The purpose of this study was to evaluate the impact of the educational program for students and their mothers, using role modeling and mothers' support in promoting a perceived family health climate in female students and their mothers. Based on this goal, a quasi-experimental plan consisting of an intervention group and a control group was approved in which pre-test, post-test and 2-month follow-up were designed to evaluate the effects of the program. Ethics approval was obtained from research ethics board of the Shiraz University of Medical Sciences. The study was approved by the ethics committee on 07/08/2019 (IR.SUMS.REC.1398.896).
Participants in this study were fifth-grade female students who studied in Shiraz schools and their mothers. Sampling was done by the cluster sampling method among the four education districts of Shiraz, each of which has 43, 39, 58, and 55 schools, respectively. From the four districts, two districts were randomly selected (districts 2 and 4). In each of the selected districts, four schools (eight schools in total) were randomly selected, of which two schools were randomly selected as the control group and two schools were randomly selected as the experimental group in each district. In each school, two classes were randomly selected, and eventually, 261 female students were selected as mentioned in the previous article by the authors(18).
In the data collection process, the first step was to visit the selected schools, meet with school principals and inform them about the content and purpose of the study. After receiving the approval of the school principals, the pre-test questionnaire form was completed by 261 fifth-grade students who met the inclusion criteria, while the questionnaire forms for mothers in the distribution envelopes were sent to them by the children. The researchers after 3 working days returned to the schools and the questionnaire forms completed by the mothers were collected. Based on the collected data, mothers' questionnaires were considered for further analysis. A total of 223 mothers after contacting them by telephone and stating the objectives and content of the study, as well as the length of the study period, agreed to participate in the study. Among the mothers who agreed to participate in the program, (109 intervention) and (114 control) were divided into two groups based on the division of their children's schools and classes. At the beginning of the intervention, mothers were adjusted for level of education, and occupation to ensure homogeneity of groups, as these factors were thought to be likely to distort the results. The demographic characteristics of the students in the intervention group and the control group are presented in Table 1.
The inclusion criteria for female students and their mother were: to be studying in public schools in Shiraz, their grade of education should be fifth, to complete the written informed consent form by students and their mothers and the exclusion criteria were: absenteeism in educational sessions for two sessions or more, refusing to continue participating in the project, leave the research environment (such as changing schools, etc.).
Data collection tools included demographic questionnaire and family health climate scale.
Demographic questionnaire included the age of the student, parental occupation, parental education, number of family members.
The Family Health climate scale was developed by Niermann et al. in 2014 to assess family members' health behaviors. This scale includes two separate scales: FHC-PA contains 14 questions with three subscales (value, cohesion, and information) and FHC-NU consists of 17 questions with four subscales (value, communication, cohesion, and consensus). Answers were given on a four-point rating scale (0 = “definitely false,” 1=“rather false,” 2=“rather true,” and 3 = “definitely true”). In a study by Niermann et al., mothers, fathers, and adolescents completed a questionnaire separately. The internal correlation was αFHC-PA = 0:92 and αFHC‐NU = 0:86 for the mothers, αFHC‐PA = 0:90 and αFHC‐NU = 0:86 for the fathers, and αFHC‐PA = 0:90 and αFHC‐NU = 0:85 for the adolescents(7).
In the Persian version of the FHC-Scale, Cronbach's alpha coefficient for FHC-PA in female students and their mothers respectively was 0.88 and 0.86 for the whole scale. Cronbach’s alpha coefficient for FHC-NU in female students and their mothers respectively was 0.83 and 0.92 for the whole scale(18).
The education program for students and their mothers was implemented with the permission of the school administration. The program included 12 sessions for students and 6 sessions for their mothers.
In the student sessions, there were six sessions related to healthy eating education and the promotion of eating behaviors. At the beginning of the sessions, students received healthy snacks such as fruit, milk, or healthy pre-prepared foods. During the sessions, various methods were used, such as; Lectures on general topics, use of audio-visual presentation, questions and answers, problem-solving, sample cases, asking students to make a list of healthy meals with the help of mothers, as well as making a list of meals that students Usually prefer to use and then a discussion was held about it. Six sessions related to physical activity were performed by doing the favorite sports of the students with the cooperation and presence of a physical activity instructor. Also during the sessions about the minimum physical activity required by adolescents and the definition of moderate to vigorous physical activities as well as types of sports such as endurance, stretching, etc. was educated through educational videos, lectures, and booklets. The research team also coordinated with a sports club to facilitate enrollment in a sports class for the intervention group.
In the mothers' group, due to the busy schedule of mothers, the number of sessions was less, so more nutritional information and physical activity were provided to mothers in the form of short texts through social media. Three sessions of nutrition education were conducted to get acquainted with the nutrition groups as well as the nutritional needs of adolescents through lectures, questions, and answers, audio-visual presentations, and brainstorming. Mothers were also encouraged to cooperate and advise on preparing their children's meal lists and to involve children in choosing food when shopping. Three physical activity sessions, first in the form of lectures and informing them of the goals of physical activity sessions and getting their consent to attend a class session at a coordinated sports club, to practice sports that did not require equipment, and also to encourage them to performed regular physical activity. Also, physical activity training videos that were appropriate for mothers and their daughters were shown. They were asked to arrange family walks in their free time and to encourage children and other family members to work as role models and provide basic and necessary facilities for their children to do physical activity.
When the questionnaire was completed by the target group, healthy nutritional snacks were provided to the students and after the intervention and data collection, booklets and educational videos were provided to the control group.
The collected data were analyzed using SPSS version 20. A Chi-square test was used to check the homogeneity of demographic variables in the control and intervention groups and a t-test was used to check the mean of the student's age in the two groups. After that, an independent t-test and Repeated Measurement Anova at the significance level of 0.05 to examine the impact of the intervention were done.