This study was an environmental instructional interventionist program based on HBM and ECO models with the purpose of improving the Performance Of Rice Consumption (PORC) among Iranian women aged 18-50 years responsible for cooking in the city of Ilam, Iran. Participants of HBM and control groups consisted of people supported by clinics and employed women were selected for the ECO group.

Before the administration of the questionnaires, the study procedure was explained for the participants succinctly. In order to obtain the probable level of women’s knowledge about the consumption of RCWTM, 30 people who had the characteristics of the target population were investigated through the questionnaire; accordingly, the level of knowledge was obtained to be 30%. Considering α=0.05 and β=20% and the minimum expected development of the knowledge following the intervention as 20%, the number of participants for each group (HBM, ECO, and Control) was obtained to be 80 in each group.

Considering the sampling method for the HBM and control groups, eight clinics were chosen through random sampling out of 13 healthcare centers in city of Ilam. In every center, two ten-household clusters (one cluster as the HBM group and another cluster as the control group) were chosen randomly. Next, using the file number of the households in healthcare centers, the cluster heads were selected. For the ECO group, six organizations were chosen randomly out of 12 organizations in the city of Ilam. After determining cluster heads in HBM and control groups along with the organizations in the ECO group, the people were invited to participate in educational sessions. The questionnaires were administered among participants whose consent was obtained as an initial evaluation. The protocol of the interventionist program was approved at the research center of water and foods in Kurdistan University of Medical Sciences.

Data collection was performed in two stages: before the intervention (December 2014) and after a period of six-month intervention (June 2015) rice consumption performance included changes in the frequency of consumption of Local Rice (LR), harvested in farms of Ilam city, Foreign Rice (FR), imported to Iran, Mixed Rice (MR), a mixture of LR and FR, (no consumption, 1-3 times per week, and 4-7 times per week respectively), and changes in the manner of cooking from Kateh (steaming rice) to Pilaw (draining rice).

The instruments in the HBM model was a researcher-made questionnaire consisted of four sections (demographic information, knowledge, the constructs of HBM model and PORC). The instrument utilized in ECO model was also a researcher-made questionnaire consisted of four sections (demographic information, knowledge, the social support construct, and PORC).

Knowledge: This section had seven questions for measuring knowledge about toxic metals, foods contaminated with toxic metals, the ways toxic metals can enter the body, and the diseases caused by consumption of foods contaminated with toxic metals. Correct answers scored one, while wrong answers received no score. The total score was obtained through mean calculation. The validity of this section was measured through test-retest method, K=0.84. In [Table/Fig-1], the constructs items of HBM and ECO groups are showed.

The Cronbach alpha obtained for perceived susceptibility, perceived seriousness, perceived benefits, perceived barriers, and self-efficacy were 0.72, 0.75, 0.8, 0.81 and 0.79, respectively.

All constructs of HBM were measured through a five-point Likert scale (completely correct=5 to completely wrong=1). The score of these constructs were evaluated through mean calculation.

The “PORC” was evaluated across two fields of frequency of the women consuming rice during the week and the manner of cooking rice. The women consuming rice were classified into three types including "consumption of LR, FR, and MR across three options (not consuming during the previous week, consuming 1-3 times per week, and consuming 4-7 times per week). Manner of cooking was evaluated based on two types of cooking Kateh and Pilaw. The validity of this section was obtained to be K=0.85 through test-retest method.

“Social support” in ECO included 12 questions related to the social network support of people for individual mother, father, sister, brother, spouse, children, friends, colleagues, neighbours, and relatives [Table/Fig-1]. The responses were evaluated at three points (often=2 to never=0). The score of this construct was applied as the social support score through calculating the mean. The Cronbach alpha coefficient obtained in the social support section was 0.88.

Different components of the intervention, the intervention time, targeted theoretical constructs, and objectives of the training sessions in the intervention program of consumed RFFTM have been presented in [Table/Fig-2] for each intervention group separately. In summary, every participant in the training sessions received the required instruction in sessions of 45-60 minutes within six months. The educational materials of the sessions included lecture, slide, role-playing, reminder cards, pamphlets, and educational CDs. In HBM group, the individuals were only given consultation by researchers. In ECO group, the people were involved in a multifaceted approach consisting of researchers along with social network including family members, friends, and colleagues. For the control group, there were no training sessions or telephone consultation. However, control group received the educational pamphlets and CDs following the completion of the educational intervention.

Considering the fact that there is no industrial factories around the rice farms in the city of Ilam and according to the conducted experiments implying the health of LR in Ilam and, more importantly, due to the contamination of the majority of rice produced in the North of country with toxic metals [2-4], Ilam LR was introduced as the RFFTM to the participants.

The training sessions of HBM group were different from those of ECO group. This was performed for role modelling of colleagues in the worksite for social support and encouraging other colleagues to consume LR. For example, first, small groups and organizations were formed to develop group support and enhance receiving social support to consume RFFTM. Next, to develop the support of family members and social network of the participants, educational groups consisted of the mother, sister, friends, colleagues, and relatives were formed in virtual spaces such as Viber, What’s App, and Telegram to realize the predetermined objectives of consuming LR. In both HBM and ECO intervention groups, the solutions for reducing consumption of FR or substituting them with LR were as follows: decreasing consumption of rice whether healthy or unhealthy in the diet, mixing LR and FR with greater portion of LR than the FR, cooking rice with a mixture of cereals and beans with a greater portion of cereals and beans, cooking foods which can be served with bread. In both of the intervention groups, rice cooking method as pilaw was emphasized as the healthy cooking method [25]. To encourage people to consume LR and continuously participate in the training sessions, a 3 kg LR package was given as a gift to every participant.

After entering data in SPSS software (version 20.0), analyses were performed. Kolmogorov-Smirnov test was used to evaluate the normality of knowledge data and the constructs of HBM and ECO model. For descriptive analysis of the variables, the descriptive statistics of frequency and mean with a confidence interval of 95% were used. To evaluate the changes in the knowledge, groups’ constructs, and PORC in the three groups before and after intervention, due to non-normality of data, the nonparametric test of Wilcoxon was used. Repeated measures’ analysis of variance was employed for comparing the consumption of LR and FR in the three groups of HBM, ECO and control before and after intervention.

The mean score of participants’ age in the HBM, ECO, and control group was 36.79±8, 33.76±5.24, and 36.4±9, respectively. In terms of academic studies, in the HBM, ECO, and control group, high school diploma (50%), academic studies (95%), and high school diploma (45%) had the highest frequency, respectively. In terms of marital status, there was no significant difference between the three groups [Table/Fig-3].

[Table/Fig-4] indicates that the mean score of knowledge, perceived sensitivity, perceived seriousness, perceived benefits, and self-efficacy in the HBM group had a significant increase after the intervention, and regarding perceived barriers there had been a significant decrease.

[Table/Fig-4] shows the development of knowledge and social support after the intervention compared with the pre-intervention period in the ECO group. In the control group, a significant decrease in the social support during the second evaluation as compared with the first evaluation was evident.

[Table/Fig-5] shows the frequency of the women consuming LR, FR, and MR for intervention and control groups separately. Growth in the consumption of LR and reduction in the consumption of FR was significant in both groups according to Wilcoxon test (p<0.001). Difference in the manner of cooking was significant for both groups. Furthermore, repeated measures’ analysis of variance indicated that the three groups under study had a significant difference in terms of consumption of LR and FR (p<0.05). Following the intervention, consumption of LR in the ECO group was greater than HBM group. Consumption of FR had decreased further in the ECO group than HBM group [Table/Fig-6,7].

[Table/Fig-6]:

Changes in consumption of local rice in terms of frequency of consumption per week in the three groups HBM, ECO and control before and after the intervention.

[Table/Fig-7]:

Changes in consumption of foreign rice in terms of frequency of consumption per week in the three groups HBM, ECO and control before and after the intervention.

This study was the first randomized controlled trial interventionist program comparing the effect of two interventionist models of HBM and ECO on the consumption of RFFTM and prevention of diseases caused by consumption of RCWTM among Iranian women. In this study, HBM intervention indicated positively significant changes in the constructs of the model, as compared with the women in the control group. However, it should be noted that these positive changes also existed in the social support construct in the ECO group as compared with the control group. These positive changes in the intervention groups were due to the implementation of instructional program.

This study was similar to other experimental studies in Iran and other countries aimed at enhancing knowledge on nutrition [25-27], perceived sensitivity, perceived seriousness about diseases caused by consumption of RCWTM [25,28], perceived benefits [25,29,30], self-efficacy [25,27], decreasing perceived barriers [25], and enhancing social support [31-33] in intervention groups. The findings of the research indicated improved knowledge in the intervention group, when compared with the control group. Better improvement in the HBM group in comparison with ECO group was due to the higher knowledge of ECO group before beginning the training intervention. The greater knowledge of organizational women before implementation of the training program might have been due to the high level of academic studies and access to information references about toxic metals and their impact on human body in this group compared to HBM group. Although the control group received absolutely no training program, they also had a slight increase in knowledge. This might have been due to reservation about the information caused after the completion of the questionnaire and the tendency of people to gain information about toxic metals. However, there was a significant difference regarding the knowledge of people in the intervention group when compared with the control group. The similar results of previous studies also suggested that there has been an increase in the nutrition knowledge of participants in control group [34].

Further, supporting the hypothesis of the study, following the educational program, women in ECO group consumed 26.25% LR more than those in HBM group. ECO group had a healthier food plan than the HBM group. This educational program resulted in greater reduction in the consumption of FR and led to an increase in the consumption of LR in the ECO group than in the HBM group. Furthermore, these results were in line with previous findings about the effect of HBM [27,30,34,35] and ECO [23,36] models in improving healthy diet in intervention groups.

In addition, a larger number of women in ECO group after the intervention consumed rice as pilaw in comparison with HBM women. In a study by Alidosti et al., changes in the methods of cooking foods were observed in the HBM intervention group [24]. In the control group, there was found no significant difference in HBM’s constructs after intervention program in intervention groups compared with the preliminary evaluation. The results of the educational intervention program indicated improved social support in the ECO group as compared with the control group after the intervention. These results were in line with other studies conducted in workplace and emphasize the positive role of social support in encouraging people to follow healthy diet [31-33].

The factor that might have led to greater success of the educational program in improving the nutritional performance of the ECO group rather than the HBM group was the development of social support on the part of mothers, fathers, sisters, brothers, spouses, children, relatives, neighbours; in other words, the development of social network was an influential factor.

Evaluation of rice consumption during the week was performed by the three items of frequency of consumption of LR, FR, and MR. A larger number of questions ars required for more precise evaluation of consumption of rice in diet such as the amount of consumed rice in terms of the type of rice (LR or FR). Due to cultural context of the region, forming social networks consisted of neighbours and implementation of the educational program in the houses of participants was impossible. Therefore, in the ECO group working women were chosen. This might have affected the results, as they had higher educational degrees compared to the HBM group members. On the other hand, for the HBM group team cooking was impossible. However, it was possible for the ECO group in the worksite. Long-term evaluation of LR consumption was not performed. Therefore, the results obtained from a long-term research can provide a fundamental basis for future studies and for the objectives of interventional programs to follow a healthy diet.

Both instructional interventionist methods in this study caused positive and significant changes in the diet of people regarding consumption of RFFTM and decreasing consumption of RCWTM. On the other hand, development of social support might have had a more effective role in improving the diet of people.

Funding/Support: This study was financially supported by the Deputy of Research and Technology of Kurdistan University of Medical Sciences, Sanandaj, Iran.