Effect of educational program based on theory of planned behavior on promoting nutritional behaviors preventing Anemia in a sample of Iranian pregnant women

This quasi-experimental study was conducted on 150 pregnant women under the auspices of health centers of Shiraz in 2020–2021. For sampling, from among urban health centers of Shiraz, two centers were randomly selected (one center for the experimental group and one center for the control group). The sampling method in each health center was simple random. In this way, first a list of all pregnant mothers in each health center was prepared and then the participants were randomly selected using a random number table. The samples were then invited to attend a health center on a certain day to get acquainted with. They were also explained the study objectives, and informed consent was obtained from participants. The sample size was calculated based on Jahangiri et al. [12]. Using the formula for comparing the mean of the variables, 40 people were determined for each group. To increase the accuracy and power of the study, 75 people per group were considered. Inclusion criteria were willingness to participate and literate pregnant women at the beginning of the fourth month of pregnancy who were referred to health centers and filed a case of an underlying disease related to anemia, such as a history of inherited and acquired diseases, including thalassemia with no history of bleeding. The exclusion criteria were unwillingness to participate in the study, absence from more than two training sessions and questionnaire completion sessions, relocation of the pregnant mother and the impossibility of accessing her.

The data collection tool included a questionnaire that was used in the study of Jahangiri et al., whose validity and reliability were confirmed [12]. Cronbach’s alpha for knowledge, attitude, subjective norm, perceived behavioral control, behavioral intention, and performance checklist was 0.71, 0.80, 0.79, 0.76, and 0.79, respectively. The total reliability of the tool was also 0.80.

The questionnaire included demographic information (age, mother’s education, spouse’s education, occupation, gestational week, number of children, family income, and hemoglobin level) and 10 questions on knowledge. A TPB-based questionnaire includes: 12 questions on attitude (For example: like any other woman, I am at risk for complications from iron deficiency in pregnancy. I do not need to take iron pills because my nutrition is good.), measured using a five-point Likert scale from (1: I strongly agree) to (5: I strongly disagree), higher scores indicate a more positive attitude toward the corresponding health behavior. 5 questions on perceived behavioral control (For example: Even if the iron pill makes me nauseous, I still take it. Due to the high cost of meat, I can use legumes and eggs as a suitable alternative.), measured by a five-point Likert scale from (1: I strongly agree) to (5: I strongly disagree). Higher scores indicate higher levels of perceived control to engage in the corresponding health behavior. 6 questions on subjective norms (For example: My husband encourages me to eat right and take iron pills. I am encouraged by health professionals when I have the right diet and take supplements.), measured by a five-point Likert scale from (1: I strongly disagree) to (5: I strongly agree). Higher scores indicate greater perceived pressure to engage in the behavior. 6 questions on behavioral intention (For example: I plan to include iron-rich foods in my diet, such as meat and legumes. I plan to take iron pills regularly until the end of my pregnancy.), using afive-point Likert scale ranging (strongly disagree) to (strongly agree). Higher scores indicate stronger intentions to engage in the corresponding health behavior. The possible score was between − 10 to + 10 for each specific factor. and 9 questions on performance checklist.

After the selection of the experimental and control group, the purpose of the study and how to do the work were explained to the participants and the staff of the health centers. The questionnaire was completed by two experimental and control groups.

Based on the pre-test results, the educational content was prepared based on the TPB. The educational intervention for the experimental group consisted of 6 sessions of 50–55 min through lectures, questions and answers, group discussion, educational posters and pamphlets, videoclips and powerpoint. The training program was conducted by a doctor of health education and health promotion, a nutritionist and a gynecologist in collaboration with two experts from the women’s health unit of Shiraz health center. Training sessions were held for 3 groups of 25 (one session per week). These sessions were about anemia in pregnancy, infection and complications of the disease, ways to prevent infection, prevalence of anemia among pregnant women, correct or change misconceptions and strengthen true beliefs, the implementation of nutritional behaviors to prevent anemia in pregnancy and its positive effects on maternal and fetal health. Each woman was also asked to describe her previous experiences with nutrition and the behaviors they should replace. Key barriers were discussed by pregnant women themselves, and solutions were offered to overcome those barriers. The benefits of having a preventive diet and regular use of supplements and solutions to reduce gastrointestinal side effects caused by their consumption were presented to pregnant women. The nutritionist was asked to speak for 20 min about the need for anemia-preventing nutritional behaviors for pregnant women, followed by a group discussion. One of the meetings was held with the presence of spouses and officials of health centers, and they received information about nutritional behaviors preventing anemia, emphasizing their supportive role.

At the end of the sessions, women and their spouses received educational CDs and booklets. Women were divided into groups of 8–10 and groups of friends were formed. In order to maintain and promote the activity of the experimental group, they received an educational text message per week. One month and two months after the educational intervention, two virtual follow-up sessions were held for women. But the control group only received routine training at the time of referral and only face-to-face from health care providers. (The intervention plan be stated in the Table 1). Three months after the educational intervention, both experimental and control groups completed the questionnaire. The control group, at the end of the study, received an educational booklet. Five women in the experimental group and three women in the control group did not complete the post-test questionnaire; therefore, the final analysis was performed on 70 people in the experimental group and 72 people in the control group. For ethical considerations, while obtaining permission from the ethics committee of Shiraz University of Medical Sciences with the code (IR.SUMS.REC.1400.222), a written consent was obtained from participants and the goals, importance and necessity of the study was explained to them. Participants were also assured that their information would remain confidential.

Data were analysed using SPSS 22. We conducted descriptive and inferential analyses, including frequencies (for categorical variables) and mean (for continuous variables), for all demographic data and questionnaire scores.using Chi-square, independent t-test and paired t-test and the significance level was considered 0.05.