Effect of Education Based on the Health Belief Model on Prevention of Sexually Transmitted Diseases in Female Victims of Sexual Assault

Background: Preventing sexually transmitted diseases is one of the main needs of the victims of sexual assault which their risks could be restricted by providing education to the victims. Therefore, the present study was conducted to evaluate the effect of education based on the Health Belief Model on the prevention of sexually transmitted diseases in female victims of sexual assault. Methods: The present randomized clinical trial was conducted at the forensics center of Babol. Samples were selected randomly and included 70 eligible women and girls who had complained of sexual assault. The intervention group was educated during a half an hour session based on the Health Belief Model with phone follow-up and educational pamphlets; the control group received routine care from the forensic center. Information was gathered at two stages before and after the intervention and then was analyzed. Results: Comparing the intervention and the control groups after the education showed a signicant difference in perceived sensitivity and intensity (p = 0.001), perceived benets (p = 0.04), perceived barriers (p = 0.001), and the performance of complained women and girls after sexual assault in preventing sexually transmitted diseases (p = 0.001). Conclusions: Education based on the Health Belief Model was effective on preventing sexually transmitted diseases. Therefore, it is recommended that this model would be used for the education of sexual assault victims for preventing sexually transmitted diseases.


Background
No society is immune from sexual violence (1). It has been estimated that 19.3% of women and 1.7% of men in the United State have been sexually assaulted during their lifetime. Also, other types of sexual violence have been reported in 439% of women and 234% of men (2). According to the results of a review study, the highest rate of sexual violence was reported in Africa and the lowest rate was reported in Asia (3). In Iran, there is not accurate and reliable statistics of sexual assault exist due to various factors such as being taboo, fear of social stigma and most importantly lack of attention and education about the manner of registering in relevant organizations. But, lack of statistics does not mean lack of this problem (4). The rate of sexual assault to incestuous women in the researches about prostitution has been reported as 22-25% and it has been reported as 12-36% among runaway girls (5).
Women and girls who have been victims of sexual assault would be exposed to various health, mental and social complications (6,7). The risk of unwanted pregnancy, getting infected with sexually transmitted diseases and HIV are some of the short and long term complications related to fertility health among female victims of sexual assault (8,9). Sexually transmitted infections is one of the serious problems that would compromise the victims of sexual assault (10,11). Although it is hard to estimate the risk of sexual infections through sexual assault, but it has been estimated that the risk of gonorrhea, trichomonas's, chlamydia and syphilis are 6-12%, 12%, 2-12% and 5%, respectively (12). In a study that was conducted in Amsterdam and investigated 1066 victims of sexual assault, the rate of positive STD tests was reported as 11.2% (13). In a study that was conducted on the girls from 9th to 12th grades, STD and HIV tests of 38.8% of them were positive and 51.6% reported that they have experienced forced sexual intercourse (14). Therefore, preventing sexually transmitted diseases is one of the primary needs of the sexual assault victims (15,16). Unfortunately, few female sexual assault victims had received health services after sexual assault. Studies about the rate of receiving medical services after sexual assault showed that only 26% of the sexual assault victims have sought medical help after the incidence (1). Therefore, educating the sexual assault victims for receiving medical services is of great importance.
To increase the effectiveness of health education for preventing sexually transmitted diseases, using appropriate health theories and models such as Health Belief Model has an important role (17).
Education based on Health Belief Model, has been used in different studies including selecting and using contraceptive methods (18), performing Pap smear test (19), preventing cigarette smoking among the youth (20), and risky behaviors (21). Also the effectiveness of this model for educating the prevention of sexually transmitted diseases in different groups such as students (22), teenagers (22) and sex workers (24) has been approved. Based on this model, to make preventive measures, the individuals should rst understand the danger of getting infected with sexually transmitted diseases (perceived sensitivity); then they should understand the depth of this risk and the seriousness of different aspects of its complications and the effect of these complications on their lives (perceived intensity) and with the positive signs that they would receive from their environment and their inner self including usefulness and applicability, the would believe in the program for preventing sexually transmitted diseases (perceived bene ts) and would nd the weight of the inhibiting factors for action less than the bene ts (perceived barriers) so that eventually, by increasing their awareness and using encouraging and supportive preventive measures, they would take measures to prevent sexually transmitted diseases (action instructions) (25,26).
In advanced countries, all the preventive and therapeutic measures provide comprehensively at the sexual assault crisis centers (27). Although in Iran there are centers titled behavioral diseases' counselling center (triangular clinics), that are aimed to present health services to these victims, most of the sexual assault victims would not refer to these centers. Instead those victims who are looking for ling a complaint, would be referred to forensics o ces for forensic examinations. The measures that would be taken for these women at forensic centers include hymen and anal examination, investigating and recording the injury marks and bruises, issuing testimony and if possible, taking forensic samples from anus, vagina and etc. and gathering the clothes contaminated with semen for sending to the laboratory to check for sperm. But providing counselling and education to the sexual assault victims about health problems including preventing sexually transmitted diseases is not a part of the forensics o ces' duties. On the other hands, since the patients who refer to the forensics o ces do not have any focus on their physical problems due to their psychological problems, they would not receive any recommendation for attending their physical problems including referring to the behavioral diseases centers.
Considering the importance of preventing sexually transmitted diseases among this high-risk group as a protection of the rights of the raped individual, referring to the forensics o ce could be a good opportunity for educating primary health and guiding these individuals toward reference centers to receive preventive services. The aim of the present study was to evaluate the effect of education based on Health Belief Model on prevention of sexually transmitted diseases in female victims of sexual assault who referred to the forensics o ce of Babol city.

Methods
The present study was a randomized controlled trial with two groups of intervention and control that was This study adheres to CON-SORT guidelines for a randomized controlled trial (CONSORT checklist, supplementary material). The inclusion criteria were being a female victims of sexual assault who had at least experienced one of the vaginal, rectal or oral penetration by the rapist that had been con rmed by the forensics o ce or had been reported by the victim herself. Other inclusion criteria were having a personal cellphone or the accessible home line and the ability to use it, being able to read and write, and not having received any health services for preventing sexually transmitted diseases after sexual assault. The exclusion criteria were previous referral to the service providing centers, having any kind of injury that required immediate attendance, occurrence of any diagnosed psychological problems during the follow up period and not answering the phone or unwillingness to continue the study. All women provided written informed consent before data collection.

Sample size calculation
The sample size for each group was calculated to be 45 considering p 01 = 0.5, p 11 = 0.9, con dence interval of 95%, test power of 80% and a sample loss of 25%.

Randomization and Recruitment
At rst, those who had the inclusion criteria were asked to participate in the study. After acceptance, individuals were assigned randomly into the intervention or the control groups based on their number in the admission list. For this purpose, codes of A and B have been assigned to the numbers 1 to 90 using table of random numbers by one of researchers. Code A indicated the control group and code B indicated the intervention group.

Measurement
Data gathering tool for this study was a multi-sectional researcher-made questionnaire. The rst section included demographic characteristics such as age, marital status, educational level, occupation, parents' educational level, parents' occupation and economic status and information about assault accident. The second part measured the primary outcomes and included attitude questions in the form of the components of the Health Belief Model which contained 4 dimensions of perceived sensitivity, perceived intensity, perceived bene ts and perceived barriers; each dimension is evaluated through 6 questions. Each question was scored from 1 (totally disagreed) to 5 (totally agreed) using 5-point Likert scale. The score of each dimension varies from 6 to 30 and higher scores indicated better conditions. Performance was evaluated through 5 questions about referring for receiving services and performing examination, vaccination, medication, and revisiting. If the answer to the rst question about referring for examination was positive, the next four questions were also answered. The options for answering these four questions were not requested, requested but not performed, and requested and performed. To determine the scienti c validity of the tool, content validity was approved using the opinions of 10 faculty members.
The reliability of the data gathering tool was desirable using test-retest method (α = 0.84).

Intervention
Participants of the control group received the pre-intervention questionnaires and completed them in the presence of the researcher to solve any possible ambiguity; then they received the routine care from the forensics o ce of Babol city. Participants of the intervention group, besides completing the preintervention questionnaires, were educated during an individual half an hour session based on the Health Belief Model (perceived sensitivity, perceived intensity, perceived bene ts, perceived barriers and action instructions). Also, some information in the form of educational pamphlets was given to them. The content of the educational pamphlets was about the important risk of getting infected with sexually transmitted diseases, their complications, symptoms of diseases and introducing behavioral diseases counselling centers and the address of these centers in Mazandaran province.
Also, phone call follow-ups were performed for the intervention group by the researcher as follows: The rst call: the following day after giving the pamphlets to the participants, they were called to be reminded of their visit to the behavioral diseases center and studying the pamphlets.
The second call: one week after the rst call they were called to determine whether they have visited the behavioral diseases center and whether they have read the pamphlets. If the participants had visited the behavioral diseases center, they would be encouraged to follow up the measurements that have been performed by the center and if they had not visited the center, they would be encouraged visit.
The third call: four weeks after the rst call they were called to determine whether they had visited the center and read the pamphlets and to remind them of completing the post-intervention questionnaire. If the participants had visited the behavioral diseases center, they would be encouraged to follow up the measurements that have been performed by the center and if they had not visited the center, they would be encouraged by the researcher to visit. Also, the researcher gave her phone number to intervention group participants so that they would call her in case of having questions. The post-intervention questionnaire was completed one month after the start of the intervention through researcher's phone call to the participants of the intervention and the control groups.
Considering the sensitivity of the subject, the researcher tried to respect all the ethical considerations.
Speci cally, the researcher made special efforts for con dentially keeping the participants' information. Also, after the post-intervention questionnaires were completed, participants of the control group were educated through phone calls and they were asked to visit appropriate centers.

Statistics
For analyzing the data based on their type, descriptive statistics, as presenting the data in tables of absolute and relative frequency distribution, chi square test, Fisher's exact test, independent t test, and paired t test and were used. All of the calculations were performed using SPSS version 16.

Results
In the beginning of the study, 39 participants were in the control group and 43 in the intervention group and eventually, data from 35 participants was analyzed (Fig. 1). The start date of this study was in December 2015 and the completion date was March 2016. The mean ± SD age of the participants in the control and intervention group were 21.17 ± 4.58 years and 21.34 ± 4.22 years, respectively. 88.6% of the control group and 91.4% of the intervention were single. The educational level of 54.3% of the control group and 74.3% of the intervention group was high school. Respectively, the educational level of the fathers and mothers of 72.8% and 77.2% of the control group and 82.8% and 94.3% of the intervention group was lower than high school. 17 participants in the control group and 12 in the intervention group were students. In the control and intervention groups, respectively, 51.4% and 45.7% of the fathers were freelancer 60% and 77.1% of the mother were housewife. The economic status of 54.3% of the control group and 48.6% of the intervention group was average. Comparing the demographic characteristics showed that both groups were homogeneous (Table 1). Also according to the results of Table 2, the two groups had no signi cant difference regarding the characteristics of sexual assault incidence including family relation between the rapist and the victim, the number of rapists and informing the family (p > 0.05). Respectively, 12 (34.3%) and 6 (17.2%) of the participants in the control group and 10 (28.6%) and 8 (22.8%) of the participants in the intervention group were aware of sexually transmitted diseases and preventive measures, with no statistically signi cant difference (p > 0.05) ( Table 2).  As shown in Table 3, the score of perceived sensitivity (p = 0.3), perceived intensity (p = 0.2), perceived bene ts (p = 0.4) and perceived barriers (p = 0.16) had no signi cant difference between both groups before the intervention. After the intervention, only the score of perceived sensitivity was signi cantly increased (p = 0.03) in control group. But in the intervention group the score of all domain was signi cantly increased (p < 0.05). At the end of the study, 17 (48.6%) of the participants in the control group and 30 (85.7%) of the participants in the intervention group referred to receive preventive cares for sexually transmitted diseases and results of chi square test showed that the difference was statistically signi cant (p = 0.001). Referring to the midwife or gynecologist, behavioral diseases counselling, hospital and general practitioner in the center in the control group was respectively 9, 3, 3 and 2 and in the intervention group was 12, 13, 2 and 3. There was no signi cant difference between both groups regarding the performed measures after vising the center (p > 0.05) ( Table 4).

Discussion
The present study has evaluated the effect of education based on Health Belief Model on preventing sexually transmitted diseases in female victims of sexual assault who referred to the forensics o ce of Babol in two groups of control and intervention. Both groups were homogeneous regarding demographic and assault characteristics. Since demographic characteristics are some of the effective factors on the components of Health Belief Model including the rate of understanding the potential of infecting with sexually transmitted diseases, its caused intensity, and perceived bene ts of and barriers to preventing diseases, that would eventually affect the individual's performance (28), by homogenizing these variables, their confounding effect was mostly eliminated in this study.
In the beginning of the study, both groups were homogeneous regarding their score of perceived sensitivity, intensity, bene ts and barriers. After the intervention, the scores of all domains were signi cantly increased in the intervention group comparing to before the intervention. Also comparing the score between the intervention and the control groups after the intervention showed that the scores were According to the results of the present study, although the score of perceived sensitivity was signi cantly increased in the control group after the intervention, the scores of other domains showed no signi cant difference. The researcher believes that this signi cant increase in the score of perceived sensitivity before and after the intervention was caused by confounding factors that were not a part of the researcher's intervention. Gaining information from the social media, friends and acquaintances could be one of the confounding factors. The questionnaire itself could be a confounding factor in the study because it could be a stimulus for learning its content (31). It seems that, in the present study, the participants' fear of sexually transmitted diseases after completing the questionnaire, has caused them to be more willing to gain information about this subject than before. Considering the comparison of the other score of the control group, although the score of perceived sensitivity was increased after the intervention in the control group, their beliefs in the bene ts of medical interventions and seeking it were not changed.
Individuals with low understanding of their potential to catch sexually transmitted diseases would more possibly perform inappropriate and risky sexual behaviors (32,33). In the contrary, the more sensitive and susceptible an individual nds themselves to a disease, they would perform preventive measure more probably (33). Therefore, the rst step is to create the sensitivity in the sexual assault victims that they might be infected with sexually transmitted diseases. On the other hand, the long-term complications of sexually transmitted diseases such as pelvic in ammatory diseases, infertility and cervix cancer could look so small and unlikely to the youth. Therefore, the emphasis should be on the asymptomatic nature of these disease and the serious risk of their complications including pelvic in ammatory diseases, ectopic pregnancy and infertility (34). This way, by expressing serious negative complications and stating them, perceived intensity should be presented to the clients. In the following, to facilitate the use of the structure of perceived intensity or bene ts, health educators should determine the exact behaviors that should be performed and highlight the bene ts and bene ts that would be achieved from that exact behavior. In general, individuals with positive beliefs about the sensitivity and intensity of a disease, would not perform the recommended behaviors unless they would understand that performing that behavior would potentially decrease the risk or threat (18,28). In the present study also, after expressing the advantage of performing preventing measures to sexually transmitted diseases against the existing barriers, and following them up and making phone calls to them and making the decision by the participants of the intervention group, this change was observed, in comparison to the control group. So, the e cacy and value of the recommended behaviors for preventing sexually transmitted infections could be explained for the female victims of sexual assault and they could be encouraged to perform health behaviors. Through education using Health Belief Model, it would be possible to reach a better understanding of the barriers to perform preventive behaviors and then make efforts to eliminate these barriers so that the path would be paved for performing health behaviors. Conducted studies have shown that perceived barriers is the most important part of the Health Belief Model for performing the recommended behaviors (25). On the other hands, to help decreasing the perceived barriers, question and answer method could be used; meaning that, the individuals would be asked about their opinion of the existing barriers to performing the recommended behaviors. Or a list of the barriers to taking action would be given to them and a solution for eliminating each of them would be provided (29).
The main aim of the present study was that sexual assault victims would refer to the centers that provide care services after sexual assault. According to the results, more than four-fth of the participants in the intervention group visited these centers for receiving services and this number was signi cantly higher than the same number in the control group. In other studies, the rate of seeking help was reported as 60% in America (35), 20% in France (36), 58.6% in Congo (37), and 21% in South Carolina (38). Lack of a signi cant difference between both groups in the performed measures after visiting the centers in the present study might be due to the fact that, although half an hour of education in the forensics o ce could be effective on the victim's referral to the centers for receiving preventive cares, the services that they would receive depends on the providers of the health services at the determined centers.

Strengths And Limitations Of The Study
The strength of the present study was that it was the rst study that was conducted in the eld of educational interventions for sexual assault victims in Iran. Results of the present study could lead to provision of health services with higher quality to sexual assault victims and employment of the graduates of the new major of forensics midwifery in the forensics o ces.
As a limitation, since the sexual assault victim does not have an appropriate psychological condition at the time of referring to the forensics o ce, it might be possible that their answers to the self-report