The Effect of Nutrition Education for Cancer Prevention Based on the Health Belief Model on Iranian Women’s Nutrition Knowledge, Attitude, and Practice | BMC Women’s Health


This study is the first study that used HBM in nutrition education for cancer prevention in Iran. We concluded that the application of HBM in nutrition education for cancer prevention could lead to the promotion of the level of nutritional knowledge, attitude and practice among Iranian women. Our results showed a low level of knowledge about the causes of cancer, the protective nutrients and those decreasing the risk of cancer, healthy cooking methods, the food guide pyramid and the healthy cooking dish before the intervention. The knowledge score was higher in women with a university education than the other groups before the intervention (p

Ahn et al. [30] showed that nutrition education had a positive impact on eating habits and nutritional knowledge in the elderly. A group of researchers in the United States conducted a program to teach children about cancer and cancer-fighting behaviors and found it effective in promoting knowledge about cancer risk factors, forming a positive attitude towards cancer risk factors and increased cancer-fighting behaviors among college students. [31]. It should be kept in mind that nutritional literacy enables people to use written information related to health. Therefore, improving nutritional knowledge has a protective effect against diseases. A systematic review showed that the majority of studies reported a significant association between nutritional knowledge and food intake [11].

We used the HBM to increase the impact of nutrition education. The HBM appears to be widely used for communication research [32]and was suggested [33] and approved [34] as a model of nutrition education. In our study, the score of HBM constructs including perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and perceived self-efficacy increased following a nutrition education program. Additionally, in this study, the perceived barriers score increased after the intervention. This implies that women recognize the obstacles and will try to solve them. Similarly, a gastric cancer intervention study of 84 Iranian housewives showed that the intervention group based on the HBM model had significantly higher scores after education. [35]. Attitude scores showed a downward trend between age, education, and socioeconomic status before the intervention. However, the difference in attitude scores tended to increase after the intervention unless socioeconomic status did. Meanwhile, an interventional study of 157 African-American women on nutrition-related cancer prevention showed that attitudes improved after a nutrition education program [13].

This study showed that the HBM-based nutrition education program has a positive effect on women’s food choices. We assessed this change using a questionnaire and three reminders and found that the nutritional practice score increased after the intervention.

The score on the question on the use of food labeling increased by 82% and the score on the question on the use of high-fat dairy products increased by 33% after the training. Therefore, participants had a better food choice after nutrition education. An increase in whole grains, low-fat dairy products, and nuts was also seen after the intervention. These food groups are made up of cancer-protecting nutrients [36]. In addition, we saw a decrease in carbohydrates, total protein, animal protein, vegetable fat, saturated fatty acids, monounsaturated fatty acids, cobalamin, iron, selenium and high fat dairy products. . Studies have shown that carbohydrate intake is positively associated with cancer via insulin and the related hormone, IGF-1 [37,38,39]. We found significant associations for the specific question of knowledge about BMI and level of education (OR = 6.44) and socioeconomic status (OR = 0.39). Similarly, differences in nutritional knowledge, attitude and practice scores between socioeconomic groups showed a downward trend after the intervention. Jing Wu et al. [40] suggested that higher consumption of total red meat, fresh red meat, processed meat, and high-fat dairy products may be a risk factor for breast cancer. Regarding fatty acids, various studies have shown that polyunsaturated fatty acids have a therapeutic role against certain types of cancer. [41]. In contrast, the consumption of saturated fatty acids has been linked to cancer [42]. A study assessed medical students’ knowledge of the association between dietary factors and cancer risk and reported that knowledge about diet and disease was higher among those with higher dietary fiber intake . [43]. In our study, an increase in the knowledge score was observed with regard to the consumption of vegetables and fruits, but it was not reached in the nutritional practice scores. Barriers to low fruit intake among participants were determined through the questionnaire. Limited budget was mentioned by 13.4% of participants as the main barrier to fruit consumption. About 10% of the participating women felt that fruit preparation was time-consuming, which could be a barrier to fruit consumption, and 2.59% limited their fruit consumption due to digestive problems. A small portion of our study sample (1.04%) reduced their fruit intake because they believe the fruit is contaminated with toxins. Additionally, participants reported a lack of vegetable consumption due to difficulty of preparation (18.75%), cost (2.07%), lack of irrigation with potable water (8.75%), 29%) or digestive problems (8.29%).

A study conducted in northwestern Iran showed that the dietary habits of people in eastern Azerbaijan over the past two decades increase the risk of gastric cancer and suggested carrying out nutritional education for a Healthy eating. [44]. In the Golestan cohort study, esophageal cancer incidence was associated with nutrient intake and dietary behaviors such as polycyclic aromatic hydrocarbons and hot tea consumption. [45]. Other Iranian studies indicated that nutrition-related attitudes were positively correlated with breast cancer prevention dietary practices. [46]. Considering that unique Iranian dietary habits are modifiable through education and regarding the burden of high cancer health care system costs imposed on patients and the government, the application of education programs would be cost-effective.

This study was limited to the intervention group. Our study was performed before and one month after the intervention, which only showed the short-term effects of the intervention. The study population was limited to women. Women have a key role in the food choices and nutritional education of children in the family. Because of the close link between maternal education and child health, we conducted this study with women. However, the results of this study cannot be generalized to men and further research with Iranian men is needed. Some confounding variables such as personality characteristics, mental health, and media may have affected the outcome, which was not assessed. Depending on the differences in scores between different age groups, a different teaching approach may need to be applied to each age group. Strengths of the current study include the large sample size, the recruitment of participants from various regions of Tehran, and the use of visual educational materials. We also used a validated instrument to measure educational intervention and assessed dietary practices by collecting dietary recalls, which many studies have not done. [25].

In conclusion, this study showed that a nutrition education program based on HBM had a positive impact on the nutritional knowledge and practices of Iranian women. Considering the cost-effectiveness of educational programs compared to treatment services, the application of health education programs can strongly promote public health.


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