The Impact of Peer Education, Utilizing the Pender Model, On Health Literacy, Lifestyle Adjustments, And Health-Promoting Behaviors Aimed at Preventing Type-2 Diabetes Among University Students

The Impact of Peer Education, Utilizing the Pender Model, On Health Literacy, Lifestyle Adjustments, And Health-Promoting Behaviors Aimed at Preventing Type-2 Diabetes Among University Students | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Impact of Peer Education, Utilizing the Pender Model, On Health Literacy, Lifestyle Adjustments, And Health-Promoting Behaviors Aimed at Preventing Type-2 Diabetes Among University Students Sahar Mohammadnabizadeh This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7296014/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Objectives Lifestyle modifications are closely linked to controlling and preventing chronic diseases like diabetes. This study aimed to evaluate the impact of peer education on both health literacy and lifestyle modifications, based on Pender's health promotion model, to prevent type 2 diabetes among university students. Methods The study conducted was a quasi-experimental intervention, based on Pender's health promotion model, among 120 university students (60 cases for each intervention and control group). For the educational intervention program, one trainer was assigned for every ten participants from the intervention group. The data were gathered through the use of three questionnaires: demographic characteristics, health literacy, and health-promoting lifestyle. The data analysis was conducted using SPSS. Results Educational programs utilizing Pender's health promotion model have shown notable improvements in students' lifestyles. Our findings indicated that post-intervention, the intervention group displayed significantly higher mean scores in lifestyle dimensions and health literacy compared to the control group, except for spiritual growth. Conclusion Given the impact of unhealthy lifestyles on the risk of diabetes, these findings underscore the importance of effective educational interventions and programs that are grounded in health promotion models. Adopting these behaviors and lifestyle changes can lead to decreased healthcare expenses, reduced stress, and minimized side effects associated with diseases. Moreover, by promoting health literacy and improving understanding of diabetes, we can empower individuals to make informed decisions about their health and ultimately promote healthier lifestyles, leading to improved quality of life for the population. Pender model Health literacy Lifestyle Diabetes Introduction Diabetes is a persistent and metabolic condition characterized by elevated blood sugar levels, resulting in various complications [ 1 ] . The diagnosis of type-2 diabetes at a younger age increases the likelihood of developing nephropathy, hypertension, chronic cardiovascular diseases, and retinopathy in comparison to individuals whose disease develops in middle age [ 2 ] . Multiple factors, including cultural, social, and environmental influences, can play a role in the onset of type-2 diabetes [ 3 ] . Given the significant medical costs associated with type-2 diabetes, there is a growing emphasis on preventive measures. Health education programs have the potential to empower young people by increasing their knowledge, influencing their health beliefs, and enhancing their decision-making skills. These programs can play a crucial role in enabling young individuals to make positive changes in their behavior and take ownership of their own health [ 4 ] . Peer education is a method that involves peers learning health information and skills in order to educate and support each other. This approach aims to not only increase knowledge, but also to influence health attitudes and behaviors by utilizing peer education [ 5 ] . Engaging in health-promoting behaviors involves adopting strategies to maintain and enhance overall well-being, leading to improvements in quality of life, self-transcendence, and capabilities [ 6 ] . Lifestyle modifications are closely linked to controlling and preventing chronic diseases like diabetes [ 7 ] . The Pender model is one of several models used to educate individuals about health-promoting lifestyle behaviors. This model emphasizes the importance of an individual's belief in the expected outcomes of a particular behavior, which in turn influences their willingness to engage in it [ 8 ] . It's fascinating that research studies have utilized the Pender model as a theoretical framework to emphasize health-promoting behaviors in diverse groups, as well as in the context of chronic diseases like hypertension, diabetes, and heart diseases [ 8 ] . According to some evidence, health literacy is considered to be a factor associated with lifestyle behaviors [ 9 ] . Health literacy is the ability of individuals to acquire, comprehend, and utilize basic health information and services to make informed decisions about their health [ 10 ] . A study conducted in several provinces of Iran revealed that 56.6% of participants had insufficient health literacy, while only 28.1% demonstrated a high level of health literacy [ 11 ] . Objectives Both health literacy and the promotion of health behaviors play a crucial role in preventing or delaying the complications of diabetes and reducing healthcare expenses associated with the rapidly increasing prevalence of diabetes. Thus, this study aimed to evaluate the impact of peer education on both health literacy and lifestyle modifications, based on Pender's health promotion model, to prevent type 2 diabetes among university students. Methods Study Design The study conducted was a quasi-experimental intervention, with the study population comprising university students. The sample size was determined using a suitable formula and based on previous studies [ 12 ] . With a power of 0.80, a mean difference of 48.47, and standard deviations of 12.98 and 12.09, and at a confidence level of 0.95, the initial estimated sample size was 52 cases for each intervention and control group. To accommodate potential subject attrition, the final sample size for each group was set at 60 cases. For the educational intervention program, one trainer was assigned for every ten participants from the intervention group, resulting in a total of six trainers. Prior to commencing the study, ethical approval was obtained from the ethics committee (Number: IR.MUMS.FHMPM.REC.1402.167). Furthermore, all participants completed the informed consent forms. The study's eligibility criteria included being of not having diabetes, not having engaged in any relevant educational programs for at least six months prior to the study, and actively participating in training sessions. Exclusion criteria encompassed participants who were unwilling to continue their participation, provided incomplete questionnaire responses, and did not attend the training sessions. The questionnaire used in our study was developed for this study. Data Collection Tools The Persian version of the health promoting lifestyle, validated by Mohammadi Zaidi et al [ 13 ] , comprised 52 items assessing lifestyle based on Pender’s model across six dimensions: dietary habits, physical activity, interpersonal relations, health responsibility, self-actualization, and stress management. Responses to the questionnaire items were scored using a Likert scale, with the following values assigned: never (1), sometimes (2), often (3), and always (4). The total score of this questionnaire demonstrated a Cronbach’s alpha coefficient of 0.88. The health literacy questionnaire comprised 33 questions related to health information availability, reading, understanding, evaluation, and intention of behavior [ 9 ] . Scores on this questionnaire ranged from 0 to 100. The validity of this tool was established and confirmed in the study by Montazeri et al [ 14 ] . Moreover, the reliability of this tool in the current study was examined, and it demonstrated a Cronbach’s alpha of 0.90. The education sessions for trainers involved a pre-test using the previously mentioned questionnaires to assess participants' health literacy and dimensions of Pender’s model. Subsequently, the trainers underwent education and communication skills review and were provided with educational materials. The training was delivered through various educational approaches such as lectures, group discussions, question and answer sessions, brainstorming, problem-solving skills, and the use of visual aids like PowerPoint presentations and pamphlets. The educational content covered topics including determining their health literacy skills, information about diabetes, investigating participants' beliefs about diabetes, risk factors for diabetes, explaining diabetes and its complications, screening and diagnostic criteria, healthy lifestyle behaviors, diet management, physical activity, stress management, and evaluation of training and knowledge management. Following the training, each trainer presented their assigned topic in the last workshop session, and received feedback from their peers to enhance their delivery skills. Subsequently, the trainers conducted the training program for the intervention group of students, which involved a 4-day, 2-hour session. Participants completed questionnaires before the intervention and at a follow-up three months later. Data analysis Paired t-tests were then used to compare means before and after the intervention, as well as to examine group differences. Furthermore, Pearson correlation was utilized to assess the relationships between health literacy and health-promoting lifestyle. The data analysis was conducted using SPSS22, with the level of statistical significance set at p < 0.05. Results According to the demographic findings presented in Table 1 , the results showed that there was no significant difference between the intervention and control groups in terms of age, marital status, and family history of diabetes. Table 1 The characteristics of participants at baseline Variable Control Intervention P value Age, Mean (Standard Deviation) 20.93 (1.76) 20.87 (1.90) 0.84 Marital status, Number (Presence) Married 7 (11.7) 10 (16.7) 0.47 Single 53 (88.3) 50 (83.3) Family history of diabetes, Number (Presence) Yes 18 (30) 11 (18.3) 0.16 No 42 (70) 49 (81.7) The scores of health literacy in the control and intervention groups indicated that the mean scores of both groups were not significantly different before the intervention (Table 2 ). However, at follow-up time, the mean score of the intervention group was significantly higher than that of the control. Table 2 Comparison of mean and standard deviation scores of health literacy Variable Time Control Intervention P value Health literacy Pretest 72.66 (9.79) 71.55 (9.94) 0.54 Follow-up 73.71 (9.89) 82.22 (8.70) 0.0001 P -value 0.27 0.0001 The results presented in Table 3 showed that there was no significant difference between the groups in lifestyle and its dimensions before the intervention. However, after the intervention, the mean scores of lifestyle dimensions (except for spiritual growth) were significantly different between the two groups, with the intervention group exhibiting higher scores. Table 3 Comparison of the mean and standard deviation scores of health-promoting lifestyle components Variable Time Control Intervention P value Health responsibility Pretest 15.53 (4.46) 15.66 (4.40) 0.46 Follow-up 15.84 (4.10) 26.15 (2.58) 0.0001 P value 0.29 0.0001 Physical activity Pretest 14.83 (4.23) 14.95 (4.22) 0.75 Follow-up 15.34 (4.09) 23.64 (3.18) 0.0001 P value 0.09 0.0001 Nutrition Pretest 15.62 (4.29) 15.42 (4.36) 0.52 Follow-up 16.07 (4.25) 25.04 (2.61) 0.0001 P value 0.09 0.0001 Spiritual growth Pretest 16.45 (4.29) 16.17 (4.46) 0.51 Follow-up 16.62 (4.17) 17.57 (3.55) 0.37 P value 0.62 0.08 Interpersonal relations Pretest 17.89 (3.87) 17.56 (4.06) 0.35 Follow-up 18.21 (3.86) 25.00 (2.53) 0.0001 P value 0.34 0.0001 Stress management Pretest 14.18 (4.15) 14.22 (4.11) 0.90 Follow-up 14.36 (4.02) 18.72 (3.27) 0.0001 P value 0.64 0.0001 Health-promoting lifestyle (total) Pretest 94.50 (26.33) 93.98 (26.40) 0.06 Follow-up 96.43 (25.53) 136.03 (26.74) 0.0001 P value 0.06 0.0001 Moreover, the findings suggest a significant correlation between health-promoting lifestyle and health literacy (Table 4 ). Table 4 Correlation matrix among health literacy and health-promoting lifestyle Variable Health-promoting lifestyle Correlation coefficient P value Health literacy 0.67 0.0001 Discussion Educational interventions based on the model of Pender's health promotion have demonstrated significant positive effects on the lifestyle of students. This aligns with findings from other studies such as Radmehr et al [ 15 ] , and Shin et al [ 16 ] . The potential for lifestyle referral schemes to support individual behavior changes, while also fostering clinical-community linkages, is an important aspect to consider in promoting healthier lifestyles among adolescents [ 17 ] . The findings of the present study suggested that peer education can be an effective method for influencing changes in adolescents' behavior and habits. The selection of peer educators from within the student body may indeed result in a stronger impact on their peers compared to other forms of instruction. This aligns with previous research that has demonstrated the efficacy of peer education interventions in promoting healthy habits and behaviors among adolescents. For instance, the study by Pooresmaeil Dorosteh et al. showed that implementing peer education led to an increase in the average score of diabetes knowledge and preventive behaviors among students [ 18 ] . Implementing peer education as a method of instruction has the potential to bring about fundamental changes in adolescents' behavior, ultimately contributing to the promotion of a healthy lifestyle and community. The results of our study demonstrated the positive impact of peer educational intervention on students' health literacy. Additionally, the significant correlation found in our study between health-promoting lifestyle and health literacy underscores the crucial impact of health literacy on promotion of health. There is evidence suggesting that health literacy is a factor related to lifestyle behaviors, with higher health literacy being associated with greater individuals capabilities to make informed decisions about their health [ 10 ] . The study by Chahardah-Cherik demonstrated a positive relationship between the dimensions of healthy behaviors and health literacy, suggesting that individuals with high levels of health literacy are more inclined to engage in health-related behaviors [ 19 ] . It is important to note that low health literacy has been recognized as a more influential predictor of an individual's health than factors such as employment status, income, race, and education level [ 9 ] . The influence of health literacy on socio-cognitive and psychological factors, such as knowledge, underscores its role in shaping health actions, including disease management [ 20 ] . This highlights the significant impact of limited health literacy, not only on individual health outcomes but also on the economic burden to society as a whole. Given these findings, further research is indeed warranted to investigate the most effective strategies for enhancing health literacy and diabetes knowledge. The findings of our study illustrated the beneficial influence of peer educational intervention, grounded in Pender's health promotion model, on the dietary habits of students. This is consistent with evidence from research involving individuals of Asian descent, indicating that dietary changes significantly contribute to the prevention of type 2 diabetes in those at risk for the disease [ 21 ] . Moreover, the findings are consistent with a study by Aguiar et al., which implemented a comprehensive 6-month intervention in participants' lifestyles and observed a shift towards healthier food consumption following the intervention [ 22 ] . Furthermore, Tuomilehto et al.'s research on diabetes prevention through lifestyle change in Finland found that individuals who received personalized dietary counseling and were given free access to supervised exercise sessions at the gym experienced a significant 58% decrease in the risk of developing diabetes [ 23 ] . Our research results demonstrate that the peer educational intervention positively influenced students' physical activity. This is in agreement with previous evidence that suggests physical inactivity, and sedentary lifestyles are contributing to the current diabetes epidemic [ 24 ] . The evidence strongly backs the recommendations for boosting exercise, as controlled interventions have shown improved metabolism of glucose with increased exercise. These results confirm that a comprehensive approach, incorporating exercise, is successful in preventing disruptions in glucose metabolism [ 25 ] . The research conducted by Radmehr et al. strengthens these results by showing significant differences, before and after the education, in the average scores of exercise [ 15 ] . Therefore, it is clear that exercise training combined with nutritional intervention are fundamental components of a lifestyle intervention program for diabetes mellitus and should be considered mandatory in such programs. This emphasizes the importance of promoting physical activity as a key element in the management and prevention of diabetes. The findings of the present study suggested that during the follow-up period, the average score for interpersonal relationships in the intervention group was notably higher compared to the control group. These results are consistent with the study conducted by Mohammadipour et al., which similarly demonstrated a significant rise in average scores for interpersonal relationships within the intervention group [ 26 ] . Additionally, Radmehr et al.'s study showed significant differences, before and after the intervention, in the mean scores of interpersonal relationships [ 15 ] . The outcomes indicate that the application of the model of Pender's health promotion yielded favorable results in bolstering interpersonal relationships, boosting motivation, enhancing self-efficacy, and fostering involvement [ 27 ] . This underscores the broader impact of health promotion interventions on social and psychological aspects, in addition to physical health. Strengthening interpersonal relationships can be a valuable component of interventions aimed at promoting overall well-being and health outcomes. The findings from our study suggested that the peer educational intervention had positive effects on stress management. This is in line with multiple studies that suggest stress significantly contribute to the onset, exacerbation, and long-term presence of diabetes [ 28 ] . Additionally, there is strong evidence that, in the context of genetic predisposition, psychosocial stress is a significant diabetes risk factor, with stress contributing to increased glucose and glycosylated hemoglobin levels [ 29 ] . The beneficial effects of stress management programs in controlling blood glucose levels have been demonstrated in study by Surwit et al [ 30 ] . This study has shown that training program of stress management is cost-effective techniques for decreasing glycosylated hemoglobin levels related to diabetes. Furthermore, Vakilian et al.'s study utilizing Pender's health promotion theory demonstrated a significant variance, before and after the intervention, in stress management within the intervention group [ 31 ] . Implementing strategies to effectively manage stress could potentially have a positive impact on overall diabetes management and contribute to improved health outcomes. The role of spirituality in influencing behavioral changes and individual motivations that impact lifestyle changes and blood glucose control has been noted in previous research [ 32 ] . Studies have indicated that spirituality not only affects individuals' mental health and moods but also has a positive impact on their physical well-being, including improved immunity and more regular endocrine function [ 33 ] . However, in our investigation, a significant difference in the spiritual growth dimension was not found before and during follow-up. This lack of significance may be due to several factors, including differences in the research community, sample size, and cultural variations. Furthermore, promoting the concept of spiritual growth may require comprehensive research efforts and long-term planning, which could contribute to these findings. It's worth noting that the limited availability of articles on this topic may have also influenced the comparisons, as they were based on only a small number of existing studies. As a result, it's important to recognize the need for further investigations to better understand the underlying mechanisms and procedures driving such findings. Further extensive research will be required to fully comprehend the role of spirituality in encouraging changes in health-related behaviors and its influence on the management of diabetes. The study's limitations have been recognized, especially in terms of using self-reported data, which may lead to self-report bias. Furthermore, it is essential to recognize that other factors, like sedentary behaviors, smoking, mental health, sociodemographic factors and sleeping patterns, have been associated with the risk of diabetes [ 34 ] . Conclusion Educational programs utilizing Pender's health promotion model have shown notable improvements in students' lifestyles. Our findings indicated that post-intervention, the intervention group displayed significantly higher mean scores in lifestyle dimensions and health literacy compared to the control group, except for spiritual growth. Given the impact of unhealthy lifestyles on the risk of diabetes, these findings underscore the importance of effective educational interventions and programs that are grounded in health promotion models. Adopting these behaviors and lifestyle changes can lead to decreased healthcare expenses, reduced stress, and minimized side effects associated with diseases. Moreover, by promoting health literacy and improving understanding of diabetes, we can empower individuals to make informed decisions about their health and ultimately promote healthier lifestyles, leading to improved quality of life for the population. Declarations Ethics approval and consent to participate The study was approved by the Mashhad University of Medical Sciences ethics board (Number: IR.MUMS.FHMPM.REC.1402.167). In this study, the principles of the Declaration of Helsinki have been followed. A written consent was obtained from all participants after explaining the aim of the study. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors received no funding for this project. Authors’ contributions SM participated in the writing and design of the study, performed the statistical analysis and drafted the manuscript. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7296014","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":505580656,"identity":"3459ff7e-e285-4238-a9b1-c864a4e85800","order_by":0,"name":"Sahar Mohammadnabizadeh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABHElEQVRIie3RsUoDMRjA8a8cnMsdXQvS6xMIKQcncuCz5CjYJXEWlOu52KU6u/gOASHilhDwluitKd07qVBBKQhiWsHFOylODvkPIRB+yV0C4HL9y4L12CrsRAB4gMAT34tiQ+LjzQl8kQD9+lk743P5MiX73ZuteymXJ2m029av1yHJoT0WLXX0kyT6YbBN+SC+nRxi0bkbxnuXlM9CrqCjMUhdQwxBlngZEwQJ5KuMmXBF7F8YAFnUkvid8lHGqkck8IcasUrPLcmh10wSe8pqc3uKPFMYCeJbYu+hiWidpJSXMTPPWJ5eDPvMHCTTK66Cvs6KWlJO4hnlx11WUbVYvqU9VKm5eeJ5FJVKLWpIc8H6sVwul8v1pz4BxFx7ODxstvwAAAAASUVORK5CYII=","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Sahar","middleName":"","lastName":"Mohammadnabizadeh","suffix":""}],"badges":[],"createdAt":"2025-08-05 04:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7296014/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7296014/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90055103,"identity":"eef7bac3-f4d5-485e-954f-bbfc6afae53a","added_by":"auto","created_at":"2025-08-28 00:42:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":611709,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7296014/v1/1f3144b7-e512-47e5-986e-f752aebec301.pdf"},{"id":90054843,"identity":"d3d056dd-d5b2-42e7-9432-d4660df4d210","added_by":"auto","created_at":"2025-08-28 00:34:06","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":29898,"visible":true,"origin":"","legend":"","description":"","filename":"Questionnaires.docx","url":"https://assets-eu.researchsquare.com/files/rs-7296014/v1/76a90be767921a0f12f580df.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Impact of Peer Education, Utilizing the Pender Model, On Health Literacy, Lifestyle Adjustments, And Health-Promoting Behaviors Aimed at Preventing Type-2 Diabetes Among University Students","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiabetes is a persistent and metabolic condition characterized by elevated blood sugar levels, resulting in various complications \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. The diagnosis of type-2 diabetes at a younger age increases the likelihood of developing nephropathy, hypertension, chronic cardiovascular diseases, and retinopathy in comparison to individuals whose disease develops in middle age \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Multiple factors, including cultural, social, and environmental influences, can play a role in the onset of type-2 diabetes \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Given the significant medical costs associated with type-2 diabetes, there is a growing emphasis on preventive measures.\u003c/p\u003e\u003cp\u003eHealth education programs have the potential to empower young people by increasing their knowledge, influencing their health beliefs, and enhancing their decision-making skills. These programs can play a crucial role in enabling young individuals to make positive changes in their behavior and take ownership of their own health \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Peer education is a method that involves peers learning health information and skills in order to educate and support each other. This approach aims to not only increase knowledge, but also to influence health attitudes and behaviors by utilizing peer education \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eEngaging in health-promoting behaviors involves adopting strategies to maintain and enhance overall well-being, leading to improvements in quality of life, self-transcendence, and capabilities \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Lifestyle modifications are closely linked to controlling and preventing chronic diseases like diabetes \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. The Pender model is one of several models used to educate individuals about health-promoting lifestyle behaviors. This model emphasizes the importance of an individual's belief in the expected outcomes of a particular behavior, which in turn influences their willingness to engage in it \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. It's fascinating that research studies have utilized the Pender model as a theoretical framework to emphasize health-promoting behaviors in diverse groups, as well as in the context of chronic diseases like hypertension, diabetes, and heart diseases \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAccording to some evidence, health literacy is considered to be a factor associated with lifestyle behaviors \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Health literacy is the ability of individuals to acquire, comprehend, and utilize basic health information and services to make informed decisions about their health \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. A study conducted in several provinces of Iran revealed that 56.6% of participants had insufficient health literacy, while only 28.1% demonstrated a high level of health literacy \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eObjectives\u003c/h3\u003e\n\u003cp\u003eBoth health literacy and the promotion of health behaviors play a crucial role in preventing or delaying the complications of diabetes and reducing healthcare expenses associated with the rapidly increasing prevalence of diabetes. Thus, this study aimed to evaluate the impact of peer education on both health literacy and lifestyle modifications, based on Pender's health promotion model, to prevent type 2 diabetes among university students.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThe study conducted was a quasi-experimental intervention, with the study population comprising university students. The sample size was determined using a suitable formula and based on previous studies \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. With a power of 0.80, a mean difference of 48.47, and standard deviations of 12.98 and 12.09, and at a confidence level of 0.95, the initial estimated sample size was 52 cases for each intervention and control group. To accommodate potential subject attrition, the final sample size for each group was set at 60 cases. For the educational intervention program, one trainer was assigned for every ten participants from the intervention group, resulting in a total of six trainers. Prior to commencing the study, ethical approval was obtained from the ethics committee (Number: IR.MUMS.FHMPM.REC.1402.167). Furthermore, all participants completed the informed consent forms. The study's eligibility criteria included being of not having diabetes, not having engaged in any relevant educational programs for at least six months prior to the study, and actively participating in training sessions. Exclusion criteria encompassed participants who were unwilling to continue their participation, provided incomplete questionnaire responses, and did not attend the training sessions. The questionnaire used in our study was developed for this study.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eData Collection Tools\u003c/h3\u003e\n\u003cp\u003eThe Persian version of the health promoting lifestyle, validated by Mohammadi Zaidi et al \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e, comprised 52 items assessing lifestyle based on Pender\u0026rsquo;s model across six dimensions: dietary habits, physical activity, interpersonal relations, health responsibility, self-actualization, and stress management. Responses to the questionnaire items were scored using a Likert scale, with the following values assigned: never (1), sometimes (2), often (3), and always (4). The total score of this questionnaire demonstrated a Cronbach\u0026rsquo;s alpha coefficient of 0.88.\u003c/p\u003e\u003cp\u003eThe health literacy questionnaire comprised 33 questions related to health information availability, reading, understanding, evaluation, and intention of behavior \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Scores on this questionnaire ranged from 0 to 100. The validity of this tool was established and confirmed in the study by Montazeri et al \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Moreover, the reliability of this tool in the current study was examined, and it demonstrated a Cronbach\u0026rsquo;s alpha of 0.90.\u003c/p\u003e\u003cp\u003eThe education sessions for trainers involved a pre-test using the previously mentioned questionnaires to assess participants' health literacy and dimensions of Pender\u0026rsquo;s model. Subsequently, the trainers underwent education and communication skills review and were provided with educational materials. The training was delivered through various educational approaches such as lectures, group discussions, question and answer sessions, brainstorming, problem-solving skills, and the use of visual aids like PowerPoint presentations and pamphlets. The educational content covered topics including determining their health literacy skills, information about diabetes, investigating participants' beliefs about diabetes, risk factors for diabetes, explaining diabetes and its complications, screening and diagnostic criteria, healthy lifestyle behaviors, diet management, physical activity, stress management, and evaluation of training and knowledge management. Following the training, each trainer presented their assigned topic in the last workshop session, and received feedback from their peers to enhance their delivery skills. Subsequently, the trainers conducted the training program for the intervention group of students, which involved a 4-day, 2-hour session. Participants completed questionnaires before the intervention and at a follow-up three months later.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003ePaired t-tests were then used to compare means before and after the intervention, as well as to examine group differences. Furthermore, Pearson correlation was utilized to assess the relationships between health literacy and health-promoting lifestyle. The data analysis was conducted using SPSS22, with the level of statistical significance set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAccording to the demographic findings presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the results showed that there was no significant difference between the intervention and control groups in terms of age, marital status, and family history of diabetes.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe characteristics of participants at baseline\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, Mean (Standard Deviation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.93 (1.76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20.87 (1.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.84\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarital status, Number (Presence)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (11.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10 (16.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53 (88.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50 (83.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily history of diabetes, Number (Presence)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11 (18.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42 (70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e49 (81.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe scores of health literacy in the control and intervention groups indicated that the mean scores of both groups were not significantly different before the intervention (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). However, at follow-up time, the mean score of the intervention group was significantly higher than that of the control.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of mean and standard deviation scores of health literacy\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTime\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth literacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePretest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72.66 (9.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e71.55 (9.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.54\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e73.71 (9.89)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e82.22 (8.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe results presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e showed that there was no significant difference between the groups in lifestyle and its dimensions before the intervention. However, after the intervention, the mean scores of lifestyle dimensions (except for spiritual growth) were significantly different between the two groups, with the intervention group exhibiting higher scores.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of the mean and standard deviation scores of health-promoting lifestyle components\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTime\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth responsibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePretest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15.53 (4.46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e15.66 (4.40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15.84 (4.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26.15 (2.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical activity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePretest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14.83 (4.23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14.95 (4.22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15.34 (4.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23.64 (3.18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNutrition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePretest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15.62 (4.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e15.42 (4.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.52\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16.07 (4.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25.04 (2.61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpiritual growth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePretest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16.45 (4.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e16.17 (4.46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.51\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16.62 (4.17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e17.57 (3.55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterpersonal relations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePretest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17.89 (3.87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e17.56 (4.06)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18.21 (3.86)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25.00 (2.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStress management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePretest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14.18 (4.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14.22 (4.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.90\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14.36 (4.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e18.72 (3.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth-promoting lifestyle (total)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePretest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e94.50 (26.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e93.98 (26.40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e96.43 (25.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e136.03 (26.74)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMoreover, the findings suggest a significant correlation between health-promoting lifestyle and health literacy (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation matrix among health literacy and health-promoting lifestyle\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eHealth-promoting lifestyle\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCorrelation coefficient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth literacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eEducational interventions based on the model of Pender's health promotion have demonstrated significant positive effects on the lifestyle of students. This aligns with findings from other studies such as Radmehr et al \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e, and Shin et al \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. The potential for lifestyle referral schemes to support individual behavior changes, while also fostering clinical-community linkages, is an important aspect to consider in promoting healthier lifestyles among adolescents \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe findings of the present study suggested that peer education can be an effective method for influencing changes in adolescents' behavior and habits. The selection of peer educators from within the student body may indeed result in a stronger impact on their peers compared to other forms of instruction. This aligns with previous research that has demonstrated the efficacy of peer education interventions in promoting healthy habits and behaviors among adolescents. For instance, the study by Pooresmaeil Dorosteh et al. showed that implementing peer education led to an increase in the average score of diabetes knowledge and preventive behaviors among students \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Implementing peer education as a method of instruction has the potential to bring about fundamental changes in adolescents' behavior, ultimately contributing to the promotion of a healthy lifestyle and community.\u003c/p\u003e\u003cp\u003eThe results of our study demonstrated the positive impact of peer educational intervention on students' health literacy. Additionally, the significant correlation found in our study between health-promoting lifestyle and health literacy underscores the crucial impact of health literacy on promotion of health. There is evidence suggesting that health literacy is a factor related to lifestyle behaviors, with higher health literacy being associated with greater individuals capabilities to make informed decisions about their health \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. The study by Chahardah-Cherik demonstrated a positive relationship between the dimensions of healthy behaviors and health literacy, suggesting that individuals with high levels of health literacy are more inclined to engage in health-related behaviors \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. It is important to note that low health literacy has been recognized as a more influential predictor of an individual's health than factors such as employment status, income, race, and education level \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. The influence of health literacy on socio-cognitive and psychological factors, such as knowledge, underscores its role in shaping health actions, including disease management \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. This highlights the significant impact of limited health literacy, not only on individual health outcomes but also on the economic burden to society as a whole. Given these findings, further research is indeed warranted to investigate the most effective strategies for enhancing health literacy and diabetes knowledge.\u003c/p\u003e\u003cp\u003eThe findings of our study illustrated the beneficial influence of peer educational intervention, grounded in Pender's health promotion model, on the dietary habits of students. This is consistent with evidence from research involving individuals of Asian descent, indicating that dietary changes significantly contribute to the prevention of type 2 diabetes in those at risk for the disease \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Moreover, the findings are consistent with a study by Aguiar et al., which implemented a comprehensive 6-month intervention in participants' lifestyles and observed a shift towards healthier food consumption following the intervention \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. Furthermore, Tuomilehto et al.'s research on diabetes prevention through lifestyle change in Finland found that individuals who received personalized dietary counseling and were given free access to supervised exercise sessions at the gym experienced a significant 58% decrease in the risk of developing diabetes \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eOur research results demonstrate that the peer educational intervention positively influenced students' physical activity. This is in agreement with previous evidence that suggests physical inactivity, and sedentary lifestyles are contributing to the current diabetes epidemic \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. The evidence strongly backs the recommendations for boosting exercise, as controlled interventions have shown improved metabolism of glucose with increased exercise. These results confirm that a comprehensive approach, incorporating exercise, is successful in preventing disruptions in glucose metabolism \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. The research conducted by Radmehr et al. strengthens these results by showing significant differences, before and after the education, in the average scores of exercise \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Therefore, it is clear that exercise training combined with nutritional intervention are fundamental components of a lifestyle intervention program for diabetes mellitus and should be considered mandatory in such programs. This emphasizes the importance of promoting physical activity as a key element in the management and prevention of diabetes.\u003c/p\u003e\u003cp\u003eThe findings of the present study suggested that during the follow-up period, the average score for interpersonal relationships in the intervention group was notably higher compared to the control group. These results are consistent with the study conducted by Mohammadipour et al., which similarly demonstrated a significant rise in average scores for interpersonal relationships within the intervention group \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. Additionally, Radmehr et al.'s study showed significant differences, before and after the intervention, in the mean scores of interpersonal relationships \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. The outcomes indicate that the application of the model of Pender's health promotion yielded favorable results in bolstering interpersonal relationships, boosting motivation, enhancing self-efficacy, and fostering involvement \u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. This underscores the broader impact of health promotion interventions on social and psychological aspects, in addition to physical health. Strengthening interpersonal relationships can be a valuable component of interventions aimed at promoting overall well-being and health outcomes.\u003c/p\u003e\u003cp\u003eThe findings from our study suggested that the peer educational intervention had positive effects on stress management. This is in line with multiple studies that suggest stress significantly contribute to the onset, exacerbation, and long-term presence of diabetes \u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. Additionally, there is strong evidence that, in the context of genetic predisposition, psychosocial stress is a significant diabetes risk factor, with stress contributing to increased glucose and glycosylated hemoglobin levels \u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. The beneficial effects of stress management programs in controlling blood glucose levels have been demonstrated in study by Surwit et al \u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. This study has shown that training program of stress management is cost-effective techniques for decreasing glycosylated hemoglobin levels related to diabetes. Furthermore, Vakilian et al.'s study utilizing Pender's health promotion theory demonstrated a significant variance, before and after the intervention, in stress management within the intervention group \u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e. Implementing strategies to effectively manage stress could potentially have a positive impact on overall diabetes management and contribute to improved health outcomes.\u003c/p\u003e\u003cp\u003eThe role of spirituality in influencing behavioral changes and individual motivations that impact lifestyle changes and blood glucose control has been noted in previous research \u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. Studies have indicated that spirituality not only affects individuals' mental health and moods but also has a positive impact on their physical well-being, including improved immunity and more regular endocrine function \u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e. However, in our investigation, a significant difference in the spiritual growth dimension was not found before and during follow-up. This lack of significance may be due to several factors, including differences in the research community, sample size, and cultural variations. Furthermore, promoting the concept of spiritual growth may require comprehensive research efforts and long-term planning, which could contribute to these findings. It's worth noting that the limited availability of articles on this topic may have also influenced the comparisons, as they were based on only a small number of existing studies. As a result, it's important to recognize the need for further investigations to better understand the underlying mechanisms and procedures driving such findings. Further extensive research will be required to fully comprehend the role of spirituality in encouraging changes in health-related behaviors and its influence on the management of diabetes.\u003c/p\u003e\u003cp\u003eThe study's limitations have been recognized, especially in terms of using self-reported data, which may lead to self-report bias. Furthermore, it is essential to recognize that other factors, like sedentary behaviors, smoking, mental health, sociodemographic factors and sleeping patterns, have been associated with the risk of diabetes \u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEducational programs utilizing Pender's health promotion model have shown notable improvements in students' lifestyles. Our findings indicated that post-intervention, the intervention group displayed significantly higher mean scores in lifestyle dimensions and health literacy compared to the control group, except for spiritual growth. Given the impact of unhealthy lifestyles on the risk of diabetes, these findings underscore the importance of effective educational interventions and programs that are grounded in health promotion models. Adopting these behaviors and lifestyle changes can lead to decreased healthcare expenses, reduced stress, and minimized side effects associated with diseases. Moreover, by promoting health literacy and improving understanding of diabetes, we can empower individuals to make informed decisions about their health and ultimately promote healthier lifestyles, leading to improved quality of life for the population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Mashhad University of Medical Sciences ethics board (Number: IR.MUMS.FHMPM.REC.1402.167). In this study, the principles of the Declaration of Helsinki have been followed. A written consent was obtained from all participants after explaining the aim of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no funding for this project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSM participated in the writing and design of the study, performed the statistical analysis and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to express their gratitude towards the Social Determinants of Health Research Center and vice president of research in Mashhad University of Medical Sciences.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUusitupa M, Khan TA, Viguiliouk E, Kahleova H, Rivellese AA, Hermansen K et al. 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Diabetologia. 2006;49(2):289\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAguiar EJ, Morgan PJ, Collins CE, Plotnikoff RC, Young MD, Callister R. Efficacy of the Type 2 Diabetes Prevention Using LifeStyle Education Program RCT. Am J Prev Med. 2016;50(3):353\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTuomilehto J, Lindstr\u0026ouml;m J, Eriksson JG, Valle TT, H\u0026auml;m\u0026auml;l\u0026auml;inen H, Ilanne-Parikka P, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344(18):1343\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAune D, Norat T, Leitzmann M, Tonstad S, Vatten LJ. Physical activity and the risk of type 2 diabetes: a systematic review and dose\u0026ndash;response meta-analysis. Eur J Epidemiol. 2015;30(7):529\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalas-Salvad\u0026oacute; J, D\u0026iacute;az-L\u0026oacute;pez A, Ruiz-Canela M, Basora J, Fit\u0026oacute; M, Corella D, et al. Effect of a Lifestyle Intervention Program With Energy-Restricted Mediterranean Diet and Exercise on Weight Loss and Cardiovascular Risk Factors: One-Year Results of the PREDIMED-Plus Trial. Diabetes Care. 2018;42(5):777\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMohammadipour F, Izadi Tameh A, Sepahvand F, Naderifar M. The impact of an educational intervention based on Pender's health promotion model on the lifestyle of patients with type II diabetes. J Diabetes Nurs. 2015;2(4):25\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHo AY, Berggren I, Dahlborg-Lyckhage E. Diabetes empowerment related to Pender's Health Promotion Model: a meta-synthesis. Nurs Health Sci. 2010;12(2):259\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlonso-Mor\u0026aacute;n E, Satylganova A, Orueta JF, Nu\u0026ntilde;o-Solinis R. Prevalence of depression in adults with type 2 diabetes in the Basque Country: relationship with glycaemic control and health care costs. BMC Public Health. 2014;14:769.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKyrou I, Chrousos GP, Tsigos C. Stress, visceral obesity, and metabolic complications. Ann N Y Acad Sci. 2006;1083:77\u0026ndash;110.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSurwit RS, van Tilburg MA, Zucker N, McCaskill CC, Parekh P, Feinglos MN, et al. Stress management improves long-term glycemic control in type 2 diabetes. Diabetes Care. 2002;25(1):30\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVakilian P, Mahmoudi M, Oskouie F, Firouzian AA, Khachian A. Investigating the effect of educational intervention based on the Pender's health promotion model on lifestyle and self-efficacy of the patients with diabetic foot ulcer: A clinical trial. J Educ Health Promot. 2021;10:466.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePenman J. Cognitive and Behavioral Changes Arising From Spirituality. J Relig Health. 2021;60(6):4082\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLucchetti G, Koenig HG, Lucchetti ALG. Spirituality, religiousness, and mental health: A review of the current scientific evidence. World J Clin Cases. 2021;9(26):7620\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMozaffarian D, Kamineni A, Carnethon M, Djouss\u0026eacute; L, Mukamal KJ, Siscovick D. Lifestyle risk factors and new-onset diabetes mellitus in older adults: the cardiovascular health study. Arch Intern Med. 2009;169(8):798\u0026ndash;807.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pender model, Health literacy, Lifestyle, Diabetes","lastPublishedDoi":"10.21203/rs.3.rs-7296014/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7296014/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eLifestyle modifications are closely linked to controlling and preventing chronic diseases like diabetes. This study aimed to evaluate the impact of peer education on both health literacy and lifestyle modifications, based on Pender's health promotion model, to prevent type 2 diabetes among university students.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThe study conducted was a quasi-experimental intervention, based on Pender's health promotion model, among 120 university students (60 cases for each intervention and control group). For the educational intervention program, one trainer was assigned for every ten participants from the intervention group. The data were gathered through the use of three questionnaires: demographic characteristics, health literacy, and health-promoting lifestyle. The data analysis was conducted using SPSS.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eEducational programs utilizing Pender's health promotion model have shown notable improvements in students' lifestyles. Our findings indicated that post-intervention, the intervention group displayed significantly higher mean scores in lifestyle dimensions and health literacy compared to the control group, except for spiritual growth.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eGiven the impact of unhealthy lifestyles on the risk of diabetes, these findings underscore the importance of effective educational interventions and programs that are grounded in health promotion models. Adopting these behaviors and lifestyle changes can lead to decreased healthcare expenses, reduced stress, and minimized side effects associated with diseases. Moreover, by promoting health literacy and improving understanding of diabetes, we can empower individuals to make informed decisions about their health and ultimately promote healthier lifestyles, leading to improved quality of life for the population.\u003c/p\u003e","manuscriptTitle":"The Impact of Peer Education, Utilizing the Pender Model, On Health Literacy, Lifestyle Adjustments, And Health-Promoting Behaviors Aimed at Preventing Type-2 Diabetes Among University Students","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-28 00:26:01","doi":"10.21203/rs.3.rs-7296014/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-09T08:31:14+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-26T05:02:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49839869010797967798890587198057227049","date":"2025-08-25T23:36:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-25T15:14:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"331374464391330851954872203136506397997","date":"2025-08-21T15:46:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"212759260037775975940968283607266911889","date":"2025-08-21T13:08:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"300286436303182994944379195674899850334","date":"2025-08-20T15:46:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-19T12:20:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-19T12:13:45+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-18T02:28:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-16T05:26:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-08-16T05:23:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"300a9375-e108-43f9-a0ef-7ed6308aa1df","owner":[],"postedDate":"August 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-29T12:25:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-28 00:26:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7296014","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7296014","identity":"rs-7296014","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}