The present study was a semi-experimental study, which was conducted after getting the ethics code from Mashhad University of Medical Sciences (IR.MUMS.NURSE.REC.1401.031) and the IRCT code (IRCT20220629055312N1), with an official introduction from Mashhad School of Nursing and Midwifery.
Due to that the majority of the Afghan immigrant population of this city live in the covered areas of Health Center No. 2 of Mashhad, this health center was chosen as the research environment. Four centers of Amir al Momenin, Bafti, Golshahr and Mehrabad were selected from the centers covered by Health Center number 2 of this city randomly. Then, the centers of Amir al-Momenin (AS) and Bafti were allocated to the intervention group, and the centers of Golshahr and Mehrabad were allocated to the control group randomly. The social, economic and cultural characteristics of the intervention and control centers were similar; They were also similar in terms of facilities, service delivery, and how to education patients. however, in order to eliminate bias in the allocation of the centers, they were randomly assigned to the intervention or control group. In this way, in each center, Afghan pregnant people with a pregnancy record were identified from the list of covered people, and then the people were selected by systematic randomness method until the number of research units reached the quorum. The researcher called the selected people to invite them to the research and stated the objectives of the research, introducing the research team, goals and the schedule of training sessionsand if they had the inclusion criteria, they entered the research after obtaining written consent. The required sample size was determined 50 people in each group due to the error level of 0.05 and the test power of 80%. Assuming 15% attrition, the final sample size of 58 people in each group was determined.
$$R\left[\frac{1+\left(w-1\right){P}_{T}}{w}- \frac{vP\frac{2}{T}}{1+\left(v-1\right){P}_{T}}\right]$$
w ≥ 1 0
$${m}_{repeated}=R\left[{\left(1+ \frac{1}{\lambda}\right)}^{2} \frac{{\left({z}_{1- {}^{\alpha }\!\left/ \!{}_{2}\right.}+{z}_{1- \beta }\right)}^{2}}{{{\Delta }^{2}}_{plan}}+ \frac{{{z}^{2}}_{1- {}^{\alpha }\!\left/ \!{}_{2}\right.}}{4}\right]$$
Population
Afghan immigrant pregnant women with a gestational age of less than 20 weeks were included in the study based on the first trimester of pregnancy sonography and who met other inclusion criteria. The inclusion criteria include informed consent of the mother, being Afghan, healthy womanFootnote 2 with single fetus pregnancy, desired pregnancy, age over 18 years and at least literate in reading and writing, having a contact number, not participating in another study at the same time, absence of disease requiring intervention in mother or fetus,Footnote 3 absence of chronic systemic disease,Footnote 4 not following a specific diet,Footnote 5 absence of severe emotional and mental disorders in the mother,Footnote 6 No smoking and drug addiction and having a legal residence permit in Iran.
The exclusion criteria include unwillingness to continue research, not participating in more than one educational session, failure to answer more than 10% of the questions in the questionnaire, and the occurrence of severe emotional and mental disorders in the mother during the research.Footnote 7
Tools and questionnaire
The demographic questionnaire and a 24-h food reminder questionnaire were the data collection tools in this study. The demographic questionnaire included age, education, occupation, marital status, husband’s education, husband’s occupation, family income, housing status, weight, height, body mass index, gestational age, gravida, abortion, stillbirth, and pregnancy complications. The 24-h food reminder questionnaire had three tables to insert the food consumed in daily meals, including the three main meals of breakfast, lunch, and dinner, and three optional snacks. Each table collected information about meals for the day. In each meal, the name of the food, household scale (ingredients of the food, the total amount of cooked food, the amount consumed by the individual), the consumption amount in grams, and the food code were entered separately. Information about the meals of two non-holidays and one holiday of the research units in three periods (before the educational intervention, immediately, and one month after the educational intervention) was entered in addition, The HBM questionnaire, a questionnaire comprising 40 questions was developed by the researcher through Literature review. HBM questionnaire was carefully crafted to assess perceived sensitivity, perceived intensity, perceived benefits, perceived barriers, action indications, and self-efficacy. A five-point Likert scale (completely agree, agree, have no opinion, disagree, and completely disagree) was used to respond to questions related to these constructs.Face validity was evaluated using qualitative and quantitative methods. Thus face-to-face interviews were held with ten pregnant Afghan immigrant women to ask them to comment on the ambiguity, appropriateness, and difficulty of each HBM questionnaire item.In quantitative face validity evaluation, impact score.
Was calculated for each item.Content validity was evaluated using qualitative and quantitative methods. In qualitative evaluation of content validity, eight experts and faculty members from Mashhad University of Medical Sciences assessed the wording, grammar and scaling of the items. The Content validity index (CVI) has been set at a minimum acceptable value of 0.7. Questions with a score of 0.7–0.78 were evaluated and modified, while items with a score of 0.79 or higher were retained.The content validity ratio (CVR) were determined to be 0.75. The questionnaire’s reliability was confirmed with a Cronbach’s alpha of 0.87.
Then the results were checked by the Nutritionist 4 software and the amount of calories, micronutrients, and macronutrients consumed by people, or in other words, the amount of people’s food intake, was analyzed.
The demographic, 24-h food reminders questionnaires and questionnaires designed according to the frame work of the HBM model was completed by research units with the guidance and explanations of the researcher at first as pre_test. In case of low literacy, the researcher personally completed the 24-h food reminder form after obtaining the information about the meals of these research units.
Intervention and analysis
The first author in groups of 8–10 people conducted the nutrition educational intervention based on the HBM model’s structures during 4 sessions of 45–60 min.
The educational content in the first session emphasized on increasing nutritional knowledge and awareness, the second session was based on the constructs of perceived sensitivity and intensity, the third session was based on the constructs of perceived benefits and barriers and the fourth session was presented based on self-efficacy and practice guidelines (Table 1).
Teaching methods, including brainstorming, group discussion, question and answer, and lectures were used alternately and appropriately. The control group received routine care and they received the content of the education in the form of a booklet at the end of the research.
Follow up time of effect of intervention was considered immediately and one month after intervention, Based on other similar studies and because of the short period of pregnancy and pregnancy conditions, this period was considered for assay [4, 28].
The collected data was entered into SPSS software version 21. The data was described by central and appropriate dispersion indices. The chi-square test (or Fisher’s exact test if needed) was used to check the distribution of qualitative demographic and clinical variables, According to the normal or non-normal distribution of demographic and clinical variables, independent t-tests or Mann–Whitney tests were used. Shapiro–Wilk tests were used to check the normality of the data and 0.05 was considered as a significant level. To check the changes in food intake, the repeated measures test (if the nutrient distribution is normal) or Friedman’s test (if the nutrient distribution is non-normal) was used. All statistical analyses were performed in SPSS version 21 and an A significance level of 0.05 is considered.
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