Khani Jeihooni et al.

BMC Endocrine Disorders (2023) 23:6 BMC Endocrine Disorders

https://doi.org/10.1186/s12902-023-01264-y

RESEARCH Open Access

Effect of educational intervention based

on PRECEDE model on lifestyle modification,
self‑management behaviors, and hypertension
in diabetic patients
Ali Khani Jeihooni1, Ali Sobhani2, Pooyan Afzali Harsini3 and Mehdi Amirkhani4*

Abstract
Background Inappropriate lifestyle and poor self-management in diabetic patients lead to many complications
including hypertension and increased disease burden. Because of insufficient studies on Effect of educational inter-
ventions on lifestyle, self-management and hypertension in diabetic patients, the present study aimed to evaluate
the Effect of educational intervention based on PRECEDE model on lifestyle, self-management, and hypertension of
diabetic patients.
Methods This clinical trial was conducted on 300 diabetic patients with hypertension. The patients were selected
using simple random sampling and divided into 2 groups of intervention (150 people) and control (150 people). The
intervention group was trained through ten 50–55 min sessions on lifestyle skills, self-management, and hypertension
control based on the PRECEDE model. Before and after the intervention, lifestyle skills, self-management, and PRECED
model constructs were evaluated using a standard questionnaire. Data were analyzed by SPSS 20 software using
t-test, Kolmogorov–Smirnov, and Chi-Square tests (P < 0.05).
Results In the intervention group, the mean score of different dimensions of lifestyle and self-management signifi-
cantly increased from 110.45 ± 18.78 to 172.58 ± 186.66 and 64.33 ± 15.24 to 144.32 ± 15.82, respectively (P = 0.001).
Mean systolic and diastolic blood pressure also decreased from 148.5 ± 5.39 to 123.54 ± 5.32 and 95.41 ± 3.12 to
72.24 ± 3.06 (P < 0.001). Moreover, the mean score of all the PRECEDE model constructs significantly increased after
the intervention. In the control group, the mean score of the PRECEDE model constructs, the dimensions of lifestyle,
self-management, and systolic and diastolic blood pressure did not change significantly before and after the interven-
tion (P > 0.05).
Conclusion ‌Based on the study’s results, the PRECEDE model was found to be a non-invasive, non-pharmacological,
cost-effective method without any complication and as a complementary action along with other methods in the
treatment of diabetic patients.
Keywords Life Style, Diabetes self-management, Diabetes Mellitus, Hypertension, PRECEDE model

3
*Correspondence: Department of Public Health, School of Health, Kermanshah University
Mehdi Amirkhani of Medical Sciences, Kermanshah, Iran
4
[email protected] Department of Nursing, School of Nursing, Fasa University of Medical
1
Nutrition Research Center, Department of Public Health, School Sciences, Fasa, Iran
of Health, Shiraz University of Medical Sciences, Shiraz, Iran
2
Department of Public Health, School of Health, Fasa University
of Medical Sciences, Fasa, Iran

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Khani Jeihooni et al. BMC Endocrine Disorders (2023) 23:6 Page 2 of 11

Background A study by Aghamalai et al. [15] showed that The edu-

Chronic diseases are one of the main issues affecting cational program based on the preceding model could
human health as life expectancy rises [1]. One of the effectively improve a healthy lifestyle in patients with
most common chronic illnesses, diabetes is referred hypertension. Azar et al. [16] showed that an educa-
to by the World Health Organization as a hidden pan- tional program based on the preceding model effectively
demic (WHO). According to previous study, if persons improves the life quality of hypertensive patients.
with diabetes effectively manage their hypertension, The results of a study entitled Effect of educational inter-
many complications may be prevented. [2]. Increas- vention based on precede model combined with self-man-
ing patients’ physical and mental function through agement theory on self-care behaviours in type 2 diabetic
lifestyle changes is the most important part of treat- patients showed that the educational intervention based on
ing chronic diseases [3]. When a person is aware of precede model alone or combined with self-management
the positive Effect a healthy lifestyle has on an illness theory could effectively improve predisposing, enabling,
and its complications, they are more likely to engage and reinforcing factors in type 2 diabetic patients [16]. A
in healthy habits [4]. Diabetics’ capacity to manage study by Barasheh et al. [17], Entitled effect of educational
their hypertension can be significantly impacted by program based on the preceding model on improving self-
educational interventions and the adoption of morally care behaviors in a semi-urban population with type 2 dia-
sound lifestyle and self-management practices [5]. Self- betes showed that Precede model would be an appropriate
management is the cornerstone of diabetes treatment, framework to educate patients with type 2 diabetes as well
and providing patients with diabetes with self-man- as promote self-care behaviors. The findings of the study
agement education is essential [6]. Self-management is of KhaniJeihooni [12] revealed that the design and perfor-
an active and practical process directed by the patient mance of educational programs based on precede model
[7]. If diabetic patients are to successfully manage their have an influence on the changes of predisposing factors,
condition, lead a healthy lifestyle, and avoid issues like reinforcing and enabling factors of overweight students,
hypertension, they must have access to enough infor- and caused the reduction of their weight.
mation [8]. Poor lifestyle choices, inappropriate self-management,
Today, education is one of the most important ele- and the increase of comorbidities such as hypertension
ments of health care [9]. Healthcare education and persist despite several studies on diabetes education.This
promotion emphasize improving lifestyle and self-man- study aims to assess the impact of an educational interven-
agement in response to people’s increasing involvement tion based on the PRECEDE model on diabetes patients’
in health-related activities. Additionally, it is one of the lifestyle, self-management, and hypertension. Furthermore,
best ways for people to maintain their health, achieved create a framework that predisposing factors (knowledge,
through effective and efficient instructional techniques attitude, and perceptions), reinforcing factors (influence of
[10]. Theories and models provide a methodical view of others, family, and peers), and enabling factors (availability
events and are a common way to evaluate successes and of resources and skills) are considered as factors affecting
failures. They provide information necessary for plan- behavior in educational diagnosis [18].
ning, carrying out, and assessing educational interven- Similar studies have been conducted in this field, but the
tions by acting as a map of the educational process [11]. present study has been done on a larger sample size than
Despite many models for health promotion, studies have similar intervention studies. Also, due to the Covid pan-
shown that the PRECEDE model is more appropriate for demic, it has used training methods in cyberspace and peer
designing health promotion programs [12]. This model it training. On the other hand, the use of educational meth-
consists of the initials of the following words (PRECEDE: ods such as group discussion, role-playing, and prepara-
Predisposing, Reinforcing, Enabling Constructs in Edu- tion and distribution of educational videos have slightly
cational, Diagnosis, and Evaluation) and. differentiated this study from similar studies. The results of
It was designed by Lawrence Green and Marshall Crot- similar studies also show that more studies are needed to
ter in 1980 to change behavior and examine an educa- optimally judge and evaluate the intervention’s impact.
tional program’s possible outcomes. The model addresses
all the educational needs for health promotion from dif- Methods
ferent aspects of values, beliefs, and attitudes and is flex- This intervention study was conducted on 300 type two
ible, acceptable, measurable, and process-oriented [13]. diabetes mellitus patients with hypertension under the
Additionally, it offers a structure for figuring out the ena- auspices of Fasa Diabetes Center. Based on previous
bling, reinforcing, and predisposing elements that affect studies [19, 20].
behavior in educational diagnostics. The most useful use The Fasa Diabetes Center received referrals for patients
of the model is to explain behavioral aspects [14]. with type 2 diabetes mellitus and hypertension who
Khani Jeihooni et al. BMC Endocrine Disorders (2023) 23:6 Page 3 of 11

matched the enrollment requirements. The inclusion determine the content validity. Lawshe index values over
criteria included active cases at the Diabetes Center, a 0.56 were considered critical, and those items were kept
history of diabetes lasting more than ten years, hyper- for research. Most goods have a 0.70 or above. Cron-
tension, no previous medication history (except for anti- bach’s alpha was used to get the dependability score,
diabetic and anti-hypertensive drugs), and underlying which came out to be 0.89. The computed reliability for
illnesses (cardiovascular, neuromuscular, cancer, etc.). knowledge, attitude, self-efficacy, predisposing factors,
Reluctance to participate and absence from more than and enabling factors, respectively, was 0.86, 0.88, 0.84,
two sessions were two exclusion criteria. 0.82, and 0.89.
400 participants with type 2 diabetes mellitus and The questionnaire contained 52 questions that evalu-
hypertension were invited to the trial based on the inclu- ated health-promoting habits across six dimensions:
sion criteria. Some, though, objected. The remaining 350 nutrition, physical activity, health responsibility, stress
patients were split into intervention and control groups management, interpersonal relationships, and self-actu-
randomly, totaling 300 patients (150 patients each). alization. The responses varied from never (score 1),
The data collection instruments included demographic occasionally (score 2), frequently (score 3), and always
questions, PRECEDE model constructs, a lifestyle ques- (score 4). (score 4). 2011 saw the Iranian version of the
tionnaire, and an instrument for diabetes self-manage- questionnaire validation by Mohammadi Zaidi et al. The
ment. Age, gender, marital status, monthly household content validity and reliability of the questionnaire were
income, education, duration of diabetes, and family his- determined to be 82% [21].
tory of diabetes were among the demographic variables The questionnaire was created by Walker and Pen-
asked. The following questions evaluated the PRECEDE der in 2008 and had 35 questions over five dimensions.
model’s constructs: Self-management includes self-integration, self-regula-
Twenty multiple-choice questions (right answer = 1, tion, engagement with medical experts, self-monitoring,
incorrect answer = 0) were used to assess knowledge. and adherence to the prescribed treatment plan. Self-
Finally, a score ranging from 0 to 20 was determined for integration (10 questions) is concerned with the ability
each patient. Ten questions measuring patients’ agree- of people with diabetes to combine daily activities with
ment or disagreement with statements were used to diabetes, whereas self-regulation (9 questions) is con-
assess their attitudes. The responses were based on a cerned with the ability of patients to self-regulate their
5-point Likert scale ranging from "totally disagree" (score behavior by monitoring the physical symptoms of diabe-
1) to "absolutely agree" (score 5); hence, each patient tes. In addition, nine questions assessed interaction with
received a score between 10 and 50. health experts and influential persons, four assessed self-
The self-efficacy was assessed using ten questions. monitoring, and three assessed adherence to the planned
The answers ranged from extremely high (scoring 4) to treatment regimen. On a 5-point Likert scale, responses
extremely low (scoring 0), resulting in a score between ranged from "totally agree" (scoring 1) to "absolutely disa-
0 and 40 for each patient. Using 10 questions, the ena- gree" (score 5). (score 5). 2011 saw the validation of the
bling variables were evaluated. The responses were based Iranian version of the instrument by Tol et al. The ques-
on a 5-point Likert scale ranging from "totally disagree" tionnaire’s content validity was established, and its reli-
(score 0) to "absolutely agree" (score 4); thus, each patient ability was evaluated as = 87% [22].
received a score between 0 and 40. Ten questions on the The current investigation was approved by the ethics
support of family members (parents, siblings, etc.), other committees of the Fasa University of Medical Science and
relatives, friends, doctors, diabetic center personnel, the Fasa Diabetes Center. Participants also supplied writ-
and health center staff were used to assess predisposing ten consent and received assurances that the information
factors. The responses were based on a 5-point Likert they submitted would be kept private. The control group
scale ranging from "totally disagree" (score 0) to "abso- participated in a 4-h educational session once the study
lutely agree" (score 4); thus, each patient received a score was over.
between 0 and 40. Prior to the intervention, the surveys were finished by
The validity of the items was assessed by generating an both groups. At the beginning of the procedure, blood
item effect score of 0.15 or higher and a content validity pressure was measured, both systolic and diastolic. The
ratio of 0.79 or higher. To assess the face validity of the educational intervention next included ten 50–55 min
measure, forty hypertensive diabetics with comparable lectures, Q&A sessions, group discussions, real-world
demographic, economic, and social characteristics were demonstrations, video clips, and PowerPoint presenta-
asked to choose options from a list. The opinions of 12 tions, depending on the outcomes of the pre-test. The
professionals in health education and health promotion, sessions covered the definition of hypertension, issues
including one nurse and one nutritionist, were used to with uncontrolled hypertension, healthy eating, regular
Khani Jeihooni et al. BMC Endocrine Disorders (2023) 23:6 Page 4 of 11

medication, ongoing hypertension control, behavioral Results

change (such as quitting smoking and drinking alcohol In this study, 300 diabetic patients with hypertension
and managing stress), self-efficacy, interpersonal sup- were assessed under the supervision of the Fasa Dia-
port, and responsibility. The role of storytellers was betes Center. The intervention and control groups had
discussed in one of the meetings that a family member, mean ages of 52.358.20 and 54.108.08 years, respectively
staff members from the Diabetes Center, and the doctor (P = 0.263). The mean duration of diabetes in the inter-
attended. vention and control groups was not significantly different
Finally, a WhatsApp group was established, and the (P = 0.304): 19.185.22 and 18.875.10 years, respectively.
patients received a brochure. The WhatsApp group According to the Chi-square test, there was no sta-
received motivational and instructive messages every tistically significant difference between the two groups
day. Participants in the training phase had the opportu- in terms of education (P = 0.190), monthly household
nity to interact with one another, share knowledge, and income (P = 0.289), family history of diabetes (P = 0.314),
ask questions to advance their experience and skills. married status (P = 202) and gender (P = 0.281). (Table 1).
Patients were divided into groups of 15 to 20 and Before the educational intervention, independent
provided information at various periods to improve t-tests revealed no significant differences between the
outcomes and emphasize the value of friends and sup- groups in knowledge, attitude, self-efficacy, enabling, and
port networks. Every two weeks, participants in the strengthening factors; however, three months after the
control and intervention groups were asked to take a educational intervention, the intervention group demon-
blood pressure reading to motivate them to stay in the strated a significant increase (Table 2).
study. Blood sugar checks were done monthly in addi- According to the independent t-test, there was no sig-
tion to hypertension control to encourage patients to nificant difference between the two groups in terms of
continue their studies. After three months, the mean lifestyle dimensions (nutrition, physical exercise, respon-
hypertension of six hypertension controls was cal- sibility, stress management, interpersonal support, and
culated. Using a single calibrated pressure gauge, the self-actualization) prior to the educational intervention;
researchers themselves evaluated hypertension. Both however, three months after the intervention, there was
groups answered questions about the intervention a significant difference between the intervention and
three months later. No samples were lost while the control groups. In addition, the t-pair test revealed a sub-
study was underway. The data were analyzed using stantial increase in lifestyle characteristics in the inter-
SPSS 22 software, Chi-square, independent t-tests, and vention group, whereas there was no significant change
t-pair tests. in the control group (Table 3).

Table 1 Demographic information of studied patients

Variables Intervention group Control group P-value
number percentage number percentage

Education Illiterate 3 3 2 1.33 0.190

Primary school 14 14 10 6.67
Secondary school 36 36 42 28
High school 65 65 68 45.33
University 32 32 28 18.67
Gender Female 86 86 79 52.67 0.281
Male 64 64 71 47.33
Marital status Single 9 9 6 4 0.202
Married 129 129 134 89.33
Divorced 9 9 6 4
Widowed 3 3 4 2.67
History of diabetes Yes Yes 34 30 20 0.314
No No 116 120 80
Household monthly income < 20,000,000 Rials < 20,000,000 Rials 42 37 24.67 0.289
20,000,000-50,000,000 Rials 20,000,000-50,000,000 Rials 73 71 47.33
>50,000,000 Rials >50,000,000 Rials 35 42 28
Khani Jeihooni et al. BMC Endocrine Disorders (2023) 23:6 Page 5 of 11

Table 2 Comparison of mean score of PRECEDE model constructs in the experimental and control groups
variable group before intervention 3 months after the Mean p-value
M±SD intervention M±SD difference

knowledge experimental 7.45±1.89 16.76±1.97 -9.31 0.001

control 7.70±1.67 8.34±1.66 -0.64 0.284
p-value 0.175 0.001
attitude experimental 21.27±4.23 43.14±4.28 -21.87 0.001
control 21.94±4.11 22.78±4.31 -0.84 0.261
p-value 0.193 0.001
self-efficacy experimental 12.16±3.38 34.13±3.58 -21.97 0.001
control 12.90±3.29 13.81±3.38 -0.91 0.159
p-value 0.317 0.001
reinforcing factors experimental 14.10±3.17 33.36±3.44 -19.26 0.001
control 13.92±3.30 14.64±3.39 -0.72 0.148
p-value 0.322 0.001
enabling factors experimental 9.98±2.20 32.14±3.18 -22.16 0.001
control 11.74±2.23 13.12±2.28 -1.38 0.159
p-value 0.144 0.001

Prior to the educational intervention, using an inde- however, 3 months after the intervention, there was
pendent t-test, there was no significant difference a significant difference between the two groups. In
between the two groups regarding diabetes self-man- addition, the t-pair test revealed a significant rise in
agement dimensions (self-integration, self-regulation, diabetes self-management characteristics in the inter-
interaction with health professionals, self-monitoring, vention group but no change in the control group
and adherence to the proposed treatment regimen); (Table 4).

Table 3 Comparison of mean score of lifestyle dimensions in the experimental and control groups
variable group before intervention 3 months after the Mean difference p-value
M±SD intervention
M±SD

Nutrition experimental 19.14±2.94 28.54±2.68 -9.4 0.001

control 18.74±2.78 19.30±2.72 -0.56 0.186
p-value 0.218 0.001
Physical exercise experimental 20.22±2.14 27.24±2.17 -7.02 0.001
control 21.55±2.10 22.17±2.19 -0.62 0.206
p-value 0.185 0.001
Responsibility experimental 18.24±3.19 29.10±3.12 -10.86 0.001
control 19.70±3.07 20.72±3.03 -1.02 0.194
p-value 0.229 0.001
Stress control experimental 16.89±2.41 27.34±2.52 -10.45 0.001
control 17.85±2.40 18.69±2.37 -0.84 0.242
p-value 0.236 0.001
Interpersonal relationships experimental 19.37±3.17 30.25±3.12 -10.88 0.001
control 18.90±3.24 19.33±3.25 -0.43 0.208
p-value 0.180 0.001
Self-actualization experimental 18.66±3.69 31.10±3.21 -12.44 0.001
control 19.72±3.75 21.03±3.54 -1.31 0.164
p-value 0.192 0.001
Total experimental 110.45±18.78 172.58±18.66 -62.13 0.001
control 113.38±18.42 119.74±17.97 -6.36 0163
p-value 0.232 0.001
Khani Jeihooni et al. BMC Endocrine Disorders (2023) 23:6 Page 6 of 11

Before the intervention, there was no significant the intervention group and the control group in terms
difference in mean systolic and diastolic hyperten- of knowledge, the most significant predisposing factor
sion between the two groups; however, three months in the PRECEDE model. a current investigation by Bazr-
after the intervention, there was a significant differ- pour et al. [23], there was a significant increase in knowl-
ence. In addition, the t-test demonstrated a substantial edge immediately and one month after the intervention.
reduction in systolic and diastolic hypertension in the The results of our study were consistent with the result
intervention group, whereas no significant change was of studies by Wang et al. [14], Khani Jeyhooni et al. [24],
detected in the control group (Table 5). Koc et al.[25], and Kaewchi et al. [26]. Using group dis-
cussion, brainstorming, and participating individuals and
Discussion peers pave the way to share information and experiences.
The predisposing factors in the educational diagnosis And this was even more important in our study due to
phase, including disease knowledge and attitude, were its large sample size. In this study, the educational inter-
explored since the PRECEDE model served as the theo- vention also had a significant effect on patients’ attitudes,
retical underpinning for the current study. Following the which was consistent with studies by Chaboksavar et al.
intervention, there were substantial differences between [27], Lin et al. [14], and Hlaing et al. [28]. In actuality, a

Table 4 Comparison of the mean score of the diabetes self-management dimensions in the two groups before and 3 months after
the educational intervention
variable group before 3 months after Mean difference p-value
intervention intervention M±SD
M±SD

Self-integration experimental 17.22±4.47 42.16±4.35 -24.94 0.001

control 18.33±4.52 21.44±4.39 -3.11 0.184
p-value 0.204 0.001
Self-regulation experimental 16.36±4.26 37.20±4.20 -20.84 0.001
control 21.12±4.22 18.17±4.18 2.95 0.175
p-value 0.177 0.001
Interaction with health professionals experimental 17.57±4.15 36.60±4.74 -19.03 0.001
control 18.62±4.11 20.58±4.27 -1.96 0.199
p-value 0.203 0.001
Self-monitoring experimental 7.08±1.33 16.27±1.40 -9.19 0.001
control 7.73±1.30 8.56±1.41 -0.83 0.187
p-value 0.199 0.001
Adherence to the treatment regimen experimental 6.14±1.08 12.08±1.14 -5.94 0.001
control 7.02±1.11 8±1.15 -0.98 0.194
p-value 0.179 0.001
Total experimental 64.33±15.24 144.32±15.82 -79.99 0.001
control 68.88±15.22 79.72±15.45 -10.84 0.114
p-value 0.201 0.001

Table 5 Comparison of the mean score of hypertension in the two groups before and 3 months after the intervention
variable group before intervention Three months after the Three months after the p-value
M±SD intervention M±SD intervention M±SD

Systolic hypertension experimental 148.67±5.39 123.54±5.32 123.54±5.32 0.001

control 146.98±5.78 147.04±5.75 147.04±5.75 0.312
p-value 0.143 0.001 0.001
Diastolic hypertension experimental 95.41±3.12 72.24±3.06 72.24±3.06 0.001
control 94.99±3.43 95.25±3.44 95.25±3.44 0.348
p-value 0.168 0.001 0.001
Khani Jeihooni et al. BMC Endocrine Disorders (2023) 23:6 Page 7 of 11

good education includes both the exploration of values intervention group’s mean score of enabling factors dra-
and attitudes as well as the acquisition of knowledge. In matically increased after the educational intervention.
the current study, educational techniques, group discus- The difference is that the researcher used the available
sions, and real-world examples, including role-playing, sampling method in this study, which is less generalizable
brainstorming, and problem-solving skills, were used to to other societies. On the other hand, the sample size and
help patients’ attitudes. A change in information can- the duration of this study were less.
not cause an intended change in action if it does not also Another important goal of the current experiment was
cause a change in attitude. to assess how the intervention affected lifestyle modifi-
Self-efficacy was another aspect that the educational cation. The control and intervention groups did not sig-
intervention greatly changed. This study showed that nificantly differ on numerous lifestyle and dietary factors
the patients’ self-efficacy was low before the study and prior to schooling. With an effective educational inter-
grew as their knowledge and attitude about the disease vention to increase diabetic patients’ knowledge and
improved. However, the management of their disease was understanding of nutritional and lifestyle concepts, many
considerably impacted by diabetic patients’ higher levels complications, including hypertension, can be avoided.
of self-efficacy. The results of the present investigation The results of a study by Oshwandi and others. [33], The
corroborated the findings of Megan et al. research, which dietary constraints of hemodialysis patients proved that
were consistent with those results. [29] and Azar et al. education had little Effect on the nutrition of hemodi-
[16]. A study by Barasheh et al. [17]. It was demonstrated alysis patients. The findings of this investigation were
that interventions leading to enhanced self-efficacy are inconsistent with those of our own. According to What-
required to improve the indicators of diabetes and its nall et al. [29], After receiving the education, the aver-
proper control. After the intervention, this study’s mean age score for physical exercise in the intervention group
score of the reinforcing elements increased significantly. increased considerably, showing an increase in patients’
Education and support contribute to the development understanding and performance of physical activity. The
of behavior. In our study, family and friend support had research by Shayesteh et al. [34] also showed that educa-
an essential and reinforcing role. Accepting the patient’s tional intervention increases the knowledge and perfor-
current status requires family support; support is also mance of hypertensive patients in physical activity, which
essential for chronic patients to manage their condition was consistent with our study. A study by Khavoshi et al.
independently. Our results were consistent with those of [35] also showed that education changes the lifestyle of
other studies because patients’ self-care benefits greatly the elderly regarding physical exercise and nutrition.
from the support of medical experts, family, and friends. With the difference in the mentioned study, the increase
[16, 30, 31]; with the difference in the mentioned studies in the physical activity score after the study was less,
the sample size and the number of training sessions were probably due to the older population, all older people.
less, and also in the study of Solhi et al., they used the The present study was also interested in personal
self-management theory in addition to the Persed model health responsibility, and based on these findings, the
for educational intervention. The enabling elements sig- educational intervention increased patients’ health
nificantly changed after the educational intervention due responsibility. Ebrahimi et al. [36] showed that edu-
to improvements in knowledge, attitude, self-efficacy, cational intervention using mobile phones positively
and reinforcing factors. The supporting elements in the affects educational intervention. In a study by Chafjiri
current study increased the participants’ intent to change et al. [36], According to our study findings, the lifestyles
their lifestyle and take control of their health, which of 70 elderly patients also improved in the responsibil-
reduced their blood pressure. Diabetes patients are more ity category. Due to educational interventions, patients
motivated to improve their lifestyle and self-manage- have a deeper understanding of their disease and change
ment, which reduces complications when they have the their behavior toward health obligations due to knowl-
necessary knowledge and a positive attitude toward life- edge and awareness. The findings likewise showed that
style modification and self-management, believe they can diabetes patients lacked efficient stress management
carry out these behaviors, and receive encouragement before the intervention. However, in contrast to Safa-
from subjective norms like family members, doctors, and bakhsh et alfindings,.’s the mean score of stress manage-
diabetes center staff. The educational intervention had a ment dramatically increased after the intervention [37].
significant positive impact on the enabling factor. Based The study by Ebrahimi et al. [38], confirmed our findings
on Doshmangir et al. [32], We identified attending educa- and suggested that educational intervention delivered via
tional sessions, offering educational resources, and hav- mobile phone has a positive effect on women’s sense of
ing the capacity to engage in regular physical activity in responsibility. In order to effectively manage the disease,
old age as enabling factors. In line with our findings, the a diabetic patient’s emotional state is essential. In the
Khani Jeihooni et al. BMC Endocrine Disorders (2023) 23:6 Page 8 of 11

current study, an improved understanding of the disease’s intervention but dramatically raised afterward. Improv-
causes and lifestyle changes, along with adjustments ing the patient’s engagement with health professionals
to performance and physical activity, resulted in better and workers boosted patient satisfaction and treatment
stress management, which can be highly helpful in treat- adherence, resulting in a quicker recovery and fewer
ing hypertension. The difference is that the face-to-face problems. In many instances, poor interaction results
teaching method was also used in our study more effec- from a lack of communication skills. In the present study,
tively than in the mentioned study. the goal of the sessions was to improve the patient’s con-
Another dimension of lifestyle evaluated in the present nection with medical personnel.
study was interpersonal relationships, which significantly After education, the self-monitoring mean score in the
increased after the intervention. Compared to other stud- intervention group climbed significantly. Self-monitoring
ies, the strengths of our study were special attention to is one of the most crucial self-management practices for
problem-solving skills, brainstorming, critical thinking, illness control and complication prevention. In a study by
and group discussions in improving patients’ self-actu- Ranaei et al., the educational intervention had no effect
alization. The intervention group’s lifestyle modification on self-monitoring, which contradicts our findings. Bap-
increased due to improved diet, physical activity, stress tista et al. [42] research showed the significant Effect of
management, health responsibility, interpersonal rela- educational intervention on the self-monitoring of blood
tionships, and self-actualization, consistent with other glucose. The results of a study by Mayor et al. [42] were
studies’ findings. (53, 56. 58). lifestyle changes can help consistent with the results of our study. At the same
diabetics stay healthier and avoid many issues, which can time, the method of training, the training content, and
help decrease risk factors, including hypertension. the method of evaluation of the participants were differ-
Aspects of self-management were also regarded in this ent from ours. Adherence to the treatment regimen was
study as crucial to managing diabetes and avoiding its another dimension that significantly improved after the
complications. The results of the study showed no sig- intervention. The results of a study by Bahiraei et al. [43],
nificant difference in the mean self-management score consistent with our study, showed the significant Effect
between the two groups prior to the intervention, prov- of face-to-face education on adherence to the treatment
ing that the samples in both groups were homogeneous. regimen,
However, education considerably changed the mean self- In the present study, the improvement of all aspects
management aspects score for the intervention group. of self-management led to self-management in diabetes
Self-integration in the intervention group significantly patients, which was consistent with previous research
increased after obtaining an education. In the current [39–41, 44, 45]. The results of a systematic review by Lean
study, the patient’s attitude toward healthcare behaviors et al. [46] 37 research have shown that frequent care and
was improved by the educational intervention and the self-management instruction can improve the prognosis
patient’s increased knowledge and awareness, leading to of severe mental illnesses. Good instructional models,
improved self-management.The educational intervention like the PRECEDE model, should be used to implement
significantly affected the mean self-regulation score in the optimal self-management, which is the cornerstone of
intervention group. The results of a study by Habibzadeh effective diabetes treatment. Within the framework of
et al. [39] showed that diabetes self-management edu- the PRECEDE paradigm, self-management theory was
cation through group discussion is more effective than employed in this study. Additionally, role-playing, group
usual education programs in the self-regulation dimen- discussions, homework, and practical skills that centered
sion. A study by Weng et al. [40] showed a significant on accumulating experiences and using scenario-based
effect of educational intervention. This is even though in education approaches were used in the sessions.
the mentioned study, only the group discussion method Three months following the intervention, mean sys-
was used, and the educational content was not presented tolic and diastolic hypertension decreased. Hypertension
by the lecturer; on the other hand, the number of sessions is a long-term condition of diabetes caused by a lack of
was limited, and only eight sessions were conducted. understanding, an unhealthy lifestyle, and poor self-man-
Comparison of the mean score of interaction with agement. The PRECEDE paradigm and an appropriate
health professionals showed the effectiveness of the inter- teaching technique changed diabetes patients’ lives and
vention, which was consistent with the results of stud- improved their self-management skills, reducing their
ies by Ranaei et al. [19], Habibzadeh et al. [39], and Liu hypertension. Shen et al. [47]. The intervention signifi-
et al. [41]. In contrast to prior studies, our intervention cantly impacted hypertension, perceived sensitivity, and
strategy, duration of follow-up, research demographic, self-efficacy. The decrease in hypertension was greater in
and sample size were unique. The mean score for inter- their study than in ours. In our study, using the PRECEDE
action with health professionals was quite low before the model resulted in enhanced knowledge, self-efficacy,
Khani Jeihooni et al. BMC Endocrine Disorders (2023) 23:6 Page 9 of 11

lifestyle modification, and self-management, which sig- the Research and Technology Dept. of Fasa University of Medical Sciences, as
well as diabetic patients for their participation in the study.
nificantly reduced hypertension. The results of Chen
et al. systematic.’s review [48]. Although different educa- Authors’ contributions
tion techniques have varying effects on patients’ hyper- AKHJ, AS, PAH and MA assisted in conceptualization and design of the study,
oversaw data collection, conducted data analysis and drafted the manuscript.
tension, educational interventions can improve patients’ AKHJ and AS conceptualized and designed the study, assisted in data analysis
hypertension in general. The findings of an investigation and reviewed the manuscript. AKHJ, AS, PAH and MA assisted in study concep-
by Ozoemena et al. [49] indicated that health education tualization and reviewed the manuscript. All authors read and approved the
final manuscript.
substantially influences hypertension in the elderly by
enhancing their knowledge and self-care skills, which is Funding
consistent with our study. Research by Saffari et al. [50] None.
showed that education through SMS could have a similar Availability of data and materials
effect as face-to-face education in lifestyle modification The datasets used and/or analyzed during the current study are available from
and hypertension control. In our study, web-based meth- the corresponding author upon reasonable request.
ods, including WhatsApp education, were used as a com-
plementary approach. Declarations
1. The study population was diabetes patients with Ethics approval and consent to participate
hypertension; therefore, it is recommended to exercise This study protocol was approved by the ethics committee of Fasa University
caution while generalizing the results to other patients. of Medical Sciences (IR.FUMS.REC.1399.179). Informed consent was taken
from all the participants. For illiterate people involved, informed consent from
2. Due to the physical condition of some patients a parent and/or legal guardian was obtained in the study. All methods were
(decrease in concentration and tolerance), sessions were carried out in accordance the declarations of Helsinki. There was an emphasis
held with short breaks. on maintaining privacy in keeping and delivering the information accurately
without mentioning the names of the participants. The participants were
3. Use of a self-report questionnaire to collect data. given the right to leave the interview at any time, and they were promised to
4. The participants in the control and intervention have access to the study results.
groups were in contact with each other outside the ses-
Consent for publication
sions, and it was possible to exchange information None.
related to the interventions. At the same time, before the
study, the necessary recommendations were given to the Competing interests
The authors declare that they have no competing interests.
participants.

Received: 23 December 2021 Accepted: 2 January 2023

Conclusion
The educational intervention significantly affected life-
style modification, improved self-management, and
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