Investigating the Effect of the Family-Centered Empowerment Model (FCEM) on the Empowerment Indicators of Student Girls with Iron Deficiency Anemia (IDA) and Their Mothers

Background and aims: Iron deficiency is one of the most important health issues in adolescents, especially girls. Today, empowerment is considered an effective program to change behavior in chronic disease control. This study was conducted to determine the effect of the family-centered empowerment model on the empowerment indicators of student girls with iron deficiency anemia and their mothers.

Methods: This is a two-group semi-experimental study conducted on 60 student girls along with their mothers, who were selected by a two-stage cluster random sampling method. Data was collected using a demographic information questionnaire and an adolescent and mother empowerment questionnaire. The intervention based on the family-centered empowerment model was implemented for the test group, and after 1.5 months, data from both groups were collected and analyzed with chi-square, independent t, and paired t-tests.

Results: The results of the independent t-test showed that there was a significant difference between the student girls in the test and control groups after the intervention in terms of empowerment indicators (p < 0.05). The results of the independent t-test showed that there was a significant difference between the mothers in the test and control groups after the intervention in terms of ability indicators (p < 0.05), while before the intervention, this difference was not significant (p > 0.05).

Conclusion: The results of the present study showed that the implementation of the family-centered empowerment model not only increased the empowerment indicators of student girls with iron deficiency anemia but also had an effect on the empowerment of their mothers.

Globally, iron deficiency (ID) is still recognized as the main cause of anemia. According to the statistics of the World Health Organization (WHO), about 1.62 billion people suffer from iron deficiency anemia (IDA) [1]. Anemia is a decrease in hemoglobin, the number and volume of red blood cells, and as a result, a decrease in the capacity to carry oxygen in the blood circulation [2,3]. The groups that are most exposed to IDA are infants, children under 6 years old, adolescents, especially teenage girls, and women of reproductive age, especially pregnant women. Adolescent boys and adult men may also suffer from IDA, but this risk is less in them [4].

According to the estimate by the WHO, 25% of students suffer from IDA, and in developing countries, the prevalence rate is reported to be from 30% to 90% [3,5]. The consequences of anemia in students include a negative effect on the central nervous system, delay in physical growth, poor academic performance in school, reduced ability to perform activities, memory loss, psychological problems, a weak immune system, and reduced quality of life [6]. The potential causes of IDA in adolescents are growth spurts, excessive excretion of iron due to heavy bleeding during menstruation or digestive diseases, lack of hygiene, lack of access to health care services, and infectious diseases such as microbial diarrhea and respiratory infections, parasitic infections, unhealthy and monotonous diets, inappropriate eating habits such as drinking tea with food or immediately after food, low level of parental awareness [7,8].

There are various strategies, such as improving the diet, fortifying foods with iron, and using iron supplements. However, teenage girls often do not consume enough iron to compensate for the losses caused by menstruation, and for this reason, the peak prevalence of ID often occurs during adolescence among women. Taking iron supplements is more or less the best available option for ID and IDA in women, young children, and teenagers, but it has side effects such as blackening of the tongue and teeth, the bad taste of iron supplements, stomach pain, nausea, and vomiting. In addition, there are other challenges, such as parents’ reluctance, friends’ influence, the high price of supplements, and reluctance to use supplements due to side effects [9-11]. So the problem of IDA remains. The results of studies conducted in different cities of Iran show that the knowledge, attitude, and performance of female students in the field of ID and anemia caused by it are at a weak level, and measures should be taken in this regard [12-14]. One of the most important aspects of disease control and prevention is providing education to at-risk groups [15]. For this purpose, several models have been developed to describe health behaviors related to health. One of the models used to change health behaviors in patients is the family-centered empowerment model (FCEM). The family-centered empowerment model emphasizes the effectiveness of the role of the individual and family members in three motivational-psychological dimensions (perceived threat, self-belief/self-control, and self-efficacy), and the evaluation dimension [16]. The main goal of the FCEM is to empower the family system (the patient and other family members) to improve the level of health. In this model, one of the family members, with the priority of parents, spouse, and children under the title of “active family member” (with the characteristics of willingness, decision-making power, and ability to cooperate), participates in all intervention steps. The set of nursing measures used in this model aims to create a partnership between nursing and family, emphasizing existing capacities, reducing risk factors, promoting health, and increasing responsibility. So this model can be a suitable practical solution for the patient and family in improving the level of health [16,17].

Considering the importance of anemia in adolescent girls who are the future mothers of society and considering the central role of the family in the processes of disease prevention and treatment [18], this study aims to determine the effect of the FCEM on the empowerment indicators of student girls with IDA and their mothers.

A quasi-experimental research was conducted with a pre- and post-test design in two test and control groups in Tehran/Iran. The sample size was considered 30 students for each group based on a similar study [19] and using the formula, n =, considering the confidence factor of 95%, test power of 80%, the standard deviation of 0.6, the mean difference of 0.48, and the attrition rate of 10%.

The inclusion criteria were

Iranian nationality, living in Tehran, age 15 - 18 years, hemoglobin less than 12 grams per deciliter, and serum ferritin less than 15 milligrams per deciliter [20], not using any type of drugs affecting anemia, such as iron or other vitamin supplements, not receiving nutritional interventions effective against anemia, not being treated with a special diet, not having any other physical or mental illness, consent of parents and teenagers to participate in the research, and having a specific address and phone number for follow-up.

The exclusion criteria were

Infection or acute illness during the intervention, absence of more than one session, and incomplete questionnaire.

Research tools

To collect data, the following instruments were used:

1. A 22-item demographic profile (age, level of education, field of study, number of family members, father's education level, mother's education level, parents' occupation, family life situation, etc.).
2. Adolescent empowerment questionnaire in 4 areas: Perceived intensity areas including 10 questions and the effectiveness range of agree (2), disagree (1), have no opinion (0.5), perceived sensitivity areas including 10 questions with the effectiveness range of agree (2), disagree (1), I have no opinion (0.5), self-efficacy areas including 40 questions on a four-point Likert scale of never (1), sometimes (2), often (3), always (4), and Eysenck's standard self-esteem questionnaire including 30 questions on a three-point Likert scale of I agree (2), I disagree (1), I have no opinion (0.5) [21].
3. Mothers' empowerment questionnaire in 4 areas: Perceived severity areas including 10 questions and the effectiveness range of agree (2), disagree (1), have no opinion (0.5), perceived sensitivity areas including 10 questions with the effectiveness range of agree (2), disagree (1), I have no opinion (0.5), self-efficacy areas including 38 questions with a four-choice Likert response of never (1), sometimes (2), often (3), always (4), ​​Cooper Smith's standard self-esteem questionnaire for adult including 35 questions based on a 4-point Likert scale (totally disagree with a score of 1 to completely agree with a score of 4) [22,23].

In this research, the validity of the questionnaire was confirmed by 10 professors of two medical sciences universities, and the reliability of the questionnaire was confirmed by 10 adolescents and 10 mothers. The Cronbach’s alpha coefficient for each of the dimensions was calculated α ≥ 0.7 (Table 1).

A two-stage cluster random sampling method was used to collect the samples. After completing the initial questionnaires and analyzing the results of the statistical tests and determining the resources, limitations, and educational needs, the student girls were placed in 5 groups of 6 people, and 8 empowerment sessions (30 - 60 minutes) twice a week were held based on model structures.

Perceived threat structure: Based on the cognitive theories of Azubel (meaningful verbal learning) and health belief, the method of combined education (speech, educational video, and group discussion) tried to improve the perceived threat in female students. By raising the sensitivity of people’s conditions to the complications of the disease, efforts were made to improve the perceived sensitivity, and by introducing the potentially dangerous nature of IDA to improve the perceived severity.

Self-efficacy structure: Based on the theories of behaviorism, Bandura’s cognitive learning and health belief, skills (such as washing hands correctly, cleaning vegetables to prevent parasitic infections, choosing a diet rich in iron and vitamin C, etc.) were tried with the method practical demonstrations, group discussion and group problem solving to improve self-efficacy in student girls.

Since the use of group problem-solving techniques increases self-esteem, and also since self-esteem has a two-way relationship with self-efficacy, this issue itself had a double effect on improving skills and self-efficacy level. In this study, the researcher observed evidence of it in adolescents through taking responsibility in improving skills related to preventing IDA, willingness to participate in meetings, active participation in group discussions, and practicing learning-related techniques.

Self-belief/self-esteem structure: The structure of self-belief/self-esteem: according to the theory of participation, the effort was to encourage students in the areas of learning by assigning responsibility to them. In this way, the researcher asked the student girls to teach their mothers what they had learned. Also, the summary of the content of each session was provided in the form of educational reminder cards that were provided to the student girls so that they could carry them with them during the implementation of the educational participation program. Any questions about what they learned were raised at the beginning of the next session, and they received the necessary answers.

Due to the possibility that the mothers were not empowered by teaching the student girls and studying the educational card, they were also invited to the school to discuss the contents that the teenager taught them and what they learned from the educational card during 1-2 sessions. In these meetings, most of the contents were expressed by the mothers regarding anemia and the solutions and actions taken by them, the calculations of dietary iron, and the researcher only had a guiding role, and if the information and functional behavior of the mothers were insufficient, more information would be added. And the necessary measures were practically shown.

Evaluation structure: The evaluation included the evaluation of the process (during the steps) and the final evaluation (after the test). During empowerment sessions, the knowledge and awareness of student girls were evaluated. Thus, in each session, 2 questions related to what was learned in the previous session were asked orally. Also, mothers, as active members of the family, were asked to answer 2 questions written on the back of each reminder card, thus recording their feedback from that meeting and presenting it to the researcher. Receiving these cards was a sign of self-esteem resulting from students taking responsibility for improving their health.

To determine the final effectiveness of the empowerment program, adolescents and mothers needed to be without intervention for 1.5 months so that their empowerment indicators could be evaluated. In the meantime, the girls were assured that they would be given any necessary questions and guidance in choosing their conscious goals in line with the various dimensions of behavior related to IDA. This caused a strong two-way relationship with the researcher. It should be noted that the control group was not trained and completed the questionnaires at the same time as the test group (final evaluation).

SPSS version 16 statistical software was used for data analysis. In descriptive statistics, mean, standard deviation, frequency, and percentage were used. According to the result of the Kolmogorov-Smirnov test based on the normal distribution of the data, independent t-tests, and paired t-tests were used to compare the two groups before and after the experiment. The significance level in this study was considered less than 0.05.

In this study, the average age of adolescent girls in the experimental group and the control group was 16.0 ± 0.77 years and 16.25 ± 0.79 years, respectively. The average age of the mothers in the test and the control group was 47.43 ± 5.72 and 46.47 ± 5.12 years. From this point of view, there was no significant difference between the two groups. According to the chi-square test, no significant difference was observed between the demographic variables in the test and control groups, and the two groups were similar in terms of demographic data (p < 0.05).

Before the intervention, there was no significant difference between the test and control groups in the mean scores of perceived sensitivity (p = 0.85), perceived intensity (p = 0.71), and overall perceived threat (p = 0.89) of student girls, while after the intervention, these differences were significant (p = 0.000).

Before and after the intervention, results showed a significant difference in the comparison of the mean scores of perceived sensitivity, perceived intensity, and the overall perceived threat of student girls in the test group (p = 0.000), but there were no significant differences in the control group.

Before the intervention, there was no significant difference between the test and control groups in the comparison of the mean scores of self-efficacy (p = 0.97) and self-esteem (p = 0.85) of the adolescents, while after the intervention, these differences were significant (p = 0.000). Also, the comparison of the average self-efficacy and self-esteem of the adolescents in the test group before and after the intervention showed a significant positive difference (p = 0.000), but in the control group, there was no significant difference (p > 0.05).

In total, the comparison of the mean capability score of student girls in the test group before and after the intervention showed a significant difference (p = 0.000), but there was no significant difference in the control group (p = 0.175) (Table 2).

Before the intervention, there was no significant difference between the test and control groups in the mean scores of perceived sensitivity (p = 0.92), perceived intensity (p = 0.64), and overall perceived threat (p = 0.69) of active family members (mothers), while after the intervention, these differences were significant (p = 0.000).

Before and after the intervention, results showed a significant difference in the comparison of the mean scores of perceived sensitivity, perceived intensity, and the overall perceived threat of active family members (mothers) in the test group (p = 0.000), but there were no significant differences in the control group.

Before the intervention, there was no significant difference between the test and control groups in the comparison of the mean scores of self-efficacy (p = 0.99) and self-esteem (p = 0.85) of the active family members (mothers), while after the intervention, these differences were significant (p = 0.000). Also, the comparison of the average self-efficacy and self-esteem of the active family members (mothers) in the test group before and after the intervention showed a significant positive difference (p = 0.000), but in the control group, there was no significant difference (p > 0.05).

In total, the comparison of the mean capability score of active family members (mothers) in the test group before and after the intervention showed a significant difference (p = 0.000), but there was no significant difference in the control p = 0.06) (Table 3).

Considering the growing prevalence of chronic diseases in Iran, it is recommended to take measures to increase the ability of patients to take care of themselves [24]. Participating in health care in the form of mutual communication between the patient, family, and health workers has a better effect on promoting self-care behaviors such as controlling disease symptoms, accepting dietary and therapeutic regimens, maintaining a healthy lifestyle, disease control, and daily functioning, and for this reason empowering all family members, especially in chronic conditions, is known to be essential [6,25].

Supporting and increasing the knowledge of family members in the field of self-care needs of chronic patients is the best source for supporting the patient and strengthening their adaptation to the existing conditions, and maintaining their quality of life. Therefore, in the process of care and education, nurses should pay special attention to this important resource and have a suitable program to improve knowledge and empower family members. Few studies have been conducted on the effect of the FCEM on people with chronic diseases and their caregivers or family members. Most of these studies have focused only on the effect of this model on patient outcomes [26-28]. However, in the current research, the effectiveness of the FCEM has been measured on adolescents with IDA and their mothers.

Based on the results of the present study, the FCEM, in its first step, was able to improve the perceived sensitivity, perceived intensity, and overall perceived threat of teenagers in the test group with the group discussion method. Considering that perceived severity and perceived sensitivity are rooted in knowledge and attitude, it can be concluded that the knowledge and attitude of adolescents under research in the test group regarding the causes, signs, symptoms, complications, and consequences of IDA have also improved. As the results showed, the FCEM in its second and third steps has been able to improve the self-efficacy and self-esteem of teenagers by using the problem-solving method or group problem-solving, and educational participation. In this step, the students faced their problems and the problem-solving process. In total, the comparison of the average empowerment scores of teenagers in the test group before and after the intervention showed a significant difference in the direction of increasing empowerment of the test group. Zarei, et al. [29] state that family-oriented empowerment can create motivation and interest for children with chronic diseases along with their families. Pilevar, et al. [30] state that empowerment programs increase self-confidence in patients and empower them in self-care.

The positive results of this model on the self-efficacy and self-esteem of adolescents with thalassemia major have also been confirmed in the study of Brinnejad, et al. [31], Nasrabadi, et al. [32]. Ateshzadeh, et al. [33] also showed in their study that the FCEM was effective in empowering people with diabetes to change their lifestyle and diet. In line with the above studies, Erni Yetti and colleagues [34] showed in a study that FCEM through the promotion of family self-efficacy was able to bring about a beneficial change in the family lifestyle and eating habits of overweight and obese teenage girls. The above studies show that the implementation of the empowerment model in children with a chronic disease improves clinical results, increases family cooperation, improves knowledge, self-efficacy, and self-esteem, and reduces morbidity and mortality caused by the disease, and reduces costs, which are in line with the results of the present study.

The results of Abedini, et al.’s research [17] also showed that after 3-5 sessions of empowerment intervention and after one and a half months, all three areas of empowerment (perceived threat, self-efficacy, and self-esteem) in patients with artificial heart valves significantly improved. Although the above study was conducted in a group of adult patients, its results confirm the findings of the present study.

Children with chronic diseases depend on their parents to adhere to the therapeutic and nutritional regimen. So, if parents lack sufficient knowledge in this field, they face a lack of control over the disease [27]. As mentioned, in the FCEM, parents also have an active role; therefore, in this study, in each training session, the adolescent was asked to transfer the educational materials to the active member of his family (mother) and participate in the education and empowerment of his family.

Yang and Conde [35] stated in their study that participation plays a vital role in empowering members to cope with accepting the nature of their illness, improving their capacity to care for their health, and promoting the health of others. So, even in elderly patients, family participation in their adherence to drug treatment has been effective in controlling blood pressure.

Based on the findings, the levels of variables of perceived sensitivity, perceived intensity, and overall perceived threat in parents have improved after the empowerment intervention. Since perceived severity and perceived sensitivity are rooted in knowledge and attitude, it can be concluded that the knowledge and attitude of the active family members (mothers) in the test group have also improved. In line with the findings of the present study, Hemtipour, et al. [27] in their study on 8-12-year-old children with thalassemia showed that the level of knowledge and awareness of their parents after using 4 training sessions of 45 - 60 minutes based on the multimedia teaching method FCEM has been upgraded. In this study, we used the face-to-face method, which seems to be a more effective method. In confirmation of this matter, Ramezani, et al. [36] state that the face-to-face educational method is more effective than other methods in increasing people’s awareness and attitude regarding the risk factors that cause cardiovascular disease.

As the results showed, the FCEM in its second and third steps has also been able to improve the self-efficacy and self-esteem of active family members (mothers). The current study examined the self-efficacy of mothers in terms of nutritional and health behaviors that they had learned through the participation of teenage girls in education, and if needed, with the help of the researcher. The increase in the self-efficacy scores of the mothers in the test group showed that teenage girls were successful in transferring concepts to their mothers and improving their self-efficacy. In the study by Hemtipour, et al. [27], the self-efficacy of parents of children with thalassemia increased significantly after using the model, which is in line with the findings of the present study. The positive results of this model on the self-efficacy and self-esteem of cardiac patients in Abedini, et al.’s study [37] and on the self-efficacy and self-esteem of family caregivers of children with thalassemia have also been confirmed in the study of Vacharasin, et al. [38].

In total, the comparison of the mean scores of the active members of the family (mothers) in the test group before and after the intervention showed a significant difference in the direction of increasing the test group’s empowerment. Examining the results indicates that the FCEM in this study has been able not only to improve the empowerment of adolescents in the test group but also to have a positive effect on the empowerment of the active family member to control IDA in the affected adolescent and improve their health. Considering the significant role of mothers in families and the significant effects of mutual relations between family members, it was expected that the empowerment of an active family member would lead to the empowerment of the entire family system. Empowering the family, in turn, increases the self-efficacy of family members in caring for chronically ill members and improves their health [39].

From the findings of the present study, it can be concluded that despite slight changes in some empowerment indicators, the FCEM can be used to improve the level of knowledge, performance, and educational participation of students at any level. Considering the results of this research and the important and strong position of students as future makers and missionaries in various fields, including health, and also increasing the statistics of chronic diseases, it is suggested to use this method as a school- and family-oriented method. It is better to implement such participatory health programs continuously in schools by planners and administrators.

Limitation

The limitations of the research in the present study were as follows: the limited sample that was studied, which is recommended to include other age groups exposed to IDA, such as pregnant women, the elderly, in addition to teenagers in future studies. Differences in psychological characteristics, interpersonal interactions, and differences in people’s motivations and personalities, teenagers’ and parents’ curiosity to receive information about IDA in other ways are factors that cannot be controlled by the researcher but may affect knowledge, self-efficacy, and subsequently, the empowering capacity. The verbal and emotional communication with the researcher and mothers and teenagers during the empowerment sessions and the friendly atmosphere in these sessions may also have influenced the results in the intervention group.

The researchers consider it necessary to appreciate the cooperation of Tarbiat Modares University officials and research assistants, and all school officials, teachers, mothers, and students.

Authors contribution

F.S.S.N.R. conducted sampling, data collection, and empowerment sessions. H.N. supervised the analysis and research process and reviewed the manuscript. All the authors read and approved the final manuscript. All of the authors have read and approved the final version of the manuscript.

Funding sources

Financial support for conducting this research was provided by the Faculty of Medical Sciences of Tarbiat Modares University, but the author(s) did not receive any financial support for the publication of this article.

Data availability: The data sets analyzed in this study are not publicly available because the privacy of the samples may be compromised. But they are available from the corresponding author (FSSNR) upon reasonable request.

Declarations

Ethical approval and consent to participate: Ethical approval was obtained from the Ethics Committee of Tarbiat Modares University (number 52/3528) before conducting this study. All the study participants provided written informed consent for their involvement.

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