12-Mataji Amirrood

JRHS 2014; 14(1): 78-83

Copyright© Journal of Research in Health Sciences


The Impact of Training on Womens Capabilities in Modifying Their Obesity-Related Dietary Behaviors: Applying Family-Centered Empowerment Model 

Maryam Mataji Amirrood (MSc)a, Mohammad Hussein Taghdisi (PhD)a*, Farzad Shidfar (PhD)b, Mahmood Reza Gohari (PhD)c

a Department of Health Education and Health Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

b Department of Nutrition, School of Nutrition, Tehran University of Medical Sciences, Tehran, Iran

c Department of Mathematics and Statistics, Faculty of Management and Medical Information, Hospital Management Research Center, Tehran University of Medical Sciences, Tehran, Iran

* Correspondence: Mohammad Hussein Taghdisi (PhD), E-mail: taghdisi.mh@gmail.com

Received: 27 July 2013, Revised: 05 October 2013, Accepted: 26 November 2013, Available online: 01 December 2013

Abstract

Background: Dietary behaviors affect obesity; therefore, it seems necessary to conduct interventions to modify behavioral patterns leading to weight-gain in the family. Our goal was to determine the impact of training on womens capabilities in modifying their obesity-related dietary behaviors in Urmia, West Azerbaijan Province, Iran: applying family-centered empowerment model.

Methods: A quasi-experimental study with Pretest-Posttest design was conducted on 90 over-weight/obese women in 2012 in two Health Centers of Urmia. Convenience sampling was done and the participants were randomly assigned to two test and control groups. Data collection was done by completing the demographic data questionnaire, the empowerment tool and dietary behavior checklist. The intervention was conducted in the form of 6 educational classes held for the test group. After two months, posttest was performed by completing the forms once again. Data were analyzed with descriptive tests, t-tests, Chi2 and Fishers test.

Results: The dietary behavior scores of the intervention group had risen from 7.4±2.11 to 9.95±2.41 (P<0.001), and the good dietary behaviors had risen from 21.4% to 61.9% (P=0.002). The good capability level of this group had risen from 23.8% to 97.61% (P<0.001), and their mean capability score had risen from 54.61±7.34 to 70.26±6.04 (P<0.001). However, the changes were not significant in the control group.

Conclusions: The educational intervention performed whit applying family-centered empowerment model in this study was proven effective in women. Hence it is advised to consider it in behavior changing interventions to promote the health of the family and community.

Keywords: Family-Centered Empowerment, Dietary Behaviors, Obesity, Women, Iran

Introduction

Nowadays life standards are on the rise, but weight gain and obesity are growing threats against health all around the world 1. World Health Organization has predicted that 1.3 billion people worldwide will be developed to overweight and 537 million to obesity by 2020 2.

The studies conducted in Iran also show the rise of obesity in recent years3. The highest prevalence of weight gain and obesity has been observed above the age of thirty and 44-72% of the rural plus 82% of the urban population have been affected 4. Dietary behaviors play a special role in weight reduction5. Changes in lifestyle are the most important reason behind the significant rise in weight gain in the past two decades6. Dietary behaviors of families are associated with obesity7. Hence performance of  interventions to correct behavioral patterns leading to weight gain in the family seem necessary to reduce the prevalence of weight gain and obesity6-7. Helping individuals and families to attain active roles in taking care of their health should be more focused on empowerment than on offering help 8.

The family empowerment can be an appropriate model for health promotion and improvement of quality of life 9. This model is a pattern resulting from a qualitative study based on grounded theory10.

The main objective of this model is to empower the family system in promoting its health. It lays emphasis on the effectiveness of the individual and other family members roles in three dimensions: motivational, cognitive and personal traits (Figure 1)9. Four executive phases for implementing this model have been designed that are continuous and cohesive: perception of threat, problem-solving, educational participation and evaluation(Figure 2)11.

Several studies have highlighted the significant role of educational programs in empowering individuals by providing the necessary knowledge and awareness12. To promote health and improve the quality of life, it seems necessary to conduct an empowerment program with the following goals: raising awareness, knowledge, self-efficacy and participation.

Many studies have been conducted on the application of the family empowerment model in educational interventions. Studies conducted on the prevention of anemia in young girls 9, and also on the impact of the aforementioned model on the knowledge, attitude and performance of multiple sclerosis caregivers 11 are such examples. These studies pointed to the positive and significant results of the application of this model in educational interventions.

Family health requires womens empowerment. Several studies declare the high prevalence of obesity in Iran (especially in women) 13. We therefore conducted a study on the impact of family empowerment training on empowering women to modify their obesity-related dietary behaviors in the city of Urmia. Our ultimate goal was to raise womens awareness and to change their attitude toward obesity and its side effects, in addition, to empower them to modify incorrect dietary behaviors in the family.

Figure 1: Family-centered empowerment model structures

Figure 2: Family-centered empowerment model executive phases 11

Methods

A quasi-experimental interventional study was conducted on 90 over-weight/obese women in the winter and spring of 2012. Forty five persons were assigned to each group (test and control). After receiving permission from the Tehran University of Medical Sciences Ethics Committee with code 16975, two health centers (Number 13 and Shaheed Nik-khah) from Urmias middle-class residential zones, West Azerbaijan Province, Iran were randomly selected. The participants were chosen through convenience sampling and randomly assigned to two test and control groups. The inclusion criteria were: being married, age 18-60 years, BMI>25,  not being pregnant at the time of the study and follow up period, able to read and write, and ability to participate in the empowerment program. The exclusion criteria were as follows: inability to continue to take part in the study, reluctance to complete the data collection tools, absence in problem-solving sessions and educational participation programs and spouses inhibition.

The research tools used in the study were as follows: demographic data questionnaire (13 questions), dietary behavior checklist (14 questions), and the empowerment evaluation questionnaire (37 questions) that included questions on awareness (example: Do you think that speed of eating effective in weight gain?), attitude (example: I'm worried about increasing my weight), Rosenbergs self-esteem (example: I take a positive attitude toward myself) 14 and self-efficacy (example: Can I choose healthy food even if it is not good taste) in dietary behaviors. A panel of 10 experts on health education and nutrition examined the questionnaires to determine their validities. Reliability of the research tools was determined by having 15 overweight/obese women complete the questionnaires. After extracting the data, the reliability was examined by calculating Cronbachs alpha. The alpha coefficient calculated for the dietary behavior checklist was 0.701 and for empowerment questionnaire and its structure was 0.78, 0.708, 0.71, 0.81 and 0.788 respectively, which were acceptable.

Dietary behavior and empowerment status scores were considered separately, and a scale of 100 was used. If participants scored 0-33 it would be considered weak dietary behavior or weak empowerment; a score of 33.1-66 was considered average and a score of 66.1-100 was considered good.

At the baseline, research tools were completed in both test and control groups. Then, upon analyzing the data in the first phase, and by taking into consideration the resources, limitations, strengths and weaknesses, the type, content, educational method and number and timings of classes were designed on the basis of family empowerment model steps (raising awareness and perceived threat, problem-solving, educational participation and evaluation in the form of process and final evaluation). The second (intervention) phase was conducted in the form of six 45-minute-long educational sessions for groups of 15 individuals. The third step was an educational participation in which the discussed contents of previous meetings were used for educational booklet and pamphlet transmitted to family active member (husband in this study), in order to their participation in modifying food behaviors associated with obesity in the family.

The meetings were only held for the intervention group and the control group did not receive any intervention. In the post test phase the food behavior checklist and empowerment tool were completed again by both groups, two months after the intervention. The results were then compared to evaluate the impact of the intervention.

Data analysis was done with SPSS 18 software. Descriptive analysis (mean and standard deviation) and inferential analysis (independent and paired t-tests, chi square and Fischers test) was performed at a significance level of 0.05.

Results

Ninety questionnaires were completed by the samples in the pretest phase, 13% of which were lost. So the study results were calculated on the basis of 87% of samples, 42 individuals in the test and 36 individuals in the control group. Their age ranged from 19-57 ye, and their average age was 33.63±8.75 years. Their average weight and body mass index (BMI) were 76.32±10.6 and 29.28±3.6 kg.m2 respectively. Around 92.3% were housewives and 7.7% were employed. All the participants were literate and 43.6% had primary and intermediate school education. Among the participants spouses, 39.7% had primary and intermediate school education, and 46.2% had non-civil service jobs. A comparison of the groups with t-test did not show a significant difference between the two groups background quantitative variables: age P=0.239; weight P=0.476; BMI P=0.78. Chi square results did not show any significant differences between the two groups background qualitative variables either: womens level of education P=0.5; womens employment status P=0.847; spouses level of education P=0.141; spouses employment status P=0.968; and level of income P=0.517.

Table 1 shows the results of Fischers test on the significance of before-after changes of the educational intervention in weak, average and good dietary behaviors in the two groups. Accordingly, good dietary behaviors in the intervention group improved from 21.4% to 52.4%. This changes were statistically significant (P=0.002). However the change was not significant in the control group (P=0.99).

Table 2 shows the results of the independent and paired t-tests performed to compare the mean and mean difference scores of dietary behaviors in the two groups. The independent t-test showed a significant difference (P<0.001) in the mean dietary behaviors scores of the two groups after the intervention. Moreover, the paired t-test showed a significant difference in the aforementioned score before and after the intervention in the intervention group (P<0.001). Table 3 illustrates the status of capability constructs before and after the educational intervention in both groups. The mean of awareness, attitude, self-esteem and self-efficacy had risen as compared to before in the intervention group; a finding confirmed by the paired t-test (P<0.001). However, the changes were not significant in the control group.

Table 4 shows the womens capability status, based on the classification given earlier. Results of the Fischer test showed that the good capability level improved significantly (P<0.001) from 23.85 to 97.61% in the intervention group. However, the changes in the control group were not significant (P=0.182).

Table 5 shows the comparison of mean and mean difference scores in capability in the two groups using independent and paired t-tests. Independent t-test showed the difference in the aforementioned scores between the two groups to be significant after the intervention (P<0.001). The paired t-test confirmed these findings too.

Table 1: Distribution of dietary behaviors in the two groups before and after the educational intervention using Fisher exact test

Table 2: Comparison of the mean and mean difference scores of dietary behaviors in the two groups

Table 3: The status of capability constructs mean and mean difference scores before and after the educational intervention in the two groups

Table 4: Distribution of capability status in the two groups before and after the educational intervention using Fisher exact test

Table 5: Comparison of the mean and mean difference scores of capability in the two groups

Discussion

The current study aimed at modifying incorrect obesity-related dietary behaviors in overweight/obese women through an educational intervention based on the family-centered empowerment model.

Pretest-posttest data analysis of dietary behaviors showed changes in both groups. The changes in the control group was not significant though the changes in the intervention group was significant, implying that the educational intervention was effective in women. The targeted dietary behaviors in the study included items such as: breakfast intake, water consumption, dairy intake, speed of food ingestion, use of sweets, fried and fast foods, omission of main meals and simultaneously doing other chores while eating. The aforementioned dietary behaviors were chosen based on several references, such as in a study which had recognized the following dietary behaviors as influential factors on obesity: skipping breakfast, high intake of fast foods, soft drinks, fried food and low intake of dairy products and fruits 15 considered to modify and reduce such behaviors in women in this study, owing to their active role in shaping dietary habits and behaviors in the family.

Increased prevalence of obesity could be rectified through public education and changes in eating and drinking habits. These methods in turn were effective in weight reduction as well 16.

Cowen and Devine showed that the educational and environmental interventions could encourage in promotion of positive nutritional behaviors. For example 42% of the intervention group had increased their intake of fruits and vegetables, and decreased intake sweets and desserts 17. Besides, educational intervention on women's behavior in the field of consumption oils and fat showed that percentage of families when cleaning meat, removed the meat visible fat had increased from 52% to 62.5% 18. The current study also showed that womens eating habits in consumption of sweet foods 28% and fatty foods 15% had decreased after the intervention.

Moreover the promotion of healthy eating behaviors in Washingtons minority groups was studied by holding an educational intervention in intermediate urban schools. According to the results the changes created after the intervention were significant in promoting healthy eating behaviors in the students 19.

This study state the positive impact of education on nutritional behavior changes. Our study results also confirm these findings.

Accordingly, in the present study, constructs of knowledge, attitudes, self-esteem and self-efficacy were as family-centered empowerment model structures, the results of the study confirmed promotion in women's capabilities in healthy eating behaviors based on these structures.

It was illustrated that adopting an empowerment program was beneficial to improve the nutrition and food environment of food insecure adults. It also increased the adult capability to adapt of changes in food and food environment 20. Educational intervention with the aim of empowering young people led to amount of participants awareness increased to 89% of the beneficial effects of dairy food. In the pretest 59% had reported to have used of dairy foods on a daily, but in the posttest it reached to 94% 21. In the present study, the consumption of dairy products in the intervention group was promoted from 52% before the educational intervention to 81% after the education. Furthermore, their awareness in the field of dairy consumption effectiveness, increased from 40% to 90% after intervention. Low consumption of dairy products made higher body mass index 22.

In Malaysia appropriate eating behaviors were typically created followed by good eating attitudes 23. Furthermore it was observed that eating attitudes scores in overweight and obese Americans girls was lower than normal-weight girls 24. Food taste was the most important predictor nutritional attitudes and most food choices 25. In the current study food taste as a barrier in healthy food choice, was reduced from 38% to10% after educational intervention.

Self-esteem and self-efficacy were both essential for learning and there was a reciprocal relationship between them 26. In the Netherlands lower weight loss was associated with lower self-efficacy 27. Besides, the important role of self-efficacy in treatment of obesity was confirmed in behavioral weight control 28.  Furthermore low self-esteem had been associated with unhealthy food behavior 29. In the present study, good self-esteem and self-efficacy scores were improved in order to correct poor eating behaviors, respectively 17% and 40% after the intervention.

After the intervention the mean scores of the capability constructs (awareness, attitude, self-esteem and self-efficacy) and health promoting behaviors had significantly increased in the intervention group, as opposed to the control group 30. The results are in line with our findings in that the mean scores of empowerment constructs and overall capability had improved after the intervention.

Among the limitations of the study is the time limit in its execution. Therefore the educational intervention was held an intensive course and the time gap considered for the posttest was 2 months, and recurrent follow-ups were not done to confirm the sustainability of results. On the other hand, the constraints of space and educational facilities in health centers led to the exclusion of some centers in sampling. Due to the shortage of financial facilities, assistance and time this study was only conducted on the women under coverage of two health centers. Therefore, generalization of the findings must be done with caution. Future studies in this field should take these limitations into account and allocate greater time and increase the population under study to increase the possibility of generalizing the findings to the community under study.

Conclusions

The current study took advantage of empowerment in increasing womens capabilities in modifying their incorrect nutritional behaviors. Therefore, in the light of these findings and those of previous studies, we recommend the application of this educational method as an appropriate model- in family and community health promotion; in this way, for effective and sustainable interventions require the empowerment of families in attaining health.

Acknowledgements

This study was sponsored by Tehran University of Medical Sciences (grant no: 16975) and conducted during 2011. We would also like to extend our gratitude to Urmia University, Urban Health Centers 13 and Shaheed Nik-khah, Dr. Javad Eshaghi, Ms. Saeedeh Mataji and all those who helped conduct this project.

Conflict of interest statement

The authors have no conflict of interest to report.

Funding

The present study was supported by grants from Center for Community Based Participatory Research.

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