Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 534
  • Home
  • Print this page
  • Email this page

   Table of Contents      
Year : 2020  |  Volume : 25  |  Issue : 3  |  Page : 224-231

The effects of a training program based on the health promotion model on physical activity in women with type 2 diabetes: A randomized controlled clinical trial

1 Department of Nursing, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
2 Nursing Care Research Center in Chronic Diseases, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
3 Department of Biostatistics and Epidemiology, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
4 Department of Internal Medicine, School of Medicine, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

Date of Submission24-Apr-2019
Date of Decision28-Apr-2019
Date of Acceptance20-Feb-2020
Date of Web Publication18-Apr-2020

Correspondence Address:
Dr. Mahin Gheibizadeh
Nursing Care Research Center in Chronic Diseases, Ahvaz Jundishapur University of Medical Sciences, Ahvaz
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijnmr.IJNMR_97_19

Rights and Permissions

Background: Physical activity among women with type 2 Diabetes Mellitus (DM) is an undesirable level. This study aimed to determine the effect of a training program based on the Health Promotion Model (HPM) on physical activity in women with type 2 DM. Materials and Methods: This randomized clinical trial was performed on 128 women with type 2 DM, who were randomly assigned to control and intervention groups. Data were collected using the Baecke Physical Activity Questionnaire (BPAQ) and a researcher-made questionnaire designed based on the HPM constructs before and 2 months after the intervention. The training was carried out in four sessions in the intervention group and the control group received regular education at the clinic. Data were analyzed using Chi-square, Fisher's exact test, paired t-test, independent t-test, and Mann–Whitney and Wilcoxon tests in Statistical Package for the Social Sciences (SPSS) software. Results: The findings showed that the mean [Standard Deviation (SD)] of physical activity in the intervention and control groups before the intervention was 6.52 (0.86) and 6.56 (1.07), respectively, and there was no significant difference between the groups (p = 0.95). However, after the intervention, the mean (SD) of physical activity in the intervention and control groups was 8.04 (0.92) and 6.33 (1.60), respectively, which showed a significant difference (t126 =9.71,p < 0.001). Conclusions: The findings of this study revealed that the training program based on the HPM has a positive effect on improving physical activity in women with type 2 DM.

Keywords: Diabetes mellitus, education, exercise, health promotion, nursing, women

How to cite this article:
Rouholamini S, Gheibizadeh M, Maraghi E, Jahanshahi A. The effects of a training program based on the health promotion model on physical activity in women with type 2 diabetes: A randomized controlled clinical trial. Iranian J Nursing Midwifery Res 2020;25:224-31

How to cite this URL:
Rouholamini S, Gheibizadeh M, Maraghi E, Jahanshahi A. The effects of a training program based on the health promotion model on physical activity in women with type 2 diabetes: A randomized controlled clinical trial. Iranian J Nursing Midwifery Res [serial online] 2020 [cited 2023 Mar 21];25:224-31. Available from: https://www.ijnmrjournal.net/text.asp?2020/25/3/224/282769

  Introduction Top

Diabetes Mellitus (DM), a prevalent metabolic disease in the world, contributes to about 9% of all deaths worldwide.[1],[2] The International Diabetes Federation (IDF) has reported an increase in the prevalence of DM worldwide, and that by the year 2045, 700 million people in the world will develop DM.[3] According to Guariguata et al. report in 2014, it is estimated that the prevalence of type 2 diabetes in Iran will increase to 12.3% in 2035.[4]

One fundamental pillar of the treatment and management of DM is physical activity.[5] Much evidence suggests that physical activity has a therapeutic effect in the prevention and management of type 2 DM, and is associated with a 60% reduction in the risk of developing DM in people with impaired glucose tolerance.[6],[7] However, according to the World Health Organization (WHO), inactivity is the fourth leading cause of death globally and accounts for approximately two million deaths annually.[8],[9] The problem of inactivity is more prevalent in women than in men. According to the British Women's Sport and Fitness Federation (WSFF), only one-fifth of women are taking part in sports for their health, and, physical activity is of low priority among women.[10] It is estimated that 90% of Iranian women with DM do not have adequate mobility and physical activity.[11]

Upgrading and maintaining physical activity is a complex behavior that is not easy to change, and even if one succeeds in changing it, it is difficult to maintain the new behavior. Health models provide a useful framework for improving health behaviors such as physical activity.[12] Pender's Health Promotion Model (HPM), by providing an appropriate framework, serves as a guide for researchers and health professionals to intervene effectively.[13],[14] According to the Pender's HPM, each person has a multidimensional totality interacting with interpersonal and physical environments and plays an active role in achieving improved health status.[15],[16],[17] The HPM focuses on three domains of personal experiences and characteristics, specific feelings and cognitions of behavior, and behavioral outcomes.[18]

The effectiveness of interventions based on the HPM on promoting healthy behaviors has been investigated in several studies.[19],[20],[21] Although related studies in diabetic women are limited, they emphasized the importance of using models in predicting physical activity.[21],[22] Nurses can provide their patients with advice regarding health-promoting behaviors such as physical activity using HPM. As they are in close relationships with their patients and are aware of their problems, they are considered the most suitable for patient education.[23],[24],[25] Considering the necessity of promoting physical activity in diabetic women and the role of HPM constructs in predicting health-promoting behaviors, the researchers decided to conduct a study with the aim to determine the effect of a training program based on HPM on physical activity in women with type 2 DM.

  Materials and Methods Top

This randomized clinical trial (IRCT20180514039655N1) was conducted with a pretest-posttest design on 128 women with type 2 DM referring to Imam Khomeini and Golestan hospitals in Ahvaz, Iran, from May to August 2018. The sample size was calculated as 128 individuals using the sample size formula and considering 10% attrition and α = 0.05, β = 0.90, d = 200, and s = 331.10 in reference to previous studies.[26]

The inclusion criteria included individuals aged 30 to 60 years, the ability to participate in training sessions, the ability to read and write, resident of Ahvaz city, lack of a physical activity restriction, lack of pregnancy, and at least 1 year since diagnosis of DM. The exclusion criteria were absence from more than one training session, becoming pregnant during the study, and medical prohibition for physical activity during the intervention. One hundred and twenty-eight eligible women were randomly assigned to control (n = 64) and intervention (n = 64) groups using a block permutation method with block size 4 (using table of random permutations). The random assignment was made by a statistical consultant who was a member of the research team [Figure 1].
Figure 1: CONSORT flow chart

Click here to view

After the random assignment of the participants to groups, the pre-test was conducted in both groups. The training program was designed based on the HPM and according to the results of the pretest. After approval of the designed educational content by three nursing faculty members and two endocrinologists, it was implemented in the intervention group. The control group received routine clinical training. The intervention group received four training sessions of 60-90 minutes (two sessions a week) using the lecture and question and answer methods. Moreover, educational films, pamphlets, and daily incentive messages were provided for them [Table 1]. A post-test was conducted for both groups 2 months after the intervention. For ethical consideration, the training package was provided to the control group after the post-test.
Table 1: The content of the training sessions in the intervention group

Click here to view

The data collection tools were a demographic information questionnaire, the Baecke Physical Activity Questionnaire (BPAQ), and a researcher-made questionnaire of HPM constructs. The BPAQ was designed in 1982,[27] and includes 16 questions in three dimensions of physical activity related to the occupation (questions 1 to 8), sports activity (questions 9 to 12), and physical activity during leisure time (questions 13 to 16). Each item is scored on a 5-point scale ranging from 1 to 5. The mean scores of each subscale are calculated. Then, the overall score of physical activity is derived from the sum of the mean scores in the 3 subscales. Thus, the total physical activity score is from 3 to 15. Higher scores represent more physical activity. Sanaee et al. reported the reliability of the Persian version of the questionnaire at 0.78, which confirms the internal consistency of the questions.[28]

The HPM questionnaire designed by the research team included 69 questions in 9 subscales of perceived feelings related to behavior (8 questions), perceived benefits (13 questions), perceived barriers (10 questions), perceived self-efficacy (10 questions), interpersonal influences (6 questions), situational influences (4 questions), immediate demands and preferences (5 questions), commitment to action (8 questions), and previous related behaviors (5 questions). The questions were scored a 5-point Likert scale ranging from 1 to 5.

To determine the content validity of the researcher-made questionnaire, it was sent to 10 faculty members of Ahvaz Jundishapur University of Medical Sciences, Iran to evaluate the proportion of the designed items. Based on their views and the Content Validity Index (CVI) and Content Validity Ratio (CVR), the necessary changes were made to the tool and the final version of the questionnaire was developed. The original version of the questionnaire included 74 questions. After determining CVI and CVR, five questions were removed and the final version was adjusted with 69 questions. Using Cronbach's alpha coefficient, the reliability of this tool was calculated at 0.85, which indicates the desirable reliability of the questionnaire. Data collected in the pre-test and post-test were analyzed using Chi-square test, Fisher's exact test, paired t-test, independent t-test, and Mann–Whitney and Wilcoxon tests in Statistical Package for the Social Sciences (SPSS) software (version 16, SPSS Inc., Chicago, IL, USA).

Ethical considerations

This study was approved by the Research Ethics Committee of Ahvaz Jundishapur University of Medical Sciences (IR.AJUMS.REC.1397.108). Ethical considerations including confidentiality of participants' information, informed consent of the participants, explanation of the research goals, voluntary participation in the research, permission to leave the study at any time, and trusteeship in using literature were taken into consideration.

  Results Top

In the present study, 128 diabetic women participated. The participants' mean [Standard Deviation (SD)] age was 47.59 (8.37) and 49.83 (8.69) years in the control and intervention groups (p = 0.11), respectively. The mean (SD) of Body Mass Index (BMI) was 26.84 (5.07) and 28.69 (5.78) in the control and intervention groups (p = 0.05), respectively. Most of the participants had a high school diploma (85.90%), were housewives (95.31%), and married (92.20%). There was no statistically significant difference between the two groups in terms of demographic information [Table 2].
Table 2: Frequency and percentage distribution of the demographic and clinical variables between the control and intervention groups

Click here to view

The results showed that there was no difference between the mean scores of physical activity between the two groups before the intervention (p = 0.95), but showed a significant difference between them after 2 months of intervention (t126 =9.71, p < 0.001). In terms of physical activity subscales, there were significant differences between the two groups after the intervention [Table 3]. Data analysis using paired t-test showed significant differences in scores of physical activity and its subscales in the intervention group, while there were no significant changes except in the sports activity subscale in the control group [Table 3].
Table 3: Comparison of mean (standard deviation) of physical activity and its domains between the control and intervention groups before and after the intervention

Click here to view

According to the findings of the study, no significant differences were found between the two groups in terms of HPM constructs before the intervention. However, 2 months after the intervention, in all model constructs, except for the previous related behavior construct (p = 0.84), statistically significant differences were found between the two groups [Table 4].
Table 4: Comparison of mean (standard deviation) of the Health Promotion Model constructs between the control and intervention groups

Click here to view

  Discussion Top

In the present study, applying a training program based on HPM empowered diabetic women in terms of physical activity performance. However, in the control group, not only an increase in the physical activity score was observed but also a significant decrease in the physical activity score over time was observed. These findings indicate the effectiveness of the educational program designed based on HPM in increasing the level of physical activity Heidari et al.[29] and Taymoori et al.[30] reported that after applying model-based training, physical activity level was significantly increased in the intervention groups, which was consistent with our findings. In fact, models reinforce behavior change and healthy behaviors by targeting important and influential elements of behavior.

Findings showed that perceived benefits of physical activity increased after the intervention in the intervention group, which means that education based on HPM has been able to make patients' viewpoints about the benefits of physical activity more positive. Zamani et al.[31] and Rahimian et al.[26] in their studies also reported similar results regarding the positive impact of model-based education on improving the attitudes of the study population toward expected behaviors.

In this study, the perceived barriers to physical activity decreased significantly after the intervention. In other words, after the intervention, they believed that there were fewer obstacles in their path to physical activity. This may have contributed to the increase in physical activity in the women in the intervention group after the intervention. Amanda et al., in their study, reported that perceived barriers are an important factor in the adherence of women with DM to healthy lifestyle behaviors.[32]

In this study, self-efficacy, commitment to action, improved interpersonal and situational influences, and immediate demands and preferences decreased in the intervention group compared to the control group after the intervention. In a study conducted by Kurnia et al., situational influences, social support, self-efficacy, and perceived benefits showed significant correlations with self-management of DM and self-efficacy was reported as an effective factor of DM self-management.[33] Taymoori et al. also stated that educational intervention based on HPM had a significant effect on decreasing immediate demands and preferences.[30] Interpersonal influence such as family has a major impact on the process of social education, sports activities,[34] and other behavioral tendencies; the level of family support for sports activities, family attitudes toward exercise, and the rate of acceptance of exercise among family members directly affect society as a whole.[35] In the study by Khalkhali et al., which was conducted to investigate the effect of family education on self-care in patients with type 2 DM, it was found that interpersonal influences, in particular the family, have the most impact on self-care and its dimensions in patients with DM.[36]

This study, like other studies, has limitations that need to be considered. One of the limitations of the study was the use of a self-report method for measuring physical activity in the participants, which is affected by the level of honesty of the participants in reporting physical activity. Another limitation was the short duration of follow-up (2 months), which makes it impossible to evaluate the effectiveness of the intervention in sustaining behavior over time. Therefore, further studies using more precise methods to measure physical activity and a longer follow-up period are recommended.

  Conclusion Top

Considering the effective role of the educational program based on the HPM in improving the level of physical activity of women with DM, it is recommended that more extensive educational interventions be designed and implemented to encourage patients to carry out physical activity to address the complications associated with DM through cost-effective and less complicated methods.


This study is part of the MSc thesis of the first author, which was financially supported by the Nursing Care Research Center in Chronic Diseases of Ahvaz Jundishapur University of Medical Sciences (NCRCCD-9702). The authors would like to express their appreciation to the sponsor of the study as well as all patients who participated in our study.

Financial support and sponsorship

Ahvaz Jundishapur University of Medical Sciences

Conflicts of interest

Nothing to declare.

  References Top

American Diabetes Association Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2013;36:S67-74.  Back to cited text no. 1
Shamsi M, Sharifirad Gh, Kachoue A, Hassanzadeh A. The effect of walking educational program on knowledge, attitude, performance, and blood sugar in women with type 2 diabetes. J Birjand Uni Med Sci 2010;17:170-9. [In Persian].  Back to cited text no. 2
International Diabetes Federation. Diabetes Facts and Figures. Brussels (Belgium): International Diabetes Federation. 2019. Available from: https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html. [Last accessed on 2019 Apr 20].  Back to cited text no. 3
Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract 2014;103:137-49.  Back to cited text no. 4
Javanbakht M, Baradaran HR, Mashayekhi A, Haghdoost AA, Khamseh ME, Kharazmi E, et al. Cost-of-illness analysis of type 2 diabetes mellitus in Iran. PLoS One 2011;6:E26864.  Back to cited text no. 5
Tanasescu M, Leitzmann MF, Rimm EB, Hu FB. Physical activity in relation to cardiovascular disease and total mortality among men with type 2 diabetes. Circulation 2003;107:2435-9.  Back to cited text no. 6
Riyahi F, Riyahi S, Yaribeygi H. Diabetes and role of exercise on its control; A systematic. Health Res J 2016;1:113-21.  Back to cited text no. 7
WHO, 2010. Global recommendations on physical activity for health. World Health Organization, Switzerland.  Back to cited text no. 8
World Health Assembly 57.17, 2004. Global strategy on diet and physical activity. WHO, Geneva.  Back to cited text no. 9
O'donovan G, Blazevich AJ, Boreham C, Cooper AR, Crank H, Ekelund U, et al. The ABC of Physical Activity for Health: A consensus statement from the British Association of Sport and Exercise Sciences. J Sports Sciences 2010;28:573-91. doi: 10.1080/02640411003671212.  Back to cited text no. 10
Khosravi-Boroujeni H, Mohammadifard N, Sarrafzadegan N, Sajjadi F, Maghroun M, Khosravi A, et al. Potato consumption and cardiovascular disease risk factors among Iranian population. Int J Food Sci Nutr 2012;63:913-20.  Back to cited text no. 11
Katzmarzyk PT. Physical activity, sedentary behavior, and health: Paradigm paralysis or paradigm shift? Diabetes 2010;59:2717-25.  Back to cited text no. 12
Mohammadi Zeidi I, Alijanzadeh M, Pakpour Hajiagah A. Factors predicting oral health-related behaviors in diabetic patients using Pender's Oral Health Promotion Model. J Isfahan Dent Sch 2016;12:183-98.  Back to cited text no. 13
Meagher-Stewart D, Underwood J, Macdonald M, Schoenfeld B, Blythe J, Knibbs K, et al. Special Features: Health policy: Organizational attributes that assure optimal utilization of public health nurses. Public Health Nurs 2010;27:433-41.  Back to cited text no. 14
Keegan JP, Chan F, Ditchman N, Chiu CY. Predictive ability of Pender's health promotion model for physical activity and exercise in people with spinal cord injuries: A hierarchical regression analysis. Rehabil Couns Bull 2012;56:34-47.  Back to cited text no. 15
Taymoori P, Falhahi A, Esmailnasab N. Application of the health promotion model in studying physical activity behavior of students in Sanandaj, Iran. J School Public Health INS Public Health Res 2011;9:35-46.  Back to cited text no. 16
Borhani M, Sadeghi R, Shojaeizadeh D, Harandi TF, Vakili MA. Teenage girls' experience of the determinants of physical activity promotion: A theory-based qualitative content analysis. Electron Physician 2017;9:5075.  Back to cited text no. 17
Strand B, Egeberg J, Mozumdar A. Health-related fitness and physical activity courses in us colleges and universities. J Res 2010;5:17-20.  Back to cited text no. 18
Aqtam I, Darawwad M. Health promotion model: An integrative literature review. Open J Nurs 2018;8:485-503.  Back to cited text no. 19
Mohsenipouya H, Majlessi F, Shojaeizadeh D, Rahimiforooshani A. The effect of educational intervention based on the Pender's Health Promotion Model on patients' self-efficacy for self-care behaviors following heart surgery. IJNR 2017;12:16-23.  Back to cited text no. 20
Noroozi A, Tahmasebi R, Ghofranipour F, Hydarnia A. Effect of health promotion model (HPM) based education on physical activity in diabetic women. Iran J Endocrinol Metabolism 2011;13:361-7.  Back to cited text no. 21
Kirk A, Macmillan F, Webster N. Application of the Trans theoretical model to physical activity in older adults with type 2 diabetes and/or cardiovascular disease. Psychol Sport Exerc 2010;11:320-4.  Back to cited text no. 22
Pender NJ. Health Promotion Model (HPM): Frequent Question and answers. 2011. Available from: http://deepblue.lib.umich.edu/handle/2027.42/85350..[Last accessed on 2017 Aug 22].  Back to cited text no. 23
Philibin CAN, Griffiths C, Byrne G, Horan P, Brady AM, Begley C. The role of the public health nurse in a changing society. J Adv Nurs 2010;66:743-52.  Back to cited text no. 24
Stanhope M, Lancaster J. Public Health Nursing: Population-Centered Health Care in the Community. St. Louis Missouri, Elsevier; 2015.  Back to cited text no. 25
Rahimian M, Mohammadi M, Mehri A, Rakhshani MH. Impact of performing health promotion model intervention on physical activity of health volunteer of Torbat-E-Jam City, Iran. Int Arch Health Sci 2016;3:87-91.  Back to cited text no. 26
Baecke Ah, Burema J, Frijters J. A short questionnaire for the measurement of habitual physical activity in epidemiological studies. Am J Clin Nutr 1982;36:936-42.  Back to cited text no. 27
Sanaei M, Zardoshtian S, Noruzi Seyed Hoseini R. The effect of physical activities on quality of life and hope life in older adults of Mazandaran province. Sport Manag Res 2013;10:137-57. [in Persian].  Back to cited text no. 28
Heydari H, Sharifirad Gh, Kamran A. Assessment of physical activity status in patients with type 2 diabetes based on Tran Theoretical model. J Health Syst Res 2014;10:429-41.  Back to cited text no. 29
Taymoori P, Niknami S, Ghofranipour F. Effects of a school-based intervention on the basis of Pender's health promotion model to improve physical activity among high school girls. Armaghane Danesh 2007;12:47-59. [in Persian].  Back to cited text no. 30
Zamani N, Ahmadi Tabatabaei SV, Khanjani N, Fadakar Davarani MM. The effect of educational intervention based on the health belief model on medication adherence among patients with diabetes referred to a diabetes center in Zarand, Kerman. J Health Dev 2017;6:97-109. [in Persian].  Back to cited text no. 31
Amanda M, Anderson Debra J, Fulbrook P. Perceived barriers to healthy lifestyle activities in midlife and older Australian women with type 2 diabetes. Collegian 2014;21:301-10.  Back to cited text no. 32
Kurnia AD, Amatayakul A, Karuncharernpanit S. Predictors of diabetes self-management among type 2 diabetics in Indonesia: Application theory of the health promotion model. Int J Nurs Sci 2017;4:260-5.  Back to cited text no. 33
Hosseini E, Farzan F. An examination of the role of social support in women's sport commitment to sports. J Sport Manag 2018;10:137-48. [in Persian].  Back to cited text no. 34
Sharifiyan E, Rahmati MM, Manocheri Nezhad M. exploration of the background factors of family, peers, school, and media in the internalization of sports culture in children and adolescents: A qualitative study. J Qual Res Health Sci 2016;5:83-95. [in Persian].  Back to cited text no. 35
Khalkhali H. The effect of family-centered education on self-care in patients with type 2 diabetes. J Urmia Nurs Midwifery Fac 2016;14:118-27. [in Persian].  Back to cited text no. 36


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]

This article has been cited by
1 Intervention Effect of Penderís Model on Mental Health of Patients With Diabetes Mellitus: A Meta-analysis
Yujia Ren, Menglong Li
Canadian Journal of Diabetes. 2022;
[Pubmed] | [DOI]
2 Application of Penderís health promotion model for type 2 diabetes treatment adherence: protocol for a mixed methods study in southern Iran
Nahid Shahabi, Zahra Hosseini, Teamur Aghamolaei, Amin Ghanbarnejad, Ahmad Behzad
Trials. 2022; 23(1)
[Pubmed] | [DOI]
3 Effects of Health Promotion Model-Based Visual Learning Module on Self-Efficacy and Health Promotion Behavior of Stroke Survivors: A Nonrandomized Controlled Trial
Shiv Kumar Mudgal,Suresh K. Sharma,Jitender Chaturvedi,Digpal Singh Chundawat
Journal of Neurosciences in Rural Practice. 2021; 12(02): 389
[Pubmed] | [DOI]
4 Effect of educational intervention on improvement of physical activities of middle-aged women
Tayebeh Rakhshani, Zahra Khiyali, Fatemeh Masrurpour, Ali Khani Jeihooni
BMC Women's Health. 2021; 21(1)
[Pubmed] | [DOI]
5 Effects of a health education program to promote healthy lifestyle and glycemic control in patients with type 2 diabetes: A randomized controlled trial
Hormoz Sanaeinasab,Mohsen Saffari,Davoud Yazdanparast,Aliakbar Karimi Zarchi,Faten Al-Zaben,Harold G. Koenig,Amir H. Pakpour
Primary Care Diabetes. 2020;
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Materials and Me...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded360    
    Comments [Add]    
    Cited by others 5    

Recommend this journal