution of Chronic Diseases among Patients in the Study Groups

Figure 1 explains the distribution of chronic diseases among patients in the study groups. The data highlights the prevalence of various chronic conditions, such as hypertension (HTN), diabetes mellitus (DM), cardiovascular disease (CVD), stroke, respiratory failure (RF), irritable bowel syndrome (IBS), eczema and disc prolapse. This distribution provides insight into the health challenges faced by the participants and underscores the importance of targeted health interventions.

HTN: Hypertension, DM: Diabetes Mellitus, CVD: Cardiovascular Disease, RF: Respiratory Failure, IBS: Irritable Bowel Syndrome

Figure 2: Distribution of Chronic Diseases among Patients in the Control Groups

Figure 2 presents the distribution of chronic diseases among patients in the control groups. Similar to Figure 1, this figure details the prevalence of various chronic conditions, allowing for a comparative analysis between the study and control groups. Understanding the distribution of these diseases is crucial for evaluating the effectiveness of the instructional program and identifying areas for improvement in health management strategies.

Table 2: The Influence of the Instructional Program on Health Behaviours of Patients in the Study and control groups

Statistical Method by Paired sample T-Test (test-retest), M= Mean score;* correlation coefficient- (r), HR-Health responsibility, PA-Physical activity, N-Nutrition, SG-Spiritual growth, IR-Interpersonal relations, SM-Stress Management; αSig=p values of SPSS output

Table 2 illustrates the impact of the instructional program on health behaviours among patients in both the study and control groups. The paired t-test results show significant improvements in health-related behaviours in the study group compared to the control group, indicating the effectiveness of the instructional program in enhancing health behaviours.

Table 3: The Influence of Sociodemographic Variables on Health-Related Behaviours among Chronic Disease Patients for the pretest of the Study Group

**--Highly Significant

Table 3 displays the influence of various sociodemographic variables on health-related behaviours among chronic disease patients in the pretest phase of the study group. The scores indicate how different characteristics, such as age, gender, and education, correlate with health behaviours, highlighting the significant role these factors play in influencing overall health outcomes.

Table 4: The Influence of 0among Chronic Disease Patients for the Pretest of the Control Group

Table 4 summarises the influence of sociodemographic variables on health-related behaviours among chronic disease patients in the control group during the pretest phase. The data reveals the baseline health behaviour scores across various characteristics. The scores indicate how different characteristics, such as age, gender, and education, correlate with health behaviours, highlighting the significant role these factors play in influencing overall health outcomes.

Table 5: The Influence of Sociodemographic Variables on Health-Related Behaviours among Chronic Disease Patients for the post-test 1 of the Study Group

**--Highly Significant

Table 5 presents the influence of sociodemographic variables on health-related behaviours among chronic disease patients in the study group after the first post-test. The results indicate improvements in overall health scores, suggesting that the instructional program effectively enhanced health behaviours across various demographic factors.

Table 6: The Influence of Sociodemographic Variables on Health-Related Behaviours among Chronic Disease Patients for the post-test 1 of the Control Group

Table 6 outlines the influence of sociodemographic variables on health-related behaviours among chronic disease patients in the control group after the first posttest. The results indicate that,despite some improvements, the control group did not experience significant changes in health behaviours, emphasising the need for structured interventions.

Table 7: The Influence of Sociodemographic Variables on Health-Related Behaviours among Chronic Disease Patients for the Post-test 2 of the Study Group

**--Highly Significant

Table 7 shows the influence of sociodemographic variables on health-related behaviours among chronic disease patients in the study group after the second post-test. The results indicate sustained improvements in health behaviours, reinforcing the effectiveness of the instructional program over time.

Table 8: The Influence of Sociodemographic Variables on Health-Related Behaviours among Chronic Disease Patients for the Post-test 2 of the Control Group

Table 8 summarises the influence of sociodemographic variables on health-related behaviours among chronic disease patients in the control group after the second post-test. The results indicate minimal changes in health behaviours, highlighting the necessity for structured educational interventions to promote healthier lifestyles.

DISCUSSION

Socioeconomic factors, particularly education and income, significantly influence health behaviours, and the instructional program positively impacted older individuals and those with lower education levels. As shown in Table 1, age, gender, and education are critical determinants of health behaviours in chronic disease patients (Mousa & Mansour, 2020). Chronic conditions, such as diabetes and hypertension, are prevalent and closely linked to health behaviours (WHO, 2013; Hwang & Oh, 2020). This study supports the notion that structured instructional programs can effectively improve health behaviours in chronic disease management (Allar, Eruchalu & Ortega, 2023).

The findings indicate that socioeconomic status plays a crucial role in shaping health behaviours, with higher education and income associated with better health outcomes (Holt-Lunstad et al., 2022). Health interventions, as highlighted in this study, can enhance physical activity levels and reduce body mass index (BMI) among patients (NIH & Karen, 2024; Alhamad & Hassan, 2023). However, socioeconomic factors can also hinder healthy behaviours, particularly for lower-income individuals (Liu et al., 2023). The association of older age and lower education with poorer health outcomes is consistent with previous research (Alageel et al., 2023; Zhu et al., 2023).

Figures 1 and 2 illustrate that diabetes and hypertension are common chronic conditions that often co- occur (Barnett et al., 2025; Anderson & Durstine, 2019; Raghoebar et al., 2024). Health education programs have the potential to motivate individuals to quit smoking, which is a significant risk factor for these conditions (Nunes, Limpo & Castro, 2018; Graf et al., 2023). In comparison with Table 3, previous studies have shown that structured instructional programs effectively reduce BMI in individuals with chronic diseases (Balaj et al., 2024; Hacker, 2024).

As indicated in Table 3, health education enhances lifestyle habits (Mousa & Mansour, 2020; WHO, 2013), while a lack of support can hinder progress. Tailored interventions are essential for promoting positive changes in health behaviours (Ghasemian et al., 2024), as sociodemographic factors significantly influence behaviour (Coleman, Ferguson & Nash, 2024). Table 4 reveals similar trends, emphasizing the necessity for targeted interventions to address gaps in health behaviours (Heriseanu et al., 2023; Sheer & Lo, 2023).

The post test results presented in Table 5 indicate that higher education levels correlate with improved health outcomes (Sadiq, 2023). Conversely, Table 6 shows that the absence of intervention in the control group led to minimal changes in health behaviours (Samuel et al., 2020). In contrast, the results in Table 7 demonstrate that ongoing health education interventions can sustain improvements in health behaviours (Kim et al., 2018).

Finally, Table 8 highlights that the control group exhibited no significant change in health behaviours, underscoring the importance of educational programs (El-Said et al., 2022). In contrast, structured instructional programs significantly enhance health behaviours, aligning with the broader literature advocating for health education in chronic disease management (Rana et al., 2024; Uemura, Yamada & Okamoto, 2021; Hassan & Mansur, 2020; Najee & Shaker, 2019; Alwardi & Khuder, 2022). These findings collectively emphasise the critical role of tailored health education programs in improving health outcomes for patients with chronic diseases.

Limitation

This study has limitations that should be acknowledged. First, the sample was drawn from a specific geographic area (Diwaniyah City, Iraq), which may limit the generalisability of the findings to other regions or populations. Second, the reliance on self-reported data may introduce bias, as participants might have provided socially desirable responses rather than accurate reflections of their health behaviours. Additionally, the study's short follow-up period may not adequately capture the long-term effects of the instructional program on health-related behaviours. Future research should consider a longitudinal design with a more diverse sample to enhance the validity and applicability of the findings.

CONCLUSION

Sociodemographic factors significantly influence health behaviours in chronic disease patients. Higher education levels correlate with better health behaviours, and educational programs can improve these behaviours. Therefore, nurses should tailor health education to different demographics, provide continuous support, and engage communities. Policymakers should prioritise health education, reduce disparities, and integrate lifestyle counselling into healthcare. This includes increasing awareness, developing culturally relevant materials, and collaborating for effective strategies.

Future scope should explore the integration of technology in health education programs, such as mobile health applications, to facilitate ongoing support for patients with chronic diseases. Additionally, studies could investigate the effectiveness of tailored interventions that address specific sociodemographic factors influencing health behaviours.

This study highlights the significant impact of sociodemographic factors on health behaviours among patients with chronic diseases. The findings underscore the necessity for targeted health promotion programs that consider these variables to improve health outcomes. Nurses and healthcare providers should prioritise culturally relevant education and continuous support to foster healthier lifestyles among patients.

Recommendation

Based on the study findings, it is recommended to develop tailored health education programs that address the specific needs of diverse demographic groups, including considerations of age, gender, education, and socioeconomic status. Additionally, healthcare providers should engage with communities through workshops and outreach initiatives focused on chronic disease management. The integration of technology, such as mobile health applications and telehealth services, can enhance ongoing support for patients. Policymakers are encouraged to advocate for health education and lifestyle counselling, particularly for underserved populations, while establishing systems for continuous support and follow-up after educational interventions. Finally, further research should be conducted to assess the long-term effects of health education programs and the role of technology in enhancing these interventions.

Conflict of Interest

The authors declare that they have no competing interests.

ACKNOWLEDGEMENT

The authors express their gratitude to the Al Diwaniyah Health Directorate for ethical approval and access to healthcare facilities, as well as to the participants for sharing their valuable insights. Special thanks are extended to colleagues and mentors in the Department of Community Health Nursing at the University of

Baghdad, Iraq for their guidance. We also acknowledge the financial support from the nursing college at the University of Baghdad, which made this study possible.

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