This study was conducted in Abadan Faculty of Medical Sciences in 2017-2019. Abadan Faculty of Medical Sciences covers the communication of three cities and their suburbs including Abadan, Khorramshahr, and Shadegan, in the Khuzestan province, in the Southwest of Iran in terms of medical education and health care. Moreover, this faculty is located in the fourth educational spatial region from the ten educational spatial areas of the Ministry of Health and Medical Education, the executive branch responsible for medical education and health within the Iranian government. Ten areas of spatial planning show the geographical breakdown of medical universities in Iran, which is approved in the form of a resolution by the Council of the Cultural Revolution as a macro-policy maker of Science and Technology in Iran .
The study was designed in five phases: 1) needs assessment by Nominal Group Technique (NGT), 2) review of nutrition course plan, 3) implementation of revised nutrition course plan, 4) evaluation by students and 5) comparison of the grade of the students in the new course by students in the previous course.
First phase: Using NGT to identify the causes of nutrition-related health problems
In the first phase, NGT was used to determine the required and essential priorities for nutrition education. This phase was completed in two steps:
In the first step, the participants, including 13 nutrition experts, declared five priorities of nutrition-related health problems in the community.
These experts were invited to participate in the study by sending an official invitation letter from the university's deputy educational director. They completed worksheets developed by high-level policymakers of Iran's Ministry of Health and Medical Education for the Iranian community-based assessment . Each expert was asked to record the first ten nutrition-related health problems observed in the city of her/his workplace. A nutrition-related health problem was a nutrition problem that directly threatens people's health. The resources and examples used to identify the problem were also listed in front of each of the problems. Then, all nutrition experts scored the listed nutrition-related health problems from 1 to 5. This ranking based on the extent of the problem, the possibility of intervention, the effectiveness of education in solving the problem, the urgency of the problem, and the social and organizational acceptability of problem-solving. For the same scoring, the scores were selected according to the following qualitative criteria: very low = 1, low = 2, average = 3, high = 4, and very high = 5. The scores gave to each problem was summed up, and a total score was obtained for that problem. Finally, five problems with the most obtained score were declared as priorities for the needs assessed nutrition-related health problems.
In the second step, an expert panel was assembled that consisted of 9 experts in health, nutrition, medicine, and nursing. In this panel, the NGT  was used to identify a preliminary list of causes of each problem in the region and categorize them into "behavioral" and "non- behavioral" types. NGT in this project lasted approximately four hours and was facilitated by the first author. Following a description of the process, group purposes with a statement of the importance of participant's contribution, clarification of the members' roles, and an explanation about how the group's output would be used, the NGT session was conducted in five steps .
Step 1: Silent generation of causes priorities.
Participants were asked to take 15 minutes to consider the following question: “What are the priorities of the behavioral and non-behavioral cause of nutrition-related health problem X in our region?” and write down their responses in private.
Step 2: ‘Round robin’ recording of causes priorities.
Each contributor was requested to express one cause priority at a time, and his/her idea was written on the flip chart without evaluation. Then, the round repeated, and each time, the most critical comment expressed.
Step 3: Clarification of causes priorities.
Each idea discussed. Participants were encouraged to share their views and express their opinions about the pros and cons of each item. There was a further explanation about each item, so everyone in the group had a full understanding of the concept. Step 4: Collapse of causes priorities.
The facilitator organized all the listed causes priorities into “behavioral” and “non- behavioral” groups, simplified them, and duplications identified and removed. These were written on a new flip chart and discussed with the group, to ensure that all participants understood and approved of the assembled causes priorities.
Step 5: Ranking of causes priorities.
Each participant was asked to rank the items on a card and allocated a point between one and five to each cause with their first preference receiving five points and their fifth predilection earning one point based on two criteria including the importance of the reason and the possibility of changing the purpose. The average score was calculated for each item. At this stage, all items that had received a rank listed so that all participants could observe them. The items were then ranked according to the average point. Then, nine experts reviewed the rankings, and agreement reached on the final list of five priorities of “behavioral” and “non-behavioral” causes.
Second phase: Review of nutrition course plan
In the second phase, the "General Principles of Nutrition" course plan in medical doctorate, and the "Nutrition and Nutrition Therapy" course plan in the bachelor of the nursing program reviewed.
Third Phase: Implementation of revised nutrition course plan
In the third phase, the revised course plan presented to the medical (n=124) and nursing (n=128) students in two consecutive semesters (1st and 2nd semester of the academic year 2018-2019) through lecture, question and answer, group discussion, team-based learning (TBL), and virtual teaching in 17 sessions.
Fourth phase: evaluation by students
In the fourth phase of the study, evaluation of implemented lesson plans was carried out via a researcher-made written form that provided to the participants, including doctorate of medicine (n=65) and baccalaureate of nursing (n=46) students who trained with revised course plans at the end of each semester. The form included two open questions: 1) “How was the quality of educational content?”; 2) “Did the educational headings meet your educational needs as a physician/nurse who will work in this community in the future?”. The responses recorded in written form without the mention of the name. The students assured about the confidentiality of the information. They were free to respond or not respond to all or part of the questions.
Method for the interpretation of the qualitative data was through a coding and systematic categorizing process . The conventional content analysis was applied to analyze the qualitative data. The purpose of conventional content analysis is the description of a phenomenon. This type of project is most appropriate when the existing theories or research literature about the studied phenomenon are limited. In this study, the researchers avoided some preconceived categories. However, the primary and secondary categories were induced from data, instead. In this case, the researchers were ﬂoating themselves on the waves of the data until they reached a new understanding . The information gathered through written form was analyzed using meaning association. That is, data analysis began by reading them repeatedly to find a thorough understanding of them. Based on her perception and understanding of the text, the researcher started to write the initial analysis to create the backgrounds for the development of codes. In other words, we determined the meaning unit and compressed it to specify the systems (Table 1). Then, the researcher categorized data by the combining, grouping primarily, and organizing of codes as context-based. Finally, secondary categorization was used based on the abstract thinking of the researcher induced from data while they were saturated in terms of classification . In other words, the overall concept was the resulting sum of these categories (themes) obtained. Finally, three themes were formed, and the researcher compiled a report about the strengths and weaknesses of the nutrition course plan according to the obtained themes (Tables 3 and 4).
Fifth phase: comparison of the grade of the students in the new course by students in the previous course.
In the fifth phase, the semester exam scores compared between the students trained with the revised lesson plan in the 1st and 2nd semester of academic year 2018-2019 and the students trained with the previous lesson plan in the second semester of 2017-2018 by one-way ANOVA followed by Tukey HSD post hoc test using IBM SPSS statistics version 21. The mean difference was significant at the 0.05 level. The methods of teaching, educator, and teaching environment were similar in all three semesters.