
==== Front
J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-217
10.4103/jehp.jehp_569_23
Original Article
The effects of web-based education on health-promoting behaviors of first-year medical sciences students: A quasi-experimental study
Khajavi Nazanin
Mohsenzadeh-Ledari Farideh 1
Sepidarkish Mahdi 2
Pasha Hajar 1
Adib-Rad Hajar 1
Ezoji Khadijeh 1
Omidvar Shabnam 1
Student Research Committee, Babol University of Medical Sciences, Babol, Iran
1 Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
2 Department of Biostatistics and Epidemiology, School of Public Health, Babol University of Medical Sciences, Babol, Iran
Address for correspondence: Dr. Shabnam Omidvar, Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran. E-mail: shomidvar@yahoo.com
2024
11 7 2024
13 21727 4 2023
24 7 2023
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
BACKGROUND:

Students, as a representative of young adults, are at risk for engagement in unhealthy lifestyle behaviors such as unhealthy eating, unhealthy relationships, and drug abuse. Health-promoting lifestyle (HPL) largely depends on adequate knowledge of healthy behaviors and hence, education is a strategy with potential positive effects on lifestyle. This study aimed at evaluating the effects of web-based education (WBE) on HPL among first-year medical sciences students.

MATERIALS AND METHODS:

This quasi-experimental study was conducted in 2020 with a single-group pretest-posttest design. Participants were 185 first-year bachelor’s and doctoral medical sciences students selected from Babol University of Medical Sciences, Babol, Iran, through multistage sampling. Study intervention was a three-week web-based educational program on HPL. Educational videos about the different components of HPL were sent to participants through WhatsApp. Data were collected before, one month after, and three months after the study intervention through the Health-Promoting Lifestyle Profile (HPLP2) and the General Health Questionnaire (GHQ). The STATA software (v. 16.0) was used for data analysis.

RESULTS:

Among 185 participants, 154 (83.69%) participants completed the study. The mean scores of HPL and its health responsibility and stress management subscales significantly increased by 4.58 (95% CI: 0.12, 9.04), 1.77 (95% CI: 0.39, 3.15), and 0.71 (95% CI: 0.13, 1.26), respectively. However, the mean scores of the nutrition, interpersonal relations, physical activity, and self-actualization subscales of HPL and the mean score of general health did not significantly change (P > 0.05).

CONCLUSION:

WBE has significant positive effects on HPL and its health responsibility and stress management subscales. Therefore, WBE through social media can be used to improve HPL among young adults, particularly students.

General health
health promotions
internet-based intervention
students
==== Body
pmcBackground

Most students throughout the world engage in high-risk behaviors such as alcohol consumption, tobacco use, limited physical activity, and unhealthy eating.[1] Unhealthy lifestyle behaviors such as limited physical activity, high-fat diet, low calcium intake, and low vegetable and fiber intake are the most important risk factors of obesity among youngsters[123] World Health Organization (WHO) reported in 2016, 39% of adults aged 18 years and over were overweight.[4] A study in Iran also reported that 61.7% of the adolescent female students had some degree of anxiety and another study showed a majority of the students were reported to be with mental health problems.[56]

Many unhealthy and life-threatening behaviors are formed in adolescence, continue to adulthood, and negatively affect adult health. Adolescents and youngsters are future adults and hence, management of their unhealthy behaviors is essential to prevent chronic diseases in adulthood.[7] Nonetheless, health-promoting interventions do not focus on them because they usually have limited, if any, major health problems.

Healthy lifestyle and health-promoting behaviors (HPBs) are among potentially effective strategies to maintain and improve health. Health promotion is an educational, social, and environmental approach that aims at health improvement through the observance of healthy lifestyle habits.[8] The concept of health promotion was developed to help individuals reach an optimum level of physical, mental, social, and spiritual health. HPBs are a set of activities that individuals continuously perform to improve or promote their health and include nutrition, physical activity, health responsibility, stress management, interpersonal relations, and self-actualization.[9]

Adequate knowledge is a major prerequisite to effective engagement in HPBs. Therefore, education is the main strategy to improve engagement in HPBs. There are different methods for HPB-related education, including computer-based education, focus group discussion, lecture, question and answer, demonstration, exercise, simulation, role playing, and E-learning. However, previous studies reported contradictory findings on the effects of education on HPBs. For example, some studies reported that educational interventions had significant positive effects on HPBs,[101112] while some studies reported their insignificant effects on HPBs.[131415]

E-learning is a method to design, provide, and evaluate education using electronic equipment. Web-based education (WBE), as an E-learning method, provides flexible and easy access to educational materials, has no transportation-related costs, and hence, has superiority over traditional teaching. Healthcare providers usually use mobile phones as an educational platform to provide their clients with timely feedback and modify their health-related behaviors. Formal WBE using mobile phones was started in 2007 in countries such as Britain, Sweden, and Italy for the education of 16–24-year-old individuals.[16] It facilitates the use of different educational resources, provision of instant feedback, interpersonal interactions, and sharing of different information, supports different applied programs, and promotes learning in health education courses.[17] The great popularity of social media among students and its significant direct effects on the different aspects of their life have turned it into a good option for WBE.[18]

There is no consensus over the effectiveness of WBE. Some studies reported that WBE significantly changed HPBs, while some studies reported that WBE had no significant positive effects on HPBs.[19] Therefore, further studies are necessary to provide better evidence respecting WBE effects on HPBs. The present study was conducted to evaluate the effects of WBE on health-promoting lifestyle (HPL) among first-year medical sciences students.

Materials and Methods

Study design and setting

This quasi-experimental study was conducted in 2020–21 (From December 2020 to May 2021) with a single-group pretest-posttest design.

Study participants and sampling

Participants were 185 first-year bachelor’s and doctoral medical sciences students of Babol University of Medical Sciences, Babol, Iran, in the 2020–2021 academic year.

Sample size was calculated based on the primary outcome of the study (score of the HPLP2).[20] It was assumed that a total sample of 185 participants, which included a 20% dropout factor and 0.9 correlation between pre and posttest measurement would provide 80% power to detect a five points difference in the mean score of the HPLP2 between two times. Assuming means of 130 in pretest and 135 in the posttest; a common standard deviation (SD) of 50; and a two-sided test having a type I error of 0.05. We described continuous and categorical variables by mean ± (SD) and counts (percentages), respectively. The variations of the HPL score over time were assessed through the linear mixed effects model and results were reported as mean difference with 95% confidence interval (95% CI). All statistical analyses were performed with STATA 17 (STATA Corp, College Station, TX, USA). The level of significance in all statistical analyses was set at 0.05.

They were selected through multistage sampling. Accordingly, academic degrees (i.e., bachelor’s and doctoral) were considered as two main strata. Among all the 586 registered students during 2020–2021 academic year, 160 students were selected. Then, a quota was given to each field of study in each stratum and finally, the name list of students and an online randomization module (www.random.org) were used to randomly select eligible participants. A phone call was made with each eligible participant for the invitation to the study. If the student did not answer the call, the next student on the list was approached. Sampling was continued until 185 students were selected. Eligibility criteria were an agreement for participation, age of 18–29 years, studentship in bachelor’s or doctoral degree, no activity-restricting physical problem, access to a mobile phone with Android, IOS, or Java operating system, account in WhatsApp, and access to Internet during the study. Exclusion criteria were reluctance to continue participation, loss of close relatives, income source, or employment, and start of a new dietary regimen during the study [Figure 1].

Figure 1 The flow diagram of the study

Data collection tool and technique

The primary and the secondary outcomes were HPL and general health which were measured using the Health-Promoting Lifestyle Profile and the General Health Questionnaire, respectively. The Health-Promoting Lifestyle Profile has 52 items in six main subscales, namely nutrition, physical activity, health responsibility, stress management, interpersonal relations, and self-actualization. Items are scored on a four-point scale as follows: 1: “Never”; 2: “Sometimes”; 3: “Often”; and 4: “Always”. The total scores of each subscale and the whole scale are calculated by summing the scores of that subscale and the scores of all items, respectively. The possible total score of the scale is 52–208, with higher scores showing better HPL. We used the Persian version of this scale which had Cronbach’s alpha of 0.82 for the whole scale and 0.64–0.91 for its subscales. Test-retest stability assessment also confirmed its acceptable stability over time.[21]

The GHQ has 28 items in four seven-item subscales, namely, somatic symptoms, anxiety and insomnia, social dysfunction, and depression. Scoring is performed on a four-point scale as follows: zero: “Not at all”; 1: “Mild”; 2: “Moderate”; and 3: “Severe”. Subscale scores more than six and total scale scores more than 22 show low general health. The Cronbach’s alpha of the questionnaire was 0.9 and the coefficient of the correlation of its score with the score of the Medical Health Questionnaire was 0.55, confirming its acceptable validity.[22]

Intervention

Study intervention was a web-based multimedia HPL-related educational program. The program was developed based on the HPL component of the self-care booklet of the Ministry of Health of Iran and included educational videos with pictures, audios, texts, and music clips. Educational materials were provided to participants through WhatsApp. The duration of each video was 3–5 minutes. Each week, one video file was provided to participants who included education about two subscales of HPL.

The content of the videos and the time of intervention were as follows:

First week and Video 1: Physical activity and health responsibility.

Second week and Video 2: Nutrition and self-conceptualization.

Third week and Video 3: Stress management and interpersonal relations.

Initially, a WhatsApp group for participants was created and then, one educational video was uploaded for them every one week for three consecutive weeks (three videos in total as well as text).

The duration of the study intervention was three weeks. Participants completed the study instruments online at three-time points, namely before, one month after, and three months after the study intervention. Instruments were uploaded on the porsline.ir website and its link was sent to participants through WhatsApp.

Ethical considerations

The Ethics Committee of Babol University of Medical Sciences, Babol, Iran, approved this study (code: IR.MUBABOL.REC.1399.203). Informed consent was obtained from participants and data were confidentially collected.

Result

A total of 185 students were recruited to the study and 154 (83.69%) of them completed the study. The mean of participants’ age was 19.23 ± 1.66 years and most of them were female (54.5%), single (97.4%), and bachelor’s students (66.9%), and lived with their families (96.1%) [Table 1].

Table 1 Participants’ demographic characteristics

Characteristics	n (%)	
Gender		
   Male	70 (45.5)	
   Female	84 (54.5)	
Marital status		
   Single	150 (97.4)	
   Married	4 (2.6)	
Educational level		
   Bachelor’s student	103 (66.9)	
   Doctoral student	51 (33.1)	
Living arrangement		
   Alone	6 (3.9)	
   With family	148 (96.1)	
Employment status		
   Employed	7 (4.5)	
   Student	147 (95.5)	
Mother’s educational level		
   Illiterate	6 (3.9)	
   Below diploma	66 (42.9)	
   University	82 (53.2)	
Father’s educational level		
   Illiterate	5 (3.2)	
   Below diploma	52 (33.8)	
   University	97 (63.0)	
Mother’s employment status		
   Housewife	100 (64.9)	
   Employed	54 (35.1)	
Father’s employment status		
   Unemployed	10 (6.5)	
   Employed	144 (93.5)	
Family type		
   Nuclear	146 (94.8)	
   Extended	8 (5.2)	
   Total	154	

The total mean score of HPL significantly increased across the three measurement time points by 4.58 points (95% CI: 0.12, 9.04; P = 0.044). Moreover, the mean scores of the health responsibility and the stress management subscales significantly increased by 1.77 points (95% CI: 0.39, 3.15; P = 0.012) and 0.71 points (95% CI: 0.13, 1.26; P = 0.015), respectively. However, the mean scores of the nutrition 0.71 (95% CI: –0.03, 1.43, P = 0.062), interpersonal relations 0.63 (95% CI: –0.11, 1.38; P = 0.097), physical activity 0.88 (95% CI: –0.16, 1.94; P = 0.098), and self-actualization –0.11 (95% CI: –1.29, 1.05; P = 0. 846) subscales of HPL as well as the mean score of general health 0.63 (95% CI: −1.82, 3.01; P = 0. 632) and it’s subscales did not significantly change across the three measurement time points [Tables 2 and 3].

Table 2 The variations of the mean scores of HPL and its subscales across the three measurement time points

Time HPL	Before (Mean±SD)	1 month after (Mean±SD)	3 months after (Mean±SD)	Mean difference (95% CI)*	P	
Nutrition	17.42±3.01	17.89±3.43	18.12±3.58	0.71 (–0.03, 1.43)	0.062	
Physical activity	16.25±4.6	17.11±4.63	17.14±4.85	0.88 (–0.16, 1.94)	0.098	
Stress management	12.27±2.54	12.96±2.59	12.98±2.53	0.71 (0.13, 1.26)	0.015	
Interpersonal relations	9.65±3.23	19.96±3.57	20.29±3.51	0.63 (–0.11,1.38)	0.097	
Health responsibility	29.87±5.97	31.47±6.27	31.64±6.42	1.77 (0.39, 3.15)	0.012	
Self-actualization	29.98±5.1	29.79±5.53	29.87±5.45	–0.11 (–1.29, 1.05)	0.846	
Total	125.46±18.47	129.2±20.4	130.05±21.46	4.58 (0.12±9.04)	0.044	
*The results of the linear mixed effects model

Table 3 The variations of the mean scores of general health and its subscales across the three measurement time points

Time General health	Before (Mean±SD)	1 month after (Mean±SD)	3 months after (Mean±SD)	Mean difference (95% CI)*	P	
Somatic symptoms	14.53±3.72	14.31±3.14	16.58±3.94	2.05 (1.19, 2.90)	<0.001	
Anxiety and insomnia	14.19±5.2	13.27±4.67	13.35±4.93	–0.84 (–1.97, 0.28)	0.143	
Social dysfunction	21.23±3.96	20.88±4.05	20.88±3.66	–0.34 (–1.19, 1.50)	0.427	
Depression	11±4.87	10.72±4.58	10.73±4.83	–0.27 (–1.35, 0.80)	0.621	
Total	60.96±10.23	59.2±10.31	61.55±11.42	0.63 (-1.82, 3.01)	0.632	
*The results of the linear mixed effects model

Discussion

This study evaluated the effects of WBE on HPL among first-year medical sciences students. Findings showed that the total mean score of HPL significantly increased across the three measurement time points. This is in agreement with the findings of several previous studies.[102324] The positive effects of the study intervention may be due to its different audiovisual components. Unlike our findings, a previous study found that education had no significant effects on high school students’ HPL.[13] This contradiction is attributable to the difference between the intervention of the studies which was developed based on the self-care booklet of the Ministry of Health of Iran in the present study and consisted only of three one-hour lecture sessions in that study.

We also found that the WBE intervention of the study significantly improved the mean scores of the health responsibility and the stress management subscales of HPL. Previous studies also reported the significant positive effects of WBE on health responsibility[11] and mobile-based education about stress management skills on stress level.[2526] However, a study on adolescents found that WBE had no significant effects on stress management.[11] This contradiction may be due to the lower age of participants in that study compared with the participants of the present study.

Our findings also revealed that WBE had no significant effects on the nutrition and the physical activity subscales of HPL. Previous studies into the effects of education on nutrition and physical activity reported inconsistent findings. For example, a systematic review showed that computer-based educational programs for obesity management had minimal effects on dietary regimen and physical activity.[27] However, two randomized controlled trials reported that WBE significantly improved nutritional status, increased vegetable and fruit consumption, and reduced anthropometric indices among adolescents.[211] Nutrition is affected by many different factors such as families’ childrearing approaches and financial status, accessible food stuff, educational environment, and peers, and hence long-term multi-component interventions are needed for its improvement.

Study findings also indicated that WBE had no significant effects on general health. General health has a significant relationship with HPL. As some aspects of HPL did not significantly change in the present study, the insignificant change in general health is justifiable.

Limitation and recommendation

The study had limitations; one of them was the lack of face-to-face interaction between instructors and learners. Moreover, participants were not obliged to use the provided education. The researcher attempted to manage the limitations by encouraging participants to actively participate in the educational program by sending reminders. Moreover, we could not control the information which they might receive in other ways.

Conclusion

This study concludes that WBE about HPL significantly improves HPL. As WBE does not need face-to-face contact between instructors and learners, it can be used to promote HPL among a wide range of individuals in different geographical areas.

List of abbreviations

HPL = Health-promoting lifestyle

GHQ = General health questionnaire

WBE = Web-based education

HPBs = Health-promoting behaviors.

Ethics approval and consent to participate

The Ethics Committee of Babol University of Medical Sciences, Babol, Iran, approved this study (code: IR.MUBABOL.REC.1399.203). All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from participants and data were confidentially collected.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and/or analyzed during the current study are available.

Authors’ contributions

NKH, SO, FM-L, and KE study concept and design. NKH recruitment participants and data collection. HP and HA-R contributed to the survey development. MS performed the statistical analysis and interpretation the results and critical revision of the manuscript. SO drafted the manuscript. All authors read and approved the final manuscript.

Financial support and sponsorship

This article is retrieved from a master science thesis in Midwifery counseling in Babol University of Medical Sciences. The Deputy Research of Babol University of Medical Sciences supported the funding (Grant No724132729).

Conflicts of interest

There are no conflicts of interest.

Acknowledgement

We gratefully acknowledge students for participating in the study as well as Health research Institute, Babol University of Medical Sciences for approving our research.
==== Refs
References

1. Zarei F Taghdisi M Tehrani H Normalizing health valuesin the socialization process J Res Heal 2012 2 169 71
2. Chen JL Weiss S Heyman MB Cooper B Lustig RH The efficacy of the web-based childhood obesity prevention program in Chinese American adolescents (Web ABC study) J Adolesc Health 2011 49 148 54 21783046
3. Al-Jawaldeh A Abbass MMS Unhealthy dietary habits and obesity: The major risk factors beyond non-communicable diseases in the eastern mediterranean region Front Nutr 2022 9 817808 35369054
4. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight (Accessed 1th July 2023)
5. Kheirkhah M Mokarie H Nisani Samani L Hosseini AF Relationship between anxiety and self-concept in female adolescents Iran journal of nursing 2013 26 19 29
6. Hezomi H Nadrian H What determines psychological well-being among Iranian female adolescents? Perceived stress may overshadow all determinants Health Promot Perspect 2018 8 79 87 29423366
7. Akseer N Mehta S Wigle J Chera R Brickman ZJ Al-Gashm S Non-communicable diseases among adolescents: Current status, determinants, interventions and policies BMC Public Health 2020 20 1908 33317507
8. Mehri A Solhi M Garmaroudi G Nadrian H Sighaldeh SS Health promoting lifestyle and its determinants among university students in Sabzevar, Iran Int J Prev Med 2016 7 65 27141284
9. Hua Y Wang B Wallen GR Shao P Ni C Hua Q Health-promoting lifestyles and depression in urban elderly Chinese PLoS One 2015 10 e0117998 25781326
10. Hassani L Alighias M Ghanbarnejad A Shahab-Jahanlu A Gholamnia-Shirvani Z Effect of educational intervention on health-promoting behaviors of high school students in Karaj city J Prev Med 2015 2 62 9
11. Coşkun S Güvenç G Bebiş H Effectiveness of web-based health education and consultation on health promotion behaviors of adolescents Gülhane Tip Dergisi 2019 61 139
12. Zahra R Masooma M Fatemeh R Mitra Z <An> educational intervention using health belief model on smoking preventive behavior among female teenagers 2011 17 15 26
13. Safabakhsh L Nazemzadeh M The effect of health promotion education on high school students lifestyle Iranian Journal of Medical Education 2013 13 58 65
14. Zareian A. Conceptual explanation of male adolescents lifestyle a qualitative research 2008
15. Parvizi S Sepahvand F Sanagu A Razzaghi N Adolescents’ health: A qualitative study on adolescents in Khorramabad Iran Journal of Nursing 2008 21 61 72
16. Papzan AAH Soleymani A Comparing cell phone-based and traditional lecture-based teaching methods’ effects on agricultural students’ learning Information and communication technology in educational sciences 2010 1
17. Wu TT Using smart mobile devices in social-network-based health education practice: A learning behavior analysis Nurse Educ Today 2014 34 958 63 24568697
18. Clarke A. Social media: 4 Political uses and implications for representative democracy 2010 Parliamentary Information and Research Service
19. Fedele DA Cushing CC Fritz A Amaro CM Ortega A Mobile health interventions for improving health outcomes in youth: A meta-analysis JAMA Pediatr 2017 171 461 9 doi: 10.1001/jamapediatrics.2017.0042 28319239
20. Mohammadi Zeidi I Pakpour Hajiagha A Mohammadi Zeidi B Reliability and validity of Persian version of the health-promoting lifestyle profile J Maz Univ Med 2012 21 102 13
21. Molavi H Validation, Factor structure, and reliability of the Farsi version of general health questionnaire-28 on Irani students Pakistan Journal of Psychological Research 2002 22 87 98
22. Walker S.N. Sechrist K.R. , and Pender N.J. Health Promotion Model-instruments to Measure Health Promoting Lifestyle: Health-promoting Lifestyle Profile [HPLP II](Adult version) 1995
23. Madani A Alizade A Ghanbarnejad A Aghamolaei T Effect of peer education on health promoting behaviors of junior high school students Iran J Health Educ Health Promot 2015 3 105 15
24. Rakhshani T Kashfi SM Movahed Nezhad L Motlagh Z Kohan N Effect of educational intervention based on self-efficacy on health-promoting behaviors in high-school girl students: A quasi-experimental study Int J Pediatr 2020 8 12461 70
25. Heber E Lehr D Ebert DD Berking M Riper H Web-based and mobile stress management intervention for employees: A randomized controlled trial J Med Internet Res 2016 18 e21 26818683
26. Heber E Ebert DD Lehr D Cuijpers P Berking M Nobis S The benefit of web- and computer-based interventions for stress: A systematic review and meta-analysis J Med Internet Res 2017 19 e32 28213341
27. Ajie WN Chapman-Novakofski KM Impact of computer-mediated, obesity-related nutrition education interventions for adolescents: A systematic review J Adolesc Health 2014 54 631 45 24534357
