Journal of Education and Health Promotion

Abstract BACKGROUND: Human papillomavirus (HPV) is the most common sexually transmitted infection 
and causes more than 90% of cervical cancers. The highest rate of infection occurs between the 
ages of 18 and 28. This study aimed to determine the effect of education based on the theory of 
planned behavior (TPB) on the intention of vaccination against HPV in female students.
MATERIALS AND METHODS: This controlled educational trial study was performed on 72 female 
students aged 18–26 years of Mashhad University of Medical Sciences by random assignment to 
intervention and control groups. For random assignment in the intervention and control groups, 
random blocking with four blocks was performed using a random number table with a ratio of 1:1. 
Data collection tools included demographic questionnaire, awareness about HPV vaccination, 
and TPB theory constructs. The control group was received the university routine training. The 
intervention group was received the virtual group training in four sessions, 60–90 min at weekly 
intervals and with educational content including TPB constructs on HPV vaccination with the 
method of lecture training, group discussion, questions and answers, and presentation of training 
package. Questionnaires were completed before, instantly, and 1 month after the educational 
intervention. Data were analyzed using the Chi‑square test, Fisher’s exact, t‑test, Mann–Whitney 
test, and Friedman test.
RESULTS: The mean age of students was 18.9 ± 1.1 years. The intervention and control groups 
were homogeneous in terms of demographic characteristics (P > 0.05). Before the intervention, 
the mean score of model constructs did not show a statistically significant difference between the 
two groups (P > 0.05), but after the intervention, in the intervention group, mean scores of attitude, 
subjective norms, perceived behavioral control, and behavioral intention in the intervention group 
was significantly higher than the control group (P < 0.001). In the intervention group, the difference 
in the mean score of HPV vaccination intention instantly (P < 0.001) and 1 month (P < 0.001) after 
the intervention significantly increased.
CONCLUSION: TPB‑based education was effective in increasing attitudes, subjective norms, and 
perceived behavioral control and the intention to vaccinate against HPV in the female students of 
Mashhad University of Medical Sciences. Therefore, it is suggested that the present educational 
intervention be widely used to educate female students.

Abstract BACKGROUND: Osteoporosis is mainly characterized by a low bone mineral density and a sharp
architectural and biomechanical deterioration in bone tissue required to maintain bone homeostasis.
The theory of planned behavior (TPB) can be considered as one of the leading theories when designing
an evidence‑based intervention. This study was carried out based on the TPB to determine the effect
of an educational intervention aimed at mothers on the prevention of osteoporosis in female students.
MATERIALS AND METHODS: A total of seventy mothers of lower secondary school students
in Tehran, Iran, participated in this experimental study which was conducted in 2019–2020. The
participants were randomly assigned to two groups, namely experimental and control groups. Based
on the TPB, a demographic and a researcher‑made questionnaire consisting of five sections were
used in order to collect data. The validity and reliability of the questionnaires were confirmed before
data collection. Four 45–60 min training programs were delivered to the subjects using the TPB.
Data were collected before, immediately after, and 1 month following the training program. Finally,
IBM SPSS Statistics 21 was used for statistical analysis.
RESULTS: No significant difference was observed in terms of attitude, subjective norms, perceived
behavioral control, behavioral intention, and osteoporosis prevention‑related behavior between the
experimental and control groups before proceeding with the intervention (P > 0.05). However, the
mean scores of attitude, subjective norms, perceived behavioral control, behavioral intention, and
behavior were significantly higher in the experimental group compared to those of the control group
following the educational intervention (P < 0.05).
CONCLUSION: It can be concluded that such interventions based on the TPB can, in fact, produce a
significant effect on osteoporosis prevention‑related behaviors. Thus, it can serve as a useful model
for planning educational interventions.

Abstract BACKGROUND: Social vitality is one of the most important social indicators to develop a sense
of public satisfaction. The aim of this study was to investigate the effect of educational intervention
based on theory of planned behavior (TPB) and self‑regulatory strategies on the social vitality of
women employee.
MATERIALS AND METHODS: In this randomized controlled field trial study, 66 women employees
of Birjand University of Medical Sciences (Iran) were selected including intervention (n = 31)
and control (n = 35). Data were collected by standard Oxford Happiness Questionnaire and a
researcher‑made questionnaire based on TPB which its the validity and reliability were confirmed.
The educational intervention consisted of 5 sessions based on the constructs of the TPB and
self‑regulatory strategies which were to the interventional group. Data analysis was performed using
the Chi‑square, Fisher’s exact test, independent t‑test, repeated measures ANOVA, and Bonferroni
post hoc test at a significance level of <0.05.
RESULTS: The mean age of women in the intervention and control group was 37.1 ± 9.3 and
36.2 ± 7.6 years (P = 0.67). Model constructs and happiness scores were homogeneous (P > 0.05)
before the intervention, in two group of study, but after attitude (P = 0.016), subjective norm (P = 0.029),
perceived behavior control (P = 0.01), intention (P = 0.006), and happiness score (P < 0.001) had
a significant increase in the intervention group. In the control group, only a significant difference
occurred over time in the happiness rate (P = 0.031).
CONCLUSIONS: The results of the present study showed the effectiveness of educational intervention
on the social vitality of women employees. Therefore, TPB is recommended to use in interventions
to promote social vitality.

Abstract BACKGROUND: Empowerment is an essential issue in women’s lives. Powerful women can act
successfully in health‑related issues more than others. This study aimed to determine the effectiveness
of an educational intervention designed based on theory of planned behavior (TPB) on health care
empowerment among married women in reproductive age.
METHODS: This randomized controlled trial was carried out among 488 reproductive‑age women
between 2018 and 2019 in Tehran, Iran. Participants were recruited using randomized cluster
sampling and divided into intervention (n = 243) and control (n = 245) groups by random allocation.
Data were collected using a self‑administered researcher‑made questionnaire based on TPB and
Health Care Empowerment Questionnaire. Validity (content validity index = 0.87; content validity
ratio  =  0.89) and reliability of the questionnaires were confirmed  ( = 0.96). Intervention was
implemented within four sessions (lasting 60 min) using eight health related scenarios based on
TPB constructs. Baseline and post intervention data (6 months after the intervention) were analyzed
by SPSS25 (Inc., Chicago, IL, USA) using independent t‑test, Chi‑squared test, Fisher’s Exact test,
Mann–Whitney, path analysis, and regression of generalized estimating equation model. P < 0.05
was considered statistically significant.
RESULTS: Results showed the mean ± standard deviation age of the participants was 33.6 ± 7.1.
Six months after the intervention, a significant difference was highlighted in health care empowerment
domains as well as behavioral intention, attitude toward behavior, subjective norms, and perceived
behavioral control (P < 0.001) between intervention and control groups.
CONCLUSION: TPB‑based educational intervention can significantly improve women’s perception
about health care empowerment. Tailoring and implementation of TPB‑based intervention by health
policy makers and health care providers is suggested to achieve better perception of empowerment
toward receiving health care among women.

Abstract BACKGROUND: Teenagers are increasingly interested in computer games, and the adverse effects
of these games are dependent on the execution of these games. The theory of planned behavior
(TPB) is one of the most important theories in behavior change. This study aimed to determine the
effect of educational planning based on TPB on the level of dependence on computer games in high
school male students in Gonabad, Iran.
MATERIALS AND METHODS: This was a randomized controlled trial. The study population was
students of computer games in Gonabad. Sixty-four students were selected by a multistage random
sampling method and were randomly divided into intervention (n = 32) and control (n = 32) groups.
Data-gathering tool was the standard questionnaire of computer game dependency and researchermade questionnaire according to TPB constructs that were completed before, immediately, and
3 months after the intervention. The intervention consisted of eight 90-min training sessions. Data
were analyzed using the Chi-square test, Fisher’s, t-test, repeated measures ANOVA, and Bonferroni
post hoc test.
RESULTS: Before the intervention, the intervention and control groups were matched for the mean
score of model constructs. However, after the intervention, the mean score of computer game
addiction significantly decreased (≤0.001). However, the mean score of knowledge, attitude,
perceived behavioral control, and behavioral intention increased, which was statistically significant.
Furthermore, the mean changes of model structures were statistically significant (P < 0.05).
CONCLUSION: The findings revealed that TPB can be used as a good theoretical framework for
designing and implementing educational programs to reduce the dependency of computer games
on students.

Abstract INTRODUCTION: It is essential to provide key information and support to every woman regarding
pregnancy and childbirth to enable all women to make a fully informed decision regarding their choice
of reproduction. The study aimed to find the impact of an educational program based on the Theory
of Planned Behavior (TPB) on health promotion and childbearing of minor thalassemia couples.
SUBJECTS AND METHODS: This study was quasi‑experimental. A total of 70 women with minor
thalassemia held in Minudasht health center were classified into two groups: study and control. The
study group received the educational program based on TPB, and the control group only received
the routine program. The data were collected using the TPB‑based questionnaire at baseline and
3 months after the intervention. They were analyzed by Chi‑square, Student’s t‑test, Wilcoxon test,
and regression analysis through SPSS version 16.
RESULTS: The mean (standard deviation) ages of the participants in the control and study group
were 30.69 (6.20) and 31.08 (6.66), respectively. There were significant differences between
the two groups (study vs. control) in terms of perceived behavioral control, intention, attitude, or
childbearing behavior (P < 0.001). The change in fertility behaviors had a significant increase in the
study group (62.8%) compared to the control group (2.9%) (P < 0.001).
CONCLUSION: Based on the results, the TPB is an effective model to explain fertility intentions
and behaviors in Iranian women with minor thalassemia; however, further researches are needed
to generalize our findings to other people including healthy women.

Abstract BACKGROUND: Insufficient physical activity is a global health‑care problem and is considered an
independent risk factor for chronic diseases. The present research aimed to explore the effect of
an educational intervention based on the theory of planned behavior (TPB) and stages of change
on promoting women’s physical activity.
MATERIALS AND METHODS: This quasi‑experimental research was conducted on 68 women
who voluntarily visited the health‑care centers of Mashhad. They were selected by randomized
multistratified sampling method and were divided into two groups of intervention (n = 34) and control
(n = 34). The data collection tools included a demographic information questionnaire, a questionnaire
based on the TPB and stages of change, and the International Physical Activity Questionnaire. The
data were statistically analyzed by SPSS software version 16 using descriptive statistics (frequency,
percentage, mean, and standard deviation) and inferential statistics (paired t‑test, correlation
coefficient, and covariance). The significance level of P < 0.05 was considered in this study.
RESULTS: No statistically significant difference was found between the intervention and control groups
before the intervention in terms of the scores of the TPB constructs and physical activity (P > 0.05).
However, after the educational intervention, a significant difference was observed in the mean scores
of TPB constructs and physical activity (P < 0.05). In addition, no statistically significant difference
was found in the stages of change between the two groups after the intervention.
CONCLUSIONS: The results of this study pointed to the effectiveness of educational intervention
and the necessity to use educational interventions to help adopt preventive behaviors. Therefore,
the use of well‑established educational models rather than conventional methods is recommended.

Abstract CONTEXT: Wearing helmet during road traffic accidents among motorcycle riders decreases the
likelihood of death by 39%. The theory of planned behavior (TPB), a psychological model helps to
explain the failure in helmet usage, by assuming a causal chain. The current study was taken up
as no studies have elicited the determinants of helmet usage in terms of TPB among health‑care
providers, the role models for healthful behavior by virtue of their profession in the current urban
Indian context.
AIMS: The aims of the study were (1) to determine the proportion of proper use of helmets
and (2) to identify TPB‑related factors and other factors influencing the use of helmets.
MATERIALS AND METHODS: A cross‑sectional study was conducted among 147 students and
staff of a tertiary health‑care center, Bengaluru, using a pretested, validated, semi‑structured,
self‑administered questionnaire. Convenience sampling was used. Hierarchical regression model
was used to explain variation in the scores of helmet‑use behavior on the basis of TPB variables.
P < 0.05 was considered as statistically significant.
RESULTS: About 65% of respondents practiced “proper use” of helmets. Intention, perceived
behavioral control (direct), and attitude (indirect) were significant predictors of helmet use (P < 0.05).
Mean scores of knowledge on helmet use and behavior showed positive correlation (P > 0.05).
CONCLUSIONS: Application of TPB in urban Indian context was successful in identifying precursors
of helmet use. This study throws a light on the strong influencers of helmet use which can assist policy
developers in developing effective programs to successfully promote the “proper use” of helmets.

Abstract INTRODUCTION: Breast cancer is the most common cancer in women. It can be diagnosed in
the first stage by screening. One of the methods for screening breast cancer is mammography.
Mammography as a health behavior needs education. The theory of planned behavior examines
the factors associated with the behavior.
AIM: This research was conducted to compare the individual and peer education on the constructs
of the theory of planned behavior in mammography.
METHODS: This study was a clinical trial. A total of 100 women who attending the selected health
centers of Isfahan city were classified randomly into two groups: peer and individual education.
Education was based on the constructs of the theory of planned behavior (attitude relative to the
mammography behavior, subjective norms, perceived behavioral control, and behavioral intention).
The data were collected using a researcher‑made questionnaire. Data were analyzed using
descriptive‑analytical statistics.
RESULTS: The mean score of attitude toward behavior in the individual education group was
significantly higher than peer education (P < 0.05). In addition, the average score of subjective norms
in peer education group was significantly higher than individual education (P < 0.05). The mean
scores of perceived behavioral control constructs and behavioral intention were not significantly
different (P > 0.05).
DISCUSSION: The results of this study showed the effectiveness of education (individual and peer)
based on the theory of planned behavior on attitude toward behavior, subjective norms, perceived
behavioral control, and behavioral intention related to performing mammography in women. It seems
that using educational intervention can be useful to promote the screening behaviors of breast cancer.
In general, there were no significant differences between the two methods in changing theoretical
constructs.

Abstract BACKGROUND: Safe‑driving behaviors of taxi drivers are fundamental to health. The present
research aimed to predict the taxi drivers’ safe‑driving behaviors based on the theory of planned
behavior (TPB) and habit.
MATERIALS AND METHODS: The present research is of a descriptive/analytical cross‑sectional type
conducted on 184 taxi drivers in Bandar Abbas who were selected through a multiple‑stratified sampling
method. Data collection instrument was a questionnaire comprised of two sections (demographic
information and the constructs of TPB.
STATISTICAL ANALYSIS USED: The data were later on analyzed via SPSS ver 19 and Pearson’s
correlation coefficient as well as multiple regressions.
RESULTS: The mean age of the participants was 45.1 (standard deviation [SD = 11.1) years, and
they had an average experience of taxi driving for 10.3 years (SD = 7.5). Subjective norms, perceived
behavioral control, and habits were the predictors of one’s intention of driving safely (r2 = 0.30,
F = 18.7, P < 0.001). Moreover, attitude, perceived behavioral control, and habits were found to be
the predictors of safe‑driving behaviors (r2 = 0.19, F = 8.1, P < 0.001). Finally, habits showed to be
a stronger predictor of safe‑driving behaviors than attitude and perceived behavioral control.
CONCLUSION: Consideration of individuals’ behavioral habits and correction of unsafe habits, focus
on the adverse effects of unsafe‑driving behaviors, goal setting to change incorrect driving habits,
attention to influential groups in altering unsafe‑driving behaviors, and careful monitoring of abiding
by the rules are suggested to promote safe‑driving behaviors.

Abstract Introduction: Mass‑media campaigns such as, “Change4Life’ in the UK and “get
active America” in the US, promote physical activity (PA) recommendations of at least
150 min/week of moderate‑to‑vigorous PA (MVPA). We investigated whether different
messages used in MVPA campaigns were associated with intention to engage in more
MVPA. Materials and Methods: Theory of planned behavior (TPB) constructs; subjective
norms, affective attitudes, instrumental attitudes and perceived behavioral control (PBC)
were applied to explain the associations between campaign messages and intentions to
engage in more MVPA. Results: A total of 1412 UK adults completed an online survey on
MVPA and TPB. The sample was 70% female and 93% white with 23% reporting meeting PA
guidelines. Participants received one of three messages: A walking message either with or
without the 150 min/week threshold (WalkT; WalkNT); a physiological description of MVPA
with the 150 min/week threshold (PhysT). ANCOVA examined group differences in intention.
Path analysis evaluated mediation by TPB variables. ANCOVA identified lower intentions to
increase MVPA in group PhysT relative to WalkT and WalkNT (P < 0.001). PBC mediated
this relationship in WalkT (β = 0.014, 95% confidence interval [CI] = 0.004–0.028) whereas
affective attitudes mediated this relationship in WalkNT (β = 0.059, 95% CI = 0.006–0.113).
Conclusions: Campaigns promoting MVPA guidelines need to choose their messages carefully.
Messages which exemplified MVPA through walking were associated with higher intentions to
increase MVPA than messages using a physiological description. Further, PBC was enhanced
when the 150 min/week threshold was promoted alongside the walking exemplar. Future
exemplars should be investigated to inform adults how to meet MVPA guidelines.

Abstract Background: Eating breakfast is crucial for adolescents to be healthy. It also improves
students’ capacity of learning and doing school homework. Although healthy habits such as
eating breakfast, weight control, and regular sleep increase the lifespan in adults, the effects of
healthy habits on school‑age children have not been studied much. The present study aimed at
investigating the impact of an educational program based on Theory of Planned Behavior (TPB)
on eating breakfast among middle school students. Materials and Methods: This interventional
study was conducted on sixth‑grade students in Qom City during the academic year 2012–2013.
First, 97 students were randomly assigned to the experimental group and 97 other students
were assigned to the control group. Then, a questionnaire was developed on eating breakfast
by the researchers according to the TPB. A pilot study was conducted to assess the reliability
of the questionnaire. To assess the validity of the questionnaire, advice by a panel of experts
was sought. To carry out a pre‑test, both groups answered the questions. After analyzing the
pre‑test results, the required content was developed for the experimental group. Educational
methods included delivering speech, discussion groups, pamphlets, and posters. The required
educational content was provided for students during five sessions and for parents in one session.
To determine the effect of educational intervention, a post‑test study was carried out 2 months
after the intervention. Collected data were analyzed using independent t‑test, χ,
[2] and repeated
measures. Results: In the experimental group, 36.7% of students were eating breakfast at least in
a day of a week, before educational intervention. After implementation of the educational program,
only 32.7% of them were continuing their past habit. There was a significant difference between the
mean scores of attitudes, perceived behavioral control, intention, and practice of eating breakfast in
the experimental and control groups (P < 0.05), while there was no significant difference between
the mean scores of subjective norms after
implementing the educational program in both
groups (P < 0.26). Conclusion: Using the TPB
improved students’ intentions and behavior
of eating breakfast. Thus, it seems necessary
to consider all effective environmental factors
on the subjective norms in the education
of healthy eating behaviors or improving
breakfast‑eating practice among students.

Abstract Background: Sedentary life has been recognized as a serious problem in today’s
Iranian society. Promoting the lifestyle with increased physical activity and prevention of
cardiovascular disease (CVD) is imperative. The purpose of this study was identifying the
determinants of physical activity in the housewives of Nain city in 2012 based on the theory
of planned behavior. Materials and Methods: In this cross‑sectional study, 120 housewives
were selected by simple random sampling method. Data collection tool was a questionnaire
designed based on a standardized and fabricated questionnaire and consisted of four parts.
The questionnaire included awareness variables, theory of structures, planned behavior,
and physical activity. Data analysis was performed using the SPSS software version 18
and associated statistical tests. Findings: The 120 housewives under study had a mean
age of 34.58 ± 6.86 years. The mean scores of awareness, attitude, motivation to perform,
subjective norms, and perceived behavioral control variables were 74.1 ± 18.5, 82.6 ± 12.1,
59.4 ± 21.7, 63.2 ± 21.2, and 48.1 ± 12.9 respectively. There was a significant relationship
between the motivation for physical activity among women and knowledge (P = 0.02)
attitude (P = 0.04) subjective norms (P = 0.002) perceived behavioral control (P = 0.001),
and physical activity (P = 0.04). Conclusions: It seems that the housewives, despite being
aware of and having a positive attitude on the benefits of physical activity, had a poor
lifestyle. Perhaps further studies can help in finding the causes of this issue and the barriers
to physical activity such as the conditions and plan for greater measures for improving
physical activity, in order to promote women’s health which has a significant role in family
and community health.