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Effects of a nutrition education intervention designed based on the health

belief model (HBM) on reducing the consumption of unhealthy snacks in the
sixth grade primary school girl...

Article · January 2017

DOI: 10.22038/ijp.2016.7567

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Original Article (Pages: 4361-4370)

Effects of a Nutrition Education Intervention Designed based on

the Health Belief Model (HBM) on Reducing the Consumption of
Unhealthy Snacks in the Sixth Grade Primary School Girls
Azam Fathi1, Gholamreza Sharifirad2, Zabihollah Gharlipour2, Javad Hakimelahi3, *Siamak
Mohebi21
1
MS Students in Health Education and Promotion, Qom University of Medical Sciences, Qom, Iran.
2
Department of Health Education and Promotion, Faculty of Health, Qom University of Medical Sciences, Qom,
Iran. 3Assistant Professor of Pediatric Diseases, Qom University of Medical Sciences, Qom, Iran.

Abstract
Background
Malnutrition can threaten mental and physical development of children while healthy nutrition can
improve mental and physical status of children. To select the best foods, children need nutrition
education. This study aimed to determine the effect of nutrition education on reducing the
consumption of unhealthy snacks in female primary school students in Qom- Iran.
Materials and Methods
This interventional study was conducted on 88 students in intervention and control groups who were
selected via multistage random sampling method. The data was collected using a valid and reliable
researcher-made questionnaire which was designed based on the health belief model (HBM). First
four training sessions were held for the intervention group; two months later, data were collected
again from both groups of students (intervention and control group). The collected data were analyzed
by SPSS version 16.0 using descriptive statistics and independent and paired t-test.
Results
The mean score of knowledge and performance of the intervention group, were 96.12 and 18.61
before the intervention which changed to 110.00 and 68.22 after the intervention. The results showed
that before the intervention there was no statistically significant difference between the two groups in
terms of mean scores of knowledge, and the constructs of the health belief model (P>0.05). After the
intervention, the scores of all variables and the behavior of unhealthy snacks consumption were
significantly increased in the intervention group (P<0.05).
Conclusion
This study showed that the nutrition education program (designed based on the HBM) was effective
in reducing the consumption of unhealthy snacks as it increased the scores of the Health Belief Model
constructs and decreased the score of perceived barriers.
Key Words: Health belief model, Iran, Students, Unhealthy snacks.

*Please cite this article as: Fathi A, Sharifirad Gh, Gharlipour Z, Hakimelahi J, Mohebi S. Effects of a Nutrition
Education Intervention Designed based on the Health Belief Model (HBM) on Reducing the Consumption of
Unhealthy Snacks in the Sixth Grade Primary School Girls. Int J Pediatr 2017; 5(2): 4361-70. DOI:
10.22038/ijp.2016.7567

*Corresponding Author:
Siamak Mohebi, Department of Health Education and Promotion, Faculty of Health, Qom University of Medical
Sciences, Qom, Iran.
E- mail: [email protected]
Received date Nov.15, 2016; Accepted date: Dec.22, 2017

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Breakfast Consumption and its Related Factors among Elementary Students

1- INTRODUCTION accordingly, children who did not consume

unhealthy snacks had a better growth
Students make up a significant
status than the other children (12).
percentage of the population; as they are at
Nutritional behaviors during childhood are
growth age and because of their physical,
one of the potential determinants of
psychological, and social characteristics,
nutritional behaviors in other stages of life.
they are highly vulnerable (1). Nutritional
As a result, it is important to train children
health, especially in childhood and during
about the benefits of healthy nutrition. The
the process of growth, plays an essential
effectiveness of education programs for
role in health (2). Multiple risk factors,
students depends on many factors. The
including obesity, hyperlipidemia, and
main goal of health education theories and
blood pressure disorders start from
models is primarily to identify these
childhood and continue to adulthood, and
factors which can be used for behavior
they are linked to illnesses in later stages
modification. Currently, there are various
of life. The results of many studies are
theories and models in health education
indicative of the rising trend of overweight
which are usually selected and utilized by
and inactivity (3); they have also warned
researchers depending on the subject of
about people’s tendency toward the
training, target population, and the results
consumption of high calorie junk foods
of previous studies.
with low nutritional value (4).
Studies by Hooper et al. (13), and Choi et
The current unfavorable behaviors and
al. (14), showed a significant positive
habits of children in our community not
relationship between the mean knowledge
only are seen as a threat to the health of
score and nutritional behavior. In addition,
this vulnerable age group, but have also
studies by Lotfi et al. (15), and Ghafari et
put our country at risk of epidemics of
al. (16), showed that nutritional behavior
non-communicable diseases. Adopting a
had a significant positive relationship with
healthy lifestyle can reduce the risk of
the scores of the perceived susceptibility,
non-communicable diseases such as
perceived severity, perceived benefits,
cardiovascular diseases, diabetes, and
perceived barriers, and self-efficacy;
osteoporosis (5). Many studies have
another study also concluded that the
reported the existence of unfavorable
increase in mothers self-efficacy and
patterns of snacks and junk food
family support play an important role in
consumption among Iranian children and
improving children's nutrition (17).
adolescents (6-8). Unhealthy snacks are
energy-dense and contain high amounts of According to some other studies (18-21),
salt and sugar. Thus, they can be increase the use of Health Belief Model as a
the risk of different diseases in adulthood framework helped to increase the scores of
such as obesity, diabetes, and awareness, perceived severity, and
cardiovascular disease (6, 9, 10). perceived benefits and reduce the score of
perceived barriers, and ultimately improve
The results of a study showed that
nutritional performance. Taking into
multiple risk factors, including parental
consideration the results of previous
education and family income level are
studies, which are suggestive of a
among the risk factors for child nutrition
relationship between nutritional behavior
(11). The results of another study showed
and some other factors (such as perceived
that 11.3% of the families served
self-efficacy, perceived benefits, perceived
unhealthy snacks for their children; the
barriers, social support, perceived
study also showed a significant
susceptibility, and perceived severity), and
relationship between the consumption of
given the positive effect of educational
junk foods and the growth of children;

Int J Pediatr, Vol.5, N.2, Serial No.38, Feb. 2017 4362

Fathi et al.

intervention on some of these constructs, it about behaviors related to unhealthy junk

seems that the Health Belief Model is a food consumption (28 questions).
suitable model for designing and Demographic part of the questionnaire
implementing an intervention program in includes questions about age, education
this field. Therefore, this model can be level of the mother and father, and job
used as an appropriate framework for the status of their parents. Questions based on
study of dietary behaviors in children, the Health Belief Model included 70 items
especially for the study of consumption of to measure knowledge, perceived
unhealthy junk foods. Therefore, this study susceptibility, perceived severity,
aimed to determine the effect of a nutrition perceived benefits, perceived barriers, self-
education program (designed based on efficacy, and social support. To measure
health belief model) on reducing the knowledge, there were 24 questions which
consumption of unhealthy snacks in were answered with true and false choices
female primary school students, in Qom and they were intended to evaluate the
city, Iran. knowledge about behaviors associated
with junk food consumption. A right
2- MATERIAL AND METHODS answer was scored 1 points and a wrong
2-1. Study design and population answer was given zero points. There were
a total of 24 items to evaluate the
This experimental interventional study was constructs of perceived susceptibility,
conducted in 2016. The study population perceived barriers, self-efficacy, and social
was consisted of female sixth grade support (six questions corresponding to
primary school students in Qom city, Iran. each construct). Moreover, 14 items were
2-2. Methods used to evaluate perceived severity and
perceived benefits (seven questions
Using multistage random sampling corresponding to each construct); these
method, a total of 88 female students were questions were scored on a four-point
selected and allocated to intervention Likert-type scale (completely agree to
group (n=44), and control group (n=44). completely disagree). These questions
( n  2( z1  z2 2 ) s ),
2 2
were designed for two ranges and every
Using the formula
d item was given a score of 1 to 4 depending
the number of samples in each group was on the option chosen on the scale.
calculated as 44 (a total of 88 students). In The third part of the questionnaire was
order to set the significance level of the designed to evaluate the performance
minimum differences in mean values of related to the consumption of unhealthy
the parameters between the two groups, we snacks; it had 28 items, which were
considered a confidence level of 95%, a answered using a five-point Likert-type
test power of 80%, and an accuracy of 0.6. scale (always, often, sometimes, rarely, or
2-3. Measuring tools: validity and never). Considering the abovementioned
reliability facts, knowledge scores ranged from 0 to
24 points. Perceived susceptibility,
In order to collect the required data, we
perceived barriers, self-efficacy, and social
used a researcher-made questionnaire
support were scored from 6 to 24 points.
which was designed based on the Health
The scores of self-efficacy, perceived
Belief Model; the questionnaire was
severity, and perceived benefits ranged
consisted of three parts including: A:
from 7 to 28 points, and the score of
demographic data (5 questions), B:
performance score ranged from 28 to 140
questions based on the Health Belief
points. In order to verify the face and
Model (70 questions), and C: questions

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Breakfast Consumption and its Related Factors among Elementary Students

content validity of the questionnaire, it was intervention program designed was also
reviewed by a panel of experts which was administered for the control group so that
consisted of five faculty members of Qom they benefit from the educational content
University of Medical Sciences; we as well.
collected their comments on the
2-6. Inclusion and exclusion criteria
questionnaire and utilized them to modify
the questionnaire. In order to determine the Inclusion criteria were the followings:
reliability of the questionnaire, in a physical and psychological readiness and
separate stage, it was completed by 20 ability to participate in the study, and
students from the same target group and being a student in public schools. Lack of
internal consistency coefficient was desire to participate in the study and being
assessed via utilizing Cronbach's alpha affected by a special disease were set as
coefficient; a coefficient of at least 0.7 was the exclusion criteria.
obtained for every construct in the 2-7. Data Analyses
questionnaire. All the questionnaires were
completed by a trained interviewer (the The collected data were analyzed by SPSS
first author) via structured interviews with version 16.0 software using descriptive
all students surveyed (both intervention statistics such as mean and standard
and control groups). deviation (SD) and independent and paired
t-test Chi-square and Mann–Whitney test.
2-4. Intervention The significance level was set at 0.05.
Education intervention for the student's Independent t- test was used to compare
intervention group was carried out within the mean scores of knowledge and all the
four 45-minute sessions through giving constructs of Health Belief Model and
lectures (accompanied with questions and performance between intervention and
answers), and using teaching aids such as control groups before and after the training
pamphlets and posters (which were intervention.
designed based on the Health Belief Moreover, paired t-test was used to
Model). The training session were held by evaluate the effectiveness of intervention
a teacher (researcher) in schools for four and compare the abovementioned variables
weeks. Mothers and teachers also attended in each group separately before and after
the training sessions. In order to consider the intervention. Chi-square test was used
the construct of social support, we invited to compare the two groups in terms of the
mothers and teachers to attend the training frequency of parents’ job status. Finally,
sessions. During that time no educational Mann Whitney U test was used to evaluate
program was implemented for students in the differences between the two groups in
the control group. terms of education level.
2-5. Ethical consideration
3- RESULTS
In order to observe ethical issues in our
study, the data was collected after According to the results, there was no
obtaining approval from the Ethics significant difference between intervention
Committee of the University and after and control groups in terms of education
making coordination with authorities. In level and job status of parents (P>0.05).
addition, before collecting the data, the Table.1 presents the data on these two
objectives of the study were explained to items. In this study, the mean and standard
the students and their mothers and a deviation (SD) of students' score of
written informed consent was obtained. knowledge (the score of 0- 24) before the
After the end of the post-test, the intervention in intervention and control

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Fathi et al.

groups, was 18.61±2.18 and 19.00±2.12, constructs of the Health Belief Model
respectively; the results of independent t- significantly increased in the intervention
test showed no significant difference group, as compared with the control group;
(P=0.41). However, after education accordingly, paired t-test showed a
intervention, students' score of knowledge significant difference (P<0.05). Table.2
was changed to 22.68±1.02 and presents the mean scores of the studied
19.84±2.42 in the intervention and control variables in the two studied groups.
groups, respectively; the results of In this study, the mean and standard
independent t-test showed a significant deviation of performance (the score of 28-
difference between the two groups 140) of the intervention group in not
(P>0.001). consuming unhealthy snacks was
The results of independent t-test showed 96.93±12.07 before the intervention which
no significant difference between the increased to 110.00±8.62 after the
intervention and control groups in terms of intervention; the results of paired t-test
constructs of the Health Belief Model showed a significant difference (P<0.001).
before the intervention (P>0.05); but after The mean and standard deviation of
conduction the education intervention, this
performance of the control group was
test showed a significant difference 96.25±11.38 before the intervention which
between the two intervention and control changed to 97.52±10.68 after the
groups (P>0.001). intervention; it did not show any
The results obtained also showed that after significant difference (P=0.17).
the intervention the mean scores of the

Table-1: Frequency distribution of the level of education of parents of the studied students
Intervention group Control group
Education level P-value
Frequency Percentage Frequency Percentage
Illiterate 4 9.1 2 4.5
Primary school 16 36.4 15 34.1
Mother’s education Junior high school 9 20.5 11 25 0.25
High school 11 25 12 27.3
Academic degree 4 9.1 4 9.1
Illiterate 2 4.5 0 0
Primary school 12 27.3 9 20.5
Father’s education Junior high school 16 36.4 17 38.6 0.17
High school 9 20.5 12 27.3
Academic degree 5 11.4 6 13.6
Housewife 40 90.9 39 88.6
Mother’s job status 0.30
Employed 4 9.1 5 11.4
Civil servant 6 13.6 7 15.9
Father’s job status Self employed 34 77.3 35 79.5 0.33
Worker 4 9.1 1 2.3

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Breakfast Consumption and its Related Factors among Elementary Students

Table-2: Comparison of mean and standard deviation of the health belief model constructs before
and after the intervention in the intervention and control groups
Intervention P-
Control group
Health Belief Model constructs group value
Mean ± SD Mean ± SD
Before education 18.15±3.34 18.50±3.46 0.64
Perceived susceptibility, (the score of 6-24) After education 22.00±2.19 18.88±3.34 0.001
Paired t-test P<0.001 P=0.008
Before education 20.11±4.55 20.97±3.84 0.33
Perceived severity, (the score of 7-28) After education 24.75±3.47 20.47±4.17 0.001
Paired t-test P<0.001 P=0.45
Before education 20.63±4.06 19.29±4.60 0.15
Perceived benefits, (the score of 7-28) After education 24.36±2.60 19.79±4.55 0.001
Paired t-test P<0.001 P<0.04
Before education 15.50±4.07 15.90±3.94 0.63
Perceived barriers, (the score of 6-24) After education 17.72±3.37 15.54±4.77 0.001
Paired t-test P<0.008 P=0.48
Before education 16.84±4.11 15.20±4.19 0.06
Self-efficacy, (the score of 6-24) After education 19.36±2.87 15.38±4.11 0.001
Paired t-test P<0.001 P=0.73
Before education 18.93±3.20 18.63±4.19 0.71
Social support, (the score of 6-24) After education 21.88±2.54 18.59±3.32 0.001
Paired t-test P<0.001 P=0.93
Before education 96.93±12.07 96.25± 11.38 0.78
Performance, (the score of 28-140) After education 110.00± 8.62 97.52± 10.68 0.001
Paired t-test P<0.001 P=0.17
SD: Standard deviation.

4- DISCUSSION
The results of our study showed that
Poor nutrition is a risk factor for many
education intervention significantly
diseases. People’s and especially
increased the score of perceived
children’s tendency toward unhealthy
susceptibility in the intervention group
foods is alarming (22). On the other hand,
after the intervention. In other words, after
eating habits are influenced by childhood
the intervention the intervention group
experiences (23, 24).
after became more susceptible to the
The results of our study showed a consequences of the consumption of
significant increase in mean score of unhealthy snacks and found themselves at
knowledge in the intervention group after risk of problems caused by the
the intervention. Studies by Kim et al. consumption of unhealthy snacks.
(13), and Amode and et al. (25), similarly However, after the intervention no
showed significant increase in mean score significant difference was observed in the
of knowledge in the intervention group control group (P=0.08).
after nutrition education, as compared with
This significant increase in this construct
their scores before the intervention. The
suggests the effectiveness of the
findings of the two mentioned studies are
educational program which was designed
consistent with the finding of the present
based on the Health Belief Model, as it
study and confirm it.
enhanced students' susceptibility to proper

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Fathi et al.

nutritional behaviors. Other studies which unhealthy snacks; we also introduced and
have utilized this model suggest that acknowledged healthy students which had
education interventions increased been selected as examples and motivated
perceived susceptibility among the studied other students to promote their self-
samples; it is consistent with the result of efficacy as well. In this study, the mean
this research (21, 26). The results of this score of self-efficacy had a significant
study showed a significant increase in the increase in the intervention group.
score of perceived severity construct in the Hoseinnejad et al. (31), and Dehdari and
intervention group after the education. Chagani (32), investigated the role of self-
Perceived severity is an individual's efficacy in predicting students' eating
subjective perception of the seriousness of behaviors and the results of the mentioned
the consequences of non-compliance with studies showed a significant positive
proper eating behaviors. The increase in relationship between the mean scores of
mean scores of perceived severity in the dietary behavior and self-efficacy.
intervention group after training has been In this study we invited the teachers and
observed in several studies, which is mothers of the students in the intervention
consistent with the result of present study group to participate in training sessions
(27, 28). and interventions, so that students obtain a
Moreover, in this study the mean score of greater perception of support from the
perceived benefits had significantly surrounding social environment, and thus
increased in the intervention group after develop higher levels of self-efficacy for
the intervention. This could have an the utilization of proper dietary behaviors.
important role in the prevention of harmful In Najimi and Ghaffari’s study (2013),
health behaviors. In a study by Siukiand et teachers and parents of students in the
al. (29), after the intervention the students intervention group, were also involved in
in the intervention group earned 82.28% of the intervention. After a three-month
total score of perceived benefits. It is in follow-up, there was a significant increase
line with the results of this study. in the students’ scores of self-efficacy and
Concerning perceived barriers construct, perceived support for the consumption of
the mean score of the intervention group fruit and vegetables (33).
was increased after the intervention and The results also showed an increase in
the results of paired t-test also proved its mean score of students’ performance in
significance. In a study by Hazavehei reducing the consumption of unhealthy
which investigated the prevention of snacks in the intervention group after
osteoporosis in female students, there was training. As the results of paired t-test
a significant increase in the score of showed the increase in score was
perceived barriers in the intervention significant. However, there was no
group after the intervention; this finding is significant difference in the control group
consistent with the result of our study (30). before and after the intervention. This
In this study, students’ self-efficacy was finding is consistent with the results of
evaluated too. Self-efficacy is an studies by Sharifirad et al. (34), and
individual’s judgments about and Kamaliand Heidarnia (35).
confidence in its own ability to perform a
4-1. The limitation and strengths of
particular action (5). In this study, in order
study
to enhance the students’ self-efficacy, we
tried to demonstrate the practical and The required data for this study was
potential results of following a healthy diet collected via students’ self-reports, thus it
through reducing the consumption of cannot be free from errors. In addition, in

Int J Pediatr, Vol.5, N.2, Serial No.38, Feb. 2017 4367

Breakfast Consumption and its Related Factors among Elementary Students

the schools where the intervention took students in other educational levels and in
place, all school authorities were not other parts of the country. It is also
involved in the program; it is one of the suggested to consider the role of families
most important limitations of this study. and their attitudes toward reducing the
Nevertheless, a trained interviewer consumption of unhealthy snacks.
completed the questionnaires via
conducting structured interviews with the 6- CONFLICT OF INTEREST: None.
study participants; it is one of the strengths 7- ACKNOWLEDGMENTS
of this study.
This paper is extracted from a health
5- CONCLUSION education master's thesis. The research
was approved byEthics Committee of Qom
The results of the study showed that the University of Medical Sciences
nutrition education program (which was (Registration code:IR. MUQ.REC.
designed based on health belief model) 2016.31). This study received a code by
was effective in reducing the consumption the Clinical Trial Registration Center
of unhealthy snacks amongsixth grade (code: IRCT2016071628952N1). The
primary school students in Qom. With
authors would like to express their thanks
increasing the scores of health belief to the educational authorities and the staffs
model constructs, the intervention had a in higher education department, all
positive impact on students’ behavior and students who participated in the study and
reducedthe consumption of unhealthy their parents, andrespectedprincipals of
snacks. Given the results obtained in this schools who had been involved in the
study and considering the impact of this study.
model in providing appropriate
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