Journal of Epidemiology & Health Care

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Research article

Knowledge and Practice after Health Education Program among Hajj 1438 H (2017) Pilgrims, in Saudi Arabia

Fahad A. Alamri1, Samar A. Amer2*and Najla J. Alhraiwil3

  • 1Family Medicine Department, Faculty of Medicine, Ministry of Health, Saudi Arabia
  • 2Public Health and Community Medicine Department, Faculty of Medicine, Ministry of Health, Saudi Arabia
  • 3Public Health Specialist, Faculty of Community Health, Ministry of Health, Saudi Arabia
Address for Correspondence; Samar A. Amer, Public Health and Community Medicine Department, Faculty of Medicine, Ministry of Health, Saudi Arabia, E-mail: Dr_samar11@yahoo.com
Citation: Alamri FA, Amer SA, Alhraiwil NJ. Knowledge and Practice after Health Education Program among Hajj 1438 H (2017) Pilgrims, in Saudi Arabia. J Epidemiol Health Care 2018;1(1): 7.
Copyright: © 2018 A. Alamri et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Journal of Epidemiology & Health Care | Volume: 1, Issue: 1
Submission: July 12, 2018 | Accepted: September 19, 2018 | Published: September 26, 2018

Abstract

Background: Hajj pilgrimage is the biggest and longest mass gathering across the globe drawing pilgrims from more than 185 countries. The rituals of Hajj are physically very demanding. These increase the risk of communicable and no communicable. Health education is one of the principal services provided for pilgrims from their arrival. The effectiveness of the applied health education program to control as much as possible the arising health problems and to updates health requirements for the 2018 Hajj, with the result that pilgrims now enjoy modern facilities and perform various rites at ease.
Aim of study: Improve the pilgrims overall health status in KSA; Through applying health education program, to increase the level health knowledge to improve some practice, at the same time determining the source of health information, among hajj 2017 pilgrims.
Methods: This is an intervention study; 5173 hajj pilgrims were randomly selected from 54 campaigns after Health Education Program. Data were collected using a questionnaire that was divided into three main parts. Part one addressed the general characteristics and hajj history. The second part addressed aspects related to knowledge, and its sources and practices. The third part briefly addresses some services and availability of some tools.
Results: Level of knowledge was very low in 8.9%, low in 23.7%, average in 40.9%, good in 17.9% and very good in 8.6% of respondents. The mean and standard deviation of practice score was 6.7±2.1 out of 8 (ranged between two and 8). Although the middle-aged pilgrims had the highest knowledge and practice scores. The old and low educated pilgrims had a little knowledge of health tips, they had a good health practice. Almost all respondents stated that they benefited from the health education program and that the health educator was successful in delivering the messages. Only 317(25.6%) reported that they had already received relevant health education messages prior to their arrival in Saudi Arabia.
Conclusion:Health educational strategy to pilgrims is effective in improving knowledge and practice andto decreases the prevalence of health disorders among hajipilgrims.

Keywords

Health education; Hajj; Pilgrims; Saudi Arabia

Abbreviations

WHO: World Health Organization; KSA: Kingdom Saudi Arabia; HE: Health Education; ARI: Acute Respiratory Infection

Introduction

Hajj pilgrimage is the biggest and longest mass gathering across the globe drawing pilgrims from more than 185 countries [1]. Due to Muslim (lunar-based) calendar, Hajj shifts forward by approximately 10 days each successive year, leading to its coincidence with different seasons every few years. Men, women, and children of all ages attend Hajj [2].
The rituals of Hajj are physically very demanding. Extreme physical stressors, such as extreme heat, sun exposure, prolonged stays at Hajj sites, dryness, of environment, overcrowding, and traffic congestions, air pollution and rough and uneven ground [3].These increase the risk of communicable and no communicable diseases [4].
The World Health Organization (WHO) defines health education as;“any combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes” and providing opportunities required to make health decisions or change health behaviors such as, hydrating, hygiene, healthy diet and sleep [5-7].
Health education is one of the principal services provided for pilgrims from their arrival. It has various modes, e.g. lectures, discussions, symposia, posters …etc. Each mode has its own merits, drawbacks and scope of effectiveness. Messages have to overcome communication barriers (e.g. physiological, psychological, environmental and cultural) [8]. The effectiveness of health education modes varies according to the setting in which it is delivered to a specific group [9-11].
The Hajj living circumstances and activities may create an environment, thus, health issues such as infections, accidents, complication of chronic diseases and climate complications may arise and affect the health & Hajj of those pilgrims [12]. The prepared nests plans made before the Hajj season ensures the optimum provision of health services for pilgrims, and to minimize disease transmission both during their stay home in the country and upon their return home [13].
Making necessary arrangements each year for the growing annual number of pilgrims that may reach up to 2,000, 000 poses a logistic challenge for the government of Saudi Arabia (as hosting country) [14], which has, since the 1950s, spent more than $100 billion to increase pilgrimage facilities [15].
Here, we conducted a study to evaluate the effectiveness of the applied health education program to control as much as possible the arising health problems and to updates health requirements for the 2018 Hajj, with the result that pilgrims now enjoy modern facilities and perform various rites at ease [16].

Objectives

To determine the source of health information, to apply health education program, to increase the level of health knowledge to improve some practice, and asses the Hajj 2017 pilgrims general health status (after haji).

Methodology

Through a post intervention study design, a stratified random sample of 5180 haji whom fulfill the selection criteria (aged >18 yrs without any mental or psychological disorders, from companies of countries that had >4000 haji pilgrims) after applying the health education programs in the targeted 54 campaigns of different countries, this study conducted in the three main cities (Mecca- Jeddah-Madinah) from August 18 to September 5, 2017 (11th -17th of Dhu’l-Hijjah), in the following places;
The calculated sample sizes were 2599 participants, calculated using Open Epi web. Targeted Population of 1,980,756 pilgrims , with 95% confidence interval, 80% power of the study, and less than 5% of errors and using the median percent of increase of knowledge after health education 15% among haji pilgrims. Then 2590 participants will be doubled to be 5190 (to compensate deviation from simple random sample), then proportionally divided into 46 different strata (nation), weighted according to the total number of pilgrims from each countries (according to the Saudi general authority of statistics (2016).

Application of the health education programs

By training 1626 medical staff (163 doctors and 1463 technicians); who were the medical teams of 54 campaigns of 45 countries (that had >4000 hajj plagiarisms). Then they educate 1,620,989 pilgrims.
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Through the use and distribute the following tools;

Data collection instrument

The questionnaire was designed in Arabic, and translated into 10 languages. The structured questionnaire divided into three parts. Part one addressed the general characteristics and hajj history. The second part addressed aspects related to knowledge, and its sources and practices. The third part briefly addresses availability of some tools and the health status after haji.
Trained data collectors did the interviewing, and some volunteers were recruited and trained for two days on how to undertake the interview. Along with constant monitoring of data to exclude incomplete responses.
Quantitative data summarized as Median and interquartile range. While Kruskall Wallis test and Mann-Whitney U test were used for their analysis while frequency and percentages for qualitative data summarization, and chi-square testing for related differences. Moreover, the level of significance p <0.05.

Results

Finally, 5173 pilgrims participated in this study selected randomly from 47countries, Arabic was the native language in about 49% of them, then English 13.2 ...etc (Figure 1) As17 questionnaires (0.03%) were, exclude due to their defects.
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Figure 1: The native language frequency distribution among participants.
67.3% of the participant were males,51% were above 50 yrs old, only about 11% were illiterate, about 66.7% had chronic diseases (74.4% of them had multiple diseases, 13.5% were diabetic, and 8.9% had cardio vascular disorders, and about 10.4% were handicapped), it was the 1st haji in 71.9%, about 91.8% of them examined before haji (89.4% as a campaign routine, and only 10.4% by themselves for self-assurance), about 22.3% didn’t vaccinated, while 21.4% received multiple vaccinations, 47.6% immunized for meningitis. The mean duration for haji in KSA was (9.3±2.9) range (4-21 days) (Table 1).
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Table 1:Shows the general characteristics of the participant haji pilgrim.
About 95.1% of the participants were interesting in receiving Health Education (HE). 25.6% of them received the HE at their native countries, while 29% received after arrival at their residence sites, and about 64.6% of them received HE at multiple sites. Only 316(6.8%) of the participant had not cell phone, while the remaining 4856(93.2%) having cell phone only about 2578(49.8%) had a smart phone with internet. Their personal knowledge obtained through the following routes boosters 38.8%, lectures (33.9%), social media and electronic webs nearly equal about (26.5%), and only 6.1% did not receive any education, as illustrated in details at (Table 2).
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Table 2: Shows the sites and sources of health knowledge among participants
The frequency distribution of the resources of some pilgrim’s tools showed that the solar umbrella is the only tool that provided as a gift on arrival or hajj had on personal acquisition). The campaigns were the main source of tools, while nearly about 12% of plagiarisms didn’t have the necessary studied tools.
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Table 3: Shows the sources and availability of some tools
Around 91.7% of the haji were had their own tools (Table 3)).The knowledge level was very low in 8.9%, low in 23.7%, average in 40.9%, good in 17.9% and very good in 8.6 % of respondents. Only 51.1% know the call No. of emergency, 78.4% reported that the medical team was available in their companies (11.7% don’t know, and only 9.6% say the medical teams was unavailable) (Table 4). The Mean and standard deviation of practice score was 6.7±2.1 out of 8 (ranged 2-8). Practice score in general was good. Except for the Following healthy ways to save food and using the solar umbrella constantly, only about 55% of answers were true, other item scores were good (Table 5). There was no difference between men and women regarding knowledge and practice scores (p >0.05) (Table 6). While the pilgrims aged 30- <50 yrs significantly had the highest knowledge and practice scores (p <0.05) (Table 7). Although, the old and low educated pilgrims had a little knowledge of health tips, they had a good health practice.
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Table 4: Shows the frequency distribution of some knowledge among studied haji pilgrims.
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Table 5: Shows the frequency distribution of some practice among haji subjects.
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Table 6: The relationship between the sex and the total knowledge and practice scores.
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Table 7: The relationship between the age groups and the total knowledge and practice scores.
Almost all pilgrims (99.6%) agreed the HE programme was beneficial, with 98.9% evaluating that program as successful in delivering the health education messages. So that (55.8%) of the pilgrims enjoy healthy hajj, only 44.25 was the morbidity rate among the studied participants from them (respiratory diseases 44.7%, heat disorders 3.7%, 2.1% inflammations, 0.88% food poisoning, 0.9% injuries, 0.94% skin disorders,1.48 complication of chronic disease, 0.73% hospitalized, and 15.3% were had multiple disorders) among studied subjects.

Discussion

In this study, we assessed the knowledge, and practices after health education program among hajj 1438H pilgrims, the majority of the represented haji sample were male (67.3%), and aged >50 yrs (51.2%), nearly more than 60% of them were educated, and 66.4% had chronic diseases, nearly similar results reported in studies [17-19]. The mean duration of stay in (Macca and Madinah ) was 10 days (d) range (4- 30) days, so environmental conditions, and health facilities during Umrah and haji are factors that influence our result [20].That was lower that study conducted on Singaporean pilgrims who 33.3% were short-trip packages with duration of stay ranging from 13 to 22 days. 60% were intermediate-trip packages with duration of stay between 24 to 31 days. Only 6.7% were long-trip packages with duration of stay ranging from 32 to 35 days [21].
The MOH in the KSA has addressed requirements and recommendations for visitors for the purposes of Hajj, through Health authorities in countries of origin to consider the physical ability and health conditions of individuals applying for Hajj [22]. So 91.8% were examined before travelling ,and only about 25% of studied haji didn’t vaccinated at all, 47.6% vaccinated against meningitis, and only 1.9% vaccinated against influenza. Although haji seasonal influenza vaccine is recommended by MOH [23], but vaccination coverage has been low before departure to Saudi Arabia [24]. That was lower than haji tips that reported that pneumococcal vaccination is indicated for about one-third regardless of the Hajj status; only 7% of pilgrims in whom pneumococcal vaccine was indicated were advised the same by general practitioners [25].
The enjoyment of health is one of the human rights, that all depends on the hygiene the most important goals in health promotion are empowerment of individuals through public awareness and knowledge about people’s health [26]. However, these studies overlook the relation between knowledge, and practice. Other studies are consistent with our findings [27,28].
The low rate for receiving pre-departure health education messages among those affluent enough to afford to travel by air, indicated a notable lapse in pre-travel preparation in the haji population, and a need for home country educational interventions that also reported by Turkestani et al. as in (Table 2) [29].
In this study, public awareness through media and public issues was good, and more health information was acquired by many uneducated (45.4%) and old age pilgrims participate, and most health problems during the trip occurred mainly in these groups, planning for their health education should be a priority as reported by Aminreza et al. [20]. The total knowledge and practice were good, although the pilgrims of old age and low level of education had little knowledge about health subjects, they had a good health attitude and practice, and the middle aged (30- <50 yrs) had the highest total knowledge and scores. Few studies have been down in the field of health knowledge during the Hajj. Aminreza et al. founded that, the Level of knowledge were very low in 12.1%, low in 25.2%, average in 38.1%, good in 20.4% and very good in 4.2% of respondents. The Mean and standard deviation of practice score was 8.19±1.32 out of 10 (ranged between 3 and 10). Although the old and low educated pilgrims had little knowledge of health tips, they had a good health attitude and practice, that consistent with this study [20].
There was no significant relationship between the sex and the total scores of knowledge and practice, different results reported by Philippe Gautret who assessed the knowledge of Hajj pilgrims about ARI (Acute Respiratory infection). Scores were also higher for female pilgrims. No other demographic or health factor had significant influence [30].
Although 99.9% of participants used mask in crowded places, the incidence of influenza was 44.7%, that explained by a systematic review on its use to prevent transmission of influenza concluded that there was no convincing evidence of protection against influenza infection and uncertainty about the mode of influenza transmission has influenced debate about when and whether to use it for pandemic influenza. Similar Observational studies have failed to demonstrate any clear benefit of its use among Hajj pilgrims [31].
The overall prevalence of health disorders among studied subjects e.g. (respiratory diseases influenza 27.4%, heat disorders 2.2%, 1.3% inflammations, 0.54% food poisoning, 0.57% injuries, 0.6% skin disorders, 0.91 complication of chronic disease, 0.32% hospitalized, and 9.4% were had multiple disorders, were significantly reduced than previous studies [32-35].
Only 27.4% of participant had respiratory disorders (influenza), that was lower than what Hosseini et al. reported that annually, about 50% of hajj pilgrims get involved in severe devastating coughs. That continue, so when turn back home transmit them to family members and other people [1]. That was significantly reduced (p <0.05%) in who use sterile jells and follow healthy practice when sneeze that agreed with, a cochrane review supports simple and low-cost interventions, particularly hand hygiene, reducing the transmission of respiratory viruses [36]. This study consists with another studies that showed that using the educational intervention (who depends on volunteers from various medical faculties and health institutes) improved knowledge and practice. Ourfindings showed significant improvement in the short-term knowledge level among intervention recipients. This effect has been established in previous studies in similar settings, including India and Saudi Arabia [8,37,38]; the authors recommended that health education-focused programmes should be conducted in small groups, preferably via specific topic lectures.
Our study had the following limitations; the limited time and resources available to conduct the current health education intervention presented a significant limitation. This population was not representative of all pilgrims. In addition, it was not possible to obtain a pretest and then directly paired responses from each of the pilgrims, some hajj may reluctant to tell the interviewers they had wrong practice because some was required e.g. vaccinated, examined pre departure, pilgrims’ self-reported behaviors may have resulted in over-reporting of correct health practices. In addition, this study design makes determining causality impossible. Anyway, educational strategy to improve knowledge re-grading health-related problems and to develop health practices among pilgrims is needed.

Conclusion

Health educational strategy to pilgrims is effective in increasing the level of knowledge to improve the practice to decreases the prevalence of health disorders among haji pilgrims across years.

Recommendations

Considerable effort on the part of governmental and private health organizations requires continuous training to face both current and future challenges, tailoring health education programs (messages ,tools ) to overcome the gaps and facing the challenges to manage hajj health hazards.

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