Identifying and Prioritizing Educational Needs of Female Adolescents in Relation to Healthy Eating Based on Analytic Hierarchy Process Model

In order to better plan health based interventions, educators and health promoters need to make decisions in this regard. In the meantime, it should be noted that, multiple criteria decision making methods with theoretical roots and accuracy of forecasting results are less considered. The current study is a descriptive research carried out on 15 experts working in Yazd Health Centers using purposeful sampling. In order to identify wrong eating habits of students, Delphi method is used. In the next step, these habits are compared, one by one, and scored with Analytical Hierarchy Process (AHP) Model. In the end, data are analyzed using Expert Choice 11 software. Seven major wrong eating habits of female adolescents are identified: junk food consumption, drinking soda and sweet drinks, eating fast food, deleting main meals, improper diets, low intake of vegetables, and not eating breakfast. Among these, low intake of vegetables, eating fast food, and not eating breakfast, with weight rate of 32.4%, 19.4% and 19.3%, are specified as the first three priorities of education. In various fields of education and health promotion, including prioritizing training needs, employing techniques with potentials of assessing multiple criteria at the same time can be highly efficient.


Introduction
After rapid growth during the first year, the fastest growth appears during adolescence which results in increased need for energy and nutrients.Failure to receive ideal diet during adolescence leads to slowed down the growth rate or even stops longitudinal growth.Also, eating well during this period plays a very important role in prevention of chronic disease including cardiovascular disease, cancer, and osteoporosis in adulthood (Story & Stang, 2005).Indeed, adults' behaviors have their root in childhood and adolescence; thus, eating habits of early years of life are of great significance.According to existing literature, only 3.22% of adolescents use the recommended amounts of fruits and vegetables (Velazquez, Pasch, Ranjit, Mirchandani, & Hoelscher, 2011).
During the past two decades, snacks consumption (one of the high-calorie foods) between meals has been increased; adolescents, almost 3 times a day, and adults, almost 2 times a day, eat low nutritional value snacks (Cohen et al., 2012).Also, solid oils, fats, and sugars constitute a large amount of empty calories in new diets which accounts for 40% of energy consumed by adolescents (Reedy & Krebs-Smith, 2010).
According to the Centers for Disease Control in the United States, most of the adolescents' diet lacks recommended amounts of vegetables, fruits and grains and is rich in sodium, instead (Committee, 2010).40% of calories for children and adolescents (2-18-years-old) come from nutrients like soda, pizza, desserts, fruit drinks, dairy desserts and whole milk.High calories beverages are also used more than milk by adolescents, on a daily basis (Reedy & Krebs-Smith, 2010).
Bad diet among female adolescents, as future mothers, is worrisome (Banerjee et al., 2009).Living condition of these girls may change so fact since childhood to marriage and during pregnancy period which deprive them of educational opportunities.Since adolescence is the best time to create a series of behavioral patterns, dietary pattern of this period of life is of utmost importance (Merchant, 2014).A review of 23 studies on the impact of health education interventions in students' eating indicated that, in most cases, health education can positively influence students' knowledge as well as eating behaviors (18 studies on increasing knowledge and 15 studies on improving eating behavior); also, 8 studies have resulted in increased positive attitudes (Dehdari, Khezeli, Bakhtiyari, & Nilsaz, 2012).
With regard to upcoming requirements, in process of health education and promotion programs, health developers and trainers are forced to make a decision.In fact, the decisions play a significant role in selecting an educational program and a health-driven plan (Mohammadi, 2009).
According to studies conducted on health education and promotion studies in Iran, it is determined that, often, techniques such as Delphi method, nominal groups, and brainstorming are used for decision making while methods, like multi-criteria decision-making methods, grounded on theoretical and mathematical prediction accuracy, are less considered.One of these multiple criteria decision making method is Analytical Hierarchy Process (Taghdisi, Asadi, & Khoshdel, 2014) Decision making with Analytical Hierarchy Process is developed by Thomas Saaty (1980) (Saaty, 1977).
Application of Analytic Hierarchy Process (AHP) in medicine indicates that AHP is an effective method to share decisions between doctor and patient.In addition, the method can evaluate different treatments to choose the best one.In health care sciences, AHP can improve health technology assessment and health policy-making In order to make decision by this approach the following steps are to be taken: 1) Define the problem and determine the information that is sought.
2) Structure the decision hierarchy in a way that the final objectives sit at the top.Then, secondary objectives, in terms of criteria, sit in the intermediate levels to the lowest level.
3) Set of pairwise comparison matrices in a way that each element in an upper level is used to compare the elements in the level immediately below.4) Use the obtained priorities for weighing priorities of an immediately lower level and continue doing this to reach the lowest level.
To make comparisons, we need a scale of numbers that indicates how many times more important one element is over another element.The scale has 1-9 level in AHP process (Saaty, 2008).For the results to be valid, some degree of compatibility is necessary.This compatibility is determined by inconsistency rate and it has to be less than 0.1 (Saaty, 1980).
In the current study, the researcher is to prioritize educational needs of female adolescents in relation to healthy eating with an approach to AHP model.

Method
The current study is a descriptive research carried out on health experts of Yazd province on 2015.In the first place, 15 experts working in Yazd Health Centers are selected using purposeful sampling.Inclusion criteria are interacting with students, being aware of their dietary status, and willingness to participate.Delphi method was used to collect data.To do so, a questionnaire is delivered to each of the experts to list wrong eating habits, common among female adolescent, regardless of priority.After analyzing their comments, removing duplicates, a list of wrong eating habits of students is prepared.The habits are: Junk food consumption, drinking soda and sweet drinks, eating fast food, deleting main meals, improper diets, low intake of vegetables, and not eating breakfast.Indeed, these behaviors are the same options preferred for AHP model.Then, after reviewing literature, three variables are used as comparison criteria of AHP model, i.e. severity, prevalence, and Changeability.(Didarloo, Shojaeezade, & mohammadian, 2014).Figure 1 depicts hierarchical structure of this study.After completing the questionnaires, data are analyzed using Expert Choice 11 software.

Results
Information obtained from AHP analysis, divided by criteria, is summarized in tables.According to experts' comment, to design an educational intervention, Changeability of a wrong eating behavior is more important than its prevalence as well as severity of adverse effects on students' health (Table 1).According to obtained results, among common wrong eating habits of female adolescents, consumption of fast foods, soda, sweet drinks, and snacks, respectively, leave more adverse effects on students' health, than others (Table 2).
Also, among listed behaviors, low intake of vegetables, not eating breakfast, eating too much fast foods, respectively, are known to be used the most by the students (Table 3).Finally, with regard to Changeability criteria and influenced by education, low intake of vegetables, not eating breakfast, high consumption of soda and sweet drinks, respectively, are identified as the most Changeable habits (Table 4).In the end, by taking all the three criteria into account simultaneously, the educational needs of students in relation to healthy eating are ranked as follows:

Discussion
Considering that identifying and prioritizing educational needs is the first step in training programs, in order to better organize the educational interventions, in this study we identified and prioritized the educational needs of female adolescents to improve their nutrition function.Among the studied criteria, to compare wrong eating habits, flexibility, with total weight of 65.3%, is recognized as the most significant one.Due to the fact that the ultimate goal of educational intervention is to change eating behavior, it seems reasonable to always consider the level of flexibility of a habit as the most significant factor in training.
Based on the obtained results, educating the students about using vegetables owns the highest weight factor in the tables.Low intake of vegetables hits the first place with regard to both prevalence and flexibility criteria.
According to CDC report, in 2010, the average fruit and vegetable consumption among high school students was 1.2 servings per day (Control & Prevention, 2011).
Fast food consumption owns the second place in the table of educational needs.Adverse consequences arising from the consumption of these foods weighs more than other wrong eating habits severity criteria Researches have also mentioned adverse effects of fast food consumption on human health so that there is a strong positive correlation between eating fast food more than 3 times per week and respiratory problems of adolescents with 13-14 years of age (Ellwood et al., 2013).As proved in the study of Sanchez et al., those listed among top fast food users, are at the greater risk of depression (up to 40%); they found a significant relationship between amount of fast food intake and incidence of depression (Sánchez-Villegas et al., 2012).Trans fatty acids found in processed foods and fast food increase the risk of cardiovascular disease (Rubinstein et al., 2015).In another study conducted by Nazari et al., the researchers concluded that the content of trans fatty acids in Iranian processed foods is much higher than permitted amount (up to 2%) (Nazari et al., 2009).Reyhani et al. indicated that eating sausages and salami with high-fat dairy can increase the risk of breast cancer risk (Reyhani, Fahami, Mosharaf, & Tarkesh, 2012).
The third educational priority is training program about eating breakfast habit of students.This is a second priority behavior and is associated with prevalence and flexibility criteria.Although not having breakfast is in the last place in term of severity of adverse consequences, its importance is discussed in several studies.Because of having positive effects on appetite, hormonal and nervous signals, breakfast can control both appetite throughout a day and individuals weight (Leidy, Ortinau, Douglas, & Hoertel, 2013;Tin, Ho, Mak, Wan, & Lam, 2011).
Studies have shown that students who eat breakfast do better than those who don't which is indicative of the importance of breakfast as a predictor of academic performance (Boschloo et al., 2012).
A Study on male students of elementary, guidance and high schools of Zahedan indicated that 2.5% of them never eat breakfast (Mortazavi & Roudbari, 2010).Also, a study on eating breakfast habit of elementary students of Qazvin indicated that 10.5 % of them go to school without eating breakfast (Rezakhani, Soheili Azad, Razaghi, & Nemati, 2012).Among female students of primary schools of Omidieh city, the rate increases to 20.5% (Karami & Ghaleh, 2015).Naeemi et al. studied male students of Qom and found that educational interventions can improve breakfast eating habit of these students (Shojaezadeh, Naeimi, Noori, Khalili, & Haghverdi, 2015)

Conclusion
According to this study, the most significant educational needs of female adolescent students of Yazd, in term of healthy eating, are as follows: low intake of vegetables, eating fast food, not eating breakfast, drinking soda and sweet drinks, deleting main meals, Junk food consumption and improper diets.It should be noted that, wrong eating habits of students described in this study are assessed with regard to the introduced criteria which may change if different set of criteria be included in prioritizing.

Figure 1 .Figure 2 .
Figure 1.Hierarchical structure of the AHP model to prioritize educational needs of female adolescents in relation to healthy eating

Table 1 .
Weight of each triple criterion

Table 2 .
Severity-weight relation of each alternative

Table 3 .
Prevalence-weight relation of each alternative

Table 4 .
Changeability-weight relation of each alternative

Table 5 .
Final weight of options with regard to all three criteria