@2024 Afarand., IRAN

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ISSN: 2383-2150    Journal of Education and Community Health 2020;7(4):293-302

Background
Lifestyle has a significant effect on making healthy behaviors among students, and the school environment as an environment for learning and changing behavior and creating a healthy society [1]. Adolescence is a unique period in life and is one of the most challenging periods of human growth [2].
Previous Studies
According to the statement of the world health organization in the First World Summit on Healthy Lifestyle in Moscow, 60% of global deaths and 80% of deaths in developing countries are due to unhealthy lifestyles, and this rate will reach 75% in the world by 2030 [3]. ...[4, 5]. Iran is one of the youngest countries in the world with more than 15 million adolescents. Adolescents are the main assets of the country. They are very effective in shaping the next generation and promoting a healthy society. Ensuring adolescent health is one of the main aims of social and economic development plans [6]. The value of health training programs depends on the effectiveness of these programs, and the effectiveness of these programs depends on the correct use of theories and models in health training [7]. ...[8]. So far, the "planned behavior theory " has been successful in a wide range of health behaviors in adolescents [9]. The planned behavior theory is one of the most complete and appropriate theories for studying behavior. This theory was proposed by Ajzan and Fishbein to predict and explain behavior in 1987. The main argument of this theory is summarized in two parts: A) individuals make their behavioral decisions based on the review of available information, and B) individuals consider the results of their actions before decision making [10]. ...[11].
Aim(s)
This study aimed to determine the effect of the training intervention in promoting healthy lifestyle behaviors of male students in middle school based on the planned behavior theory.
Research type
This study is a randomized controlled trial.
Research society, place and time
The study was carried out on the male students in the middle school of Rafsanjan city in 2017-2018.
Sampling method and number
The sample size was determined to be 60 people using the formula for determining the sample size according to the study of Hassani et al. [12]. The sampling method was multi-stage. First, the list of schools was prepared by referring to the Education Department of Rafsanjan city. Then, of 16 public high schools for male students in the first grade, four high schools were randomly selected, two high schools were selected as the intervention group, and two high schools were selected as the control group. In each group, 60 people (n=30 in each school) were randomly selected from the eighth grade based on the inclusion and exclusion criteria. Inclusion criteria were no physical disability, heart disease, respiratory and mental illness, and obtaining parental consent. Exclusion criteria were migration and transfer of students, absence of more than two sessions, and lack of cooperation in completing the questionnaire. The items such as questionnaire code, school name, research institute, the anonymity of the questionnaire, confidentiality of information were considered in the design of the questionnaire, and data collection.
Used devices&materials
The data collection tool was a researcher-made questionnaire modeled based on similar studies [13]. The validity and reliability of the questionnaire were examined and confirmed through a pilot study. The face validity of the questionnaire was investigated by qualitative and quantitative methods. In the qualitative method, the opinions of 10 students were examined, regarding the apparent validity and the level of difficulty in understanding the expressions of the items through interviews. In the quantitative method, the impact factor of all questions of each construct was more than 1.5. The questionnaire content was validated by performing the expert panel method among 10 health education and health promotion specialists. The content validity ratio of the questions was 0.62-1. The content validity index of the items for each construct was more than 0.79. The questionnaire reliability was investigated by the participating 30 students using calculating the internal consistency of the items. The Cronbach's alpha coefficients for awareness, attitude, subjective norms, perceived behavior control, behavioral intention constructs were 0.74, 0.70, 0.73, 0.85, 0.85, and 0.70 respectively. The final questionnaire consisted of 3 sections including demographic information, awareness, and the constructs of the planned behavior theory. Demographic information included the items of student's demographic characteristics. The second part included questions for measuring student's awareness of a healthy lifestyle with 11 items. The third part included the constructs of the planned behavior theory, consisting of attitude and subjective norms with 16 and 9 questions, respectively, as well as the perceived behavior control and behavioral intention with 7 questions. These questions were measured using 5 items Likert scale. It should be noted that all questions with negative semantic load were scored, reversely. The research was carried out after obtaining permission from the Research Council of the Health Faculty of Rafsanjan University of Medical Sciences, the education authorities, and the parents' consent of the students. The target group in this study was male students in the eighth grade of middle school. Parents of students, principals, and teachers of the school were considered as the secondary target group. We referred to the high schools through cooperation with the principals and taking into account the class schedule of the subjects. Therefore, the research process and aims were explained to the school principals and teachers. Students were also assured that the information in the questionnaire was confidential and anonymous. The pre-test for initial evaluation (before the training intervention). The training requirements were identified based on the planned behavior theory and then, training goals were designed in the 5 topics (increase awareness, changing attitudes toward behavior, training parents and teachers, training based on the perceived behavior control, increased behavioral intent to have a greater impact on behavior). 4 topics were presented during 10 training sessions for students and one topic was presented during 2 training sessions for parents of students and principals and teachers of each school (n=12). Training sessions were held in each school once a week, and the duration of the training session was equivalent to the usual time for holding a class in the schools. Parents of students, principals, and teachers were also grouped, and one session was held for each group. There was no intervention for the control group. The questionnaires were filled by the eighth-grade students of the intervention and control groups to evaluate the effect of the training intervention 3 months after the last training session. The data were analyzed by SPSS 16 software using the paired T, independent T, and the Chi-square tests at a significance level of less than 0.05. The Kolmogorov-Smirnov test was used to check the normality of the data.
Findings by Text
The age range of students in the control and intervention groups was 13-15. Most of the subjects of the intervention and control groups were 14 (56.9%) and 13 years old (57.1%). The results of the Chi-square test showed no significant difference between the intervention and control groups in terms of all demographic variables (p<0.05; Table 1). Also, the results of the independent T and paired T-tests showed no significant difference between the mean and standard deviation of the scores of awareness, attitude, mental norms, perceived behavioral control, and behavioral intention of lifestyle (physical activity, healthy diet, and tobacco smoking) in the intervention and control groups (p<0.05). While, the mean and standard deviation of the scores of these variables were significantly different in the intervention group (p<0.05) 3 months after the training intervention, but there was no significant difference in the control group (p<0.05; Table 2).
Main comparison to the similar studies
This study aimed to investigate the effect of training intervention based on the planned behavior theory. The results showed that the awareness and attitude of the subjects were improved in the group under training, 3 months after the intervention. While no significant change was observed in the control group. ...[14]. The results of the study of Seyedemami et al. [15] showed that training intervention of physical activity for health liaisons has increased their awareness and attitude. Also, Ebrahimi et al. [16] concluded that training intervention has caused a positive and increasing change in students' awareness and attitudes about healthy eating. …[17-19]. The present findings were under the studies of Salahi et al. [20], Seo et al. [21], and Bashirian et al. [22]. The results of Kuh and Makerth [23] showed that mental norms were not effective in students' physical activity. The results of the study of Gholami et al. [24] also showed that mental norms did not have a direct effect on fruit and vegetable consumption. The results of this study indicate an increase in perceived behavioral control of students in the intervention group in the field of physical activity behaviors, healthy diet, and the harms of tobacco smoking after the training intervention. The results of the study of Qeisvandi et al. [25] showed that training intervention has increased perceived behavioral control in students. The study of Barfi et al. [26] also showed that training based on the theory of planned behavior has increased the ability to deal with smoking abuse in the intervention group. In this regard, there were studies such as Fathi et al. [27] that the mean score of perceived behavior control regarding the use of hookah and cigarettes was not significantly increased compared to the control group after the training while it increased in the intervention group compared to the control group 3 months after the training intervention. …[28]. The results showed that both groups had low behavioral intentions about physical activity behavior, healthy eating and smoking before the intervention, while it increased in the intervention group compared to the control group 3 months after the training intervention. The results of the study of Sheikh Ahmadi et al. [29] showed that the training intervention based on the theory of planned behavior has been effective in increasing students' behavioral intention for reducing the consumption of ready foods. The study of Fathi et al. [27] also shows a statistically significant increase in the mean score of non-smoking intention after training intervention in the intervention group. However, the results of Hazawei et al.'s study [30] showed that the mean score of intent to promote nutritional behaviors among the elderly did not increase in the experimental group after the training intervention. Training based on the theory of planned behavior improved the lifestyle (physical activity, healthy diet, and tobacco smoking) of students in the intervention group. The results of the study of Shafieinia et al. [31] show that the interventions based on the theory of planned behavior affect the physical activity behavior of female employees, which is consistent with the findings of this study. The results of the study of Khani, Jihuni et al. [32] also show that training interventions based on the theory of planned behavior are effective in preventing hookah use in high school students. Also, the results of the study by Barati et al. [33] showed that the intervention based on the theory of planned behavior is effective in preventing drug abuse in students, which is consistent with the findings of this study. However, the results of the study of Ahmadi Tabatabai et al. [34] showed that the training intervention based on the theory of planned behavior has little effect on the physical activity of the Health Center staff of Kerman city. The results of this study were not consistent with the study of Carson et al. [35].
Suggestions
It is suggested that interventions based on the structures of this theory be designed and implemented to promote students' lifestyle behaviors; because it can prevent complications, high costs, and deaths caused by choosing an unhealthy lifestyle in adulthood.
Limitations
The limitations of this study were the lack of training equipment in each class and the inability of some families to provide sports equipment for students.
Conclusions
The training interventions with a focus on awareness, attitude, mental norms, control of perceived behavior, and behavioral intention seem to be an important step in improving healthy lifestyle behavior in students. In this way, the complications, heavy costs, and deaths due to an unhealthy lifestyle can be prevented in adulthood.
Acknowledgments
We would like to appreciate the students and teachers of Shahid Vejdani, Shahid Beheshti, Iqbal Lahori, and Shahid Abbaspour schools, the officials for school health, and the Education Security and faculty members of Rafsanjan University of Medical Sciences.
Conflict of interest
No conflict of interest has been reported by the authors.
Ethical Permissions
This study was approved by the Research Council of Rafsanjan University with the ethics code of IR.RUMS.REC.1396.136.
Funding Sources
This article has been conducted by the financial support of the Vice Chancellor for Research of Rafsanjan University of Medical Sciences from the approved project of 96115.

TABLES and CHARTS

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