Findings are presented based on SM benchmarks in the following.
SM mix: The components of the SM mix were explored and presented in a former study[8] and were used in the quantitative phase of the present study to develop the study intervention (Table 1).
Identifying the intended behavior: Two behaviors were identified, i.e. breakfast consumption at home and snack consumption at school.
“When I awake, I have no appetite for breakfast and hence, eat snack at school (a student).
I eat breakfast at home because it is easier and more comfortable. Moreover, I can eat at home whatever I want for breakfast (a student).
Internal and external competing factors for behavior modification: Barriers and competing factors in breakfast consumption were stress, entertainments, high-calorie dinner, immobility, loneliness, and school vacation. Both students and parents highlighted that stress, nighttime entertainments (watching television and using tablet), lonely eating, sleep inadequacy, high-calorie dinner late at night, and morning boredom negatively affect appetite for breakfast. On the other hand, morning exercise can cause physical and mental happiness and positively affect morning appetite.
At exam days, my daughter has high levels of stress and hence, has no appetite for breakfast (a mother). In the morning, I have stress to be late at school and to be absent (a student). I stay awake late at nights to watch my favorite serials. Therefore, I awake late in the morning and have neither time nor appetite for breakfast (a student). If children eat a high-calorie dinner late at night, they may feel full in the morning and will have no appetite for breakfast (a mother). In the morning, I’m bored and do not value eating or what to eat. But, a little exercise increases my appetite (a student). When a child sees three glasses of milk on the table, he/she understands that other family members are going to eat breakfast. This can increase his/her appetite (a mother). In summer, almost all school-age children awake late in the morning and don’t eat breakfast (a mother).
Theoretical concepts related to the behavior: Factors which might facilitate students’ engagement in the breakfast consumption behavior were fear over the complications of breakfast skipping, perceived self-efficacy, and perceived benefits. Fear over the complications of breakfast skipping consisted of the two subcategories of fear over obesity and fear over illness.
Fear greatly affects children, particularly the girls. For instance, if a teacher attributes the ailment of a student to breakfast skipping, other students will understand the importance of breakfast consumption (a father).
Perceived self-efficacy also included two subcategories, namely responsibility assignment and vicarious experience. Participants highlighted that assigning responsibilities to students provides them with the opportunity to personally experience a given behavior and attempt to successfully show it. Moreover, vicarious experiences with peers, family members, and school staff can contribute to healthy breakfast consumption.
My daughter is thirteen-year-old and can make breakfast for herself. Of course, she previously was also able to make breakfast and she made breakfast for her father and brother when I was not at home (a mother). They provided us with a food made of lentil. I didn’t like it at all. But, when I saw my friends and teachers were eating it, I tested it and found it good (a student).
The perceived benefits of breakfast consumption came into four subcategories, namely physical, intellectual (or learning-related), emotional, and social benefits.
My children said that those mothers of their friends who didn’t eat breakfast were inattentive to them (a mother). In the morning, children are sleepy and hence, their attention is not adequately concentrated. However, breakfast eliminates their sleepiness (a mother). Last year, one of my classmates told me about the bad smell of my mouth and refused sitting next to me. Since then, I eat breakfast (a student).
Segmentation; the role of supporters: Parents and school staff were identified as the supporters of the breakfast consumption behavior. The more attentive the mothers and the school staff are to breakfast consumption by students, the more likely the students will consume breakfast. “Healthy snack time” at school can also encourage healthy snack consumption among students.
Before breakfast, I give them orange juice. Or for instance, as they like to eat flavored milk, I mix milk with honey or banana. They drink it with appetite (a mother). School staff have given us an eating plan and have required us to provide our children with healthy snacks, according to the plan, to be eaten at the healthy eating time at school (a mother).
Phase II: the quantitative study
Design and setting
As a randomized controlled trial based on the SM benchmarks, the quantitative study was conducted from 2018 to 2019, in girls’ guidance schools in Khoraambad, Iran. The trial was registered in the Iranian Registry of Clinical Trials (code: IRCT20170201032347N1).
Sample
Participants were female guidance school students. Eligibility criterion was agreement for participation and exclusion criteria were incomplete answering to study instruments and more than one absence from the intervention sessions. Participants were selected through multistage random sampling. Initially, Khorramabad city was divided into three hypothetical areas according to the socioeconomic status of its residents. Then, two girls’ schools were randomly selected from each area. The selected six schools were randomly allocated to a control group (three schools) and an intervention group (three schools). After that, a random sample of students was selected from each educational level (i.e. levels seventh, eighth, and ninth). Flow chart for trial recruitment is attached(Figure 1). Using the sample size calculation for the comparison of two means and with an attrition rate of 10%, sample size was calculated to be 48. Sample size calculation formula was, .
Intervention
Based on the SM campaign launched by Colorado Nutrition Network for healthy eating promotion among the preschool children of low-income families[12], a ten-week healthy eating campaign was developed and conducted using SM strategies (Table 1). The theme of the program was “Test delicious homemade snacks”. The campaign was conducted at school level and all students and school staff were informed about the campaign through a healthy eating exhibition and campaign posters. Educations about healthy eating were integrated into the weekly educational programs of the students and their teachers were asked to provide students, on a weekly basis, with educations about the consumption of healthy breakfast and snack. Moreover, the buffet staff of the schools were asked to replace potato chips and cheese puffs in the buffet shelves with healthy snacks (Appendix 1). Besides, a ten-week educational program on healthy breakfast and snack consumption was implemented for students. Initially, students in each school were divided into three small groups with 5–6 students from each educational level. Then, a one-hour educational session was held for each group. In the first session, healthy and unhealthy snacks were introduced to students through animations and posters and then, animations were provided to students for personal use and posters were hanged on school boards. In sessions 2–9, each student made a healthy snack in the school kitchen in the presence of all her group members and provided explanations about the snack ingredients and its advantages. She had already learned how to make the snack at home from her parents. All her group members tested her snack. In the tenth session, all students made healthy homemade snacks and presented them in a healthy eating exhibition at school.
Educational materials for the sessions were developed based on the theoretical concepts related to healthy breakfast and snack consumption identified in the qualitative phase of the study. These concepts were perceived self-efficacy, fear over the complications of breakfast skipping, and perceived benefits. Accordingly, based on the perceived self-efficacy concept, students were asked to explain about the preparation of an innovative healthy snack and show its preparation in a step-by-step approach. Moreover, they verbally and practically encouraged each other for the consumption of healthy breakfast and snack. Based on the perceived benefits concept, students were asked to talk with each other about the benefits of healthy homemade snacks such as their good taste, low cost, easy preparation and eating, as well as their positive physical, intellectual (or learning-related), emotional, and social effects. The role-paying method was used to deliver educations about these benefits. In addition, based on the concept of fear over complications, participants were provided with educations about the complications of breakfast skipping and unhealthy snack consumption such as weight gain, dental caries, and reduced immunity. Participants were also encouraged to discuss about the necessity of healthy breakfast consumption by both obese and thin people.
Reinforcing educational messages were sent to parents and school staff through social networks. Virtual groups in social networks were also created for parents and school staff, where they were asked to share their experiences.
Participants in the control group just received healthy nutrition services routinely provided at schools in Iran. These services included the provision of warm food which were cooked in places with unknown hygienic conditions and were provided to students at high costs in healthy snack buffet at schools. Educational intervention was carried out based on the Edgar Dale's Pyramid of Learning[24]. Figure 2.
Outcome measures
The primary outcome of the study was the factors affecting healthy breakfast consumption which were measured using the 38-item Factors behind Breakfast Consumption Scale. This scale contains four domains, namely product or preferences which can restrict healthy breakfast consumption, readiness to pay for costs, place-related preferences, and channels which promote healthy breakfast consumption. The items of the product domain were scored on a five-point scale from 1 (“Completely disagree”) to 5 (“Completely agree”). The items of the promotion domain were scored dichotomously as either 1 (“Yes”) or 0 (“No”). The items of the place domain were described using frequency distribution. The face, content, and construct validity of this scale were assessed and confirmed in a former study. That study reported that the four-domain structure of the scale explained 61.73% of the variance of the factors affecting breakfast consumption and the Cronbach’s alpha of the scale was 0.71[25]. This scale was administered to participants before and six months after the onset of the study intervention.
The secondary outcome of the study was the healthy breakfast and snack consumption behaviors. These behaviors were assessed over a seven-day period using a scale with items scored 1–4.
Data analysis
Statistical data analysis was done using the SPSS software (v. 20.0) and at a significance level of less than 0.05. Categorical variables were described via absolute and relative frequencies and numerical variables were described via mean and standard deviation. Between-group comparisons concerning categorical and numerical variables were made using the Chi-square and the independent-sample t tests, respectively. The effects of confounders were removed through univariate modeling in three models which were respectively adjusted for pretest readings (Model 1), pretest readings and mother’s occupation (Model 2), and pretest readings, mother’s occupation, and parents’ educational level(Model 3).
Results
The means of participants’ age in the intervention and the control groups were 13.71±0.91 and 13.75±1.2, respectively. No statistically significant differences were observed between the groups concerning participants’ and their parents’ characteristics as well as the place of breakfast consumption (P > 0.05), except for parents’ educational level and mother’s occupation (Table 2). The mean score of restrictive preferences(Product), readiness for paying the costs(Price), promotion channels and behavior improved significantly after intervention in intervention group (Table 3). The results of univariate modeling illustrated significant between-group differences concerning product, price, promotion, and behavior (P < 0.05; Table 4).