In the present study, to increase awareness about diabetes, its types, risk factors, complications, and symptoms were discussed. In the Farahmand study, after the EI, the mean score of awareness, perceived susceptibility, severity, benefits, and barriers in type 2 diabetic patients increased significantly compared to the control group . In the study of Bayat et al., after implementing the educational program, awareness in both intervention and control groups increased significantly, probably due to the implementation of regular training programs at the center. However, a significant increase in attitude and behavior was observed only in the intervention group . Sadeghi et al.'s educational trial indicated the HBM's effectiveness in educating people over 30 years old referred for diabetes screening; they suggested the HBM be used alongside traditional education methods . Moreover, Shojaeizadeh study showed that, in educating diabetic patients, the empowerment model had desirable potentials compared to the medical approach currently common in diabetes education, thus considering concepts, including patient empowerment and self-care behavior adoption, improve the results of interventions in chronic patients such as diabetes is inevitable. On the other hand, changing the approach in in-service education of people involved in educating diabetic patients in the field of health care is necessary .
As regards the construct of perceived susceptibility, acceptance-expression of susceptibility to the complications of diabetes, besides the prohibited foods causing complications of diabetes and the genetic factors involved in developing diabetes in other healthy members of the family, were discussed. Regarding the perceived severity construct, beliefs of students in that diabetes can lead to their death, serious complications in them (due to involvement of more organs), high economic costs on them and their families, as well as making them disabled were discussed. As regards the construct of perceived benefits, beliefs of students in that following nutritional principles (using recommended food groups) and doing adequate and appropriate physical activity results in self-confidence in maintaining their health were argued. For the construct of perceived barriers, beliefs of students in that unawareness of the nutritional principles should not result in nonadherence to them, and also that adherence to such principles does not cause them to stay away from their favorite foods were discussed. For perceived self-efficacy, identification of beneficial and harmful foods, in general, was argued; according to the current program, a significant increase in the mean scores of constructs and behavior was observed.
Shabibi et al. and Dadkhah Tehrani et al. showed that the mean scores of perceived susceptibility, severity, benefits, barriers, and self-efficacy, as well as self-care behaviors, before the intervention, were at moderate and low levels. However, after the intervention, the mean score of each construct of the HBM and self-care behaviors increased significantly [8, 13]. In a systematic review of Zare et al., while emphasizing the use of behavior change models, such as social cognitive theory, HBM, and self-efficacy, mentioned promoting diabetes self-care behaviors, combining models, and considering other determinants at the community level to improve the effectiveness of interventions . In their meta-analysis study, Dandan Liang et al., reviewing 17 studies, confirmed peer support for key variables in promoting self-management and self-efficacy in diabetes . Ghoreishi et al., in their EI based on social cognitive theory on diabetes self-care behaviors, emphasized that emotional adjustment, self-efficacy to overcome barriers, and self-regulation can predict self-care and that the program promotes awareness and self-efficacy in diabetic patients .
Among the studies measured more objective aspects of the consequences of EI, a clinical trial of Shao et al. in 2018 showed that in the intervention group, diabetes education increased the average scores of HBM variables (perceived susceptibility, severity, barriers, and self-efficacy) and improved uric acid, physical activity, body mass index, and waist ratio after the intervention; while in the control group, between consecutive intervals and follow-up, no significant differences were observed . In a study with a different research community, Karimi et al. examined the effect of education based on HBM on diet adherence in pregnant women with gestational diabetes; their research results indicated the usefulness and significant impact of such training on the constructs of the model . In his study, Farahani Dastjani investigated the effect of HBM-based education on adherence to medication regime in patients with diabetes. According to their findings, three months after the EI, the constructs of perceived susceptibility, benefits, and self-efficacy, as well as cues to action and behavior in adherence to the medication regime, increased significantly compared to the pre-intervention. In contrast, the constructs of perceived barrier and severity showed insignificant differences compared to pre-intervention .
These results show that health education interventions in the HBM framework are practical approaches in educating and promoting proper health behaviors concerning type 2 diabetes among students. Moreover, based on this study's results and other relevant evidence, this type of education may be included in diabetes-related health promotion programs among students, thus benefiting from its effects on maintaining and promoting students' health behaviors.
One of the strengths of the present study is considering students at risk and emphasizing the prevention and health promotion, especially in adolescents, conducting research in a border and less privileged city. One of the limitations of the present study is the study of behaviors abstractly, some of which can be examined objectively with parents' help; further, self-report and gender (male) can result in students' carelessness in completing questionnaires. Thus, parental involvement is suggested to evaluate behaviors.