the concept of mental health is a state of health in which a person knows his abilities , can deal with normal life pressures , can be fruitful to the community , and can also have the power of decision - making and participation .
self - esteem means the acceptance and a value that a person feels in him .
psychologists also believe that self - esteem is a portion of mental health , and they consider the enjoyment of self - esteem as a basic and central cause of the social  emotional adjustment of the people .
self - esteem involves all the daily activities of humans , so it is one of the most important aspects of one 's personality and a determinant of the actualization and behavioral characteristics of human beings , and most of the experts know it as an important and fundamental factor in social and emotional adjustment .
this characteristic is a general feature in all human beings and is not limited or transient , but is fixed and permanent .
people with a low level of self - esteem should be diagnosed , to improve their self - esteem , with appropriate educational programs .
students are constantly exposed to stressors and experience numerous problem due to the nature of their life during immigration to other places far from home .
the precede model is a model for health education and promotion planning , which is used for changing behavior .
green and kreuter believe that the precede model has been considered successful in the application of clinical and field trials .
this model provides a framework in which the factors affecting behavior , such as : the predisposing , enabling , and reinforcing factors in the educational and assessment phases are determined .
the precede model can be used as a guideline to analyze health problems or health behaviors , and also to determine knowledge , attitudes , and those beliefs that are effective in changes .
several studies , particularly in the last 15 years , suggest that self - esteem is considered as a major psychological factor influencing health and quality of life .
it has also been determined that a sense of empowerment and value trace is created for every person with increasing his / her self - esteem , and positive changes flourish in them to gain success , such as : academic achievement , more efforts for success , having a high self - esteem , and a great desire to preserve and promote health .
a research on self - esteem and mental health in canada showed that the most important mental need in 87.4% of the adolescents was self - esteem .
a significant relationship was found between low self - esteem and behavioral problems , such as , lack of confidence in relation to others , loss of social relations , and anxiety and depression .
wright , et al . in a large interventional study , in australia , tried to improve and evaluate community awareness and participation in mental health and mental disorders of individuals , 12 to 18 years of age , using the precede model , while the researchers survey and effort did not show any study based on the precede model for promoting both self - esteem and mental health among students in iran .
subsequently , this study was performed to evaluate the effect of an educational - participatory program , based on the precede model , for promoting the self - esteem and mental health of students in iran .
this is a pre - post experimental study with the control group , conducted during 2006  2007 .
the studied population was the first year students ( the freshman students ) of medical sciences from two universities in the north east of iran .
sampling was done initially , based on a pilot study , among universities of medical sciences in the north east of iran .
two universities were selected that showed a high prevalence of psychological problems among their students and they also had similar academic conditions and situations .
next , one of the two universities was randomly assigned as the case group and the other was identified as the control group .
considering p1 = 0.27 , p2 = 0.05 , z = 1.96 , z = 1.64 , and with confidence interval values of 95% , the sample size was determined to be more than 134 students .
the students were randomly selected based on a stratified random sampling method . following this ,
both the groups were matched for age , sex , discipline , and educational degree .
the inclusion criteria were , studying in medical science subjects , passing at least one university educational term , and voluntary participation in the study .
exclusion criteria were , having a psychiatric disorder and not volunteering for participation in the study .
the following tools were used for data collection . in order to prepare this section of instruments , after a literature review on information resources , a questionnaire was designed .
for assessing the predisposing factors , the questions were designed in three parts : ( a ) demographic data ; ( b ) knowledge including a 10-item , three - choice option questions with 
somewhat answers , with a possible range score from 0 to 20 ( example : do you know the conflicts of the situations you encounter ? ) ; and ( c ) attitude including an 18-item scale ( six points that included ,  disagree a little ,  disagree ,  completely disagree ,  agree a little , 
agree ,  completely agree ) with a possible range score of 6 to 36 .
( example : the best way to prevent getting sick , i see the physician regularly ) . for assessing the enabling factors a 10-item , three - choice option questions with 
somewhat answers were designed , related to economic , religious , and environmental factors , with a possible range of score from 0 to 20 ( example : do you think economic conditions are involved in predicting health behaviors , particularly in your mental health ? ) . for assessing the reinforcing factors
yes ,  no , and  somewhat as answers ( example : have you been encouraged by others such as family , teachers , classmates , friends , etc ? ) for determining the content validity of the tools , the questionnaires were given to seven faculty members in the related subjects . after the announcement of their viewpoints and after resolving the problems and reforming the faults , they were submitted to 50 medical students , for reviewing and verifying from the sentences , matching points of view , with implementation , purposes , and aims of the scale producer , and resolving any objection or challenge regarding the understanding of the same concept from each question , by the students . after reviewing and correction of the cases ,
the reliability of the questionnaire was estimated for 188 students , using the internal consistency and test  retest .
the cronbach 's alpha coefficients for internal consistency of the scales were 0.74 , 0.78 , and 0.78 , respectively , and after three weeks of test  retest , the reliability coefficients were 0.80 , 0.77 , and 0.77 , respectively . this known and standard tool , which was developed by rosenberg ( 1989 ) , includes 10 questions , and each question is scored based on a four - choice options scale , from 
quite agree to  disagree , with divers scoring for question numbers 9 , 6 , 5 , and 2 .
hemmati has reported a cronbach 's alpha coefficient of 0.78 for the farsi translation of this questionnaire .
the general health questionnaire-28 is the most recognized screening tool in psychiatry and mental health status , and has had dramatic effects on the development of researches .
the 28-item questionnaire was made in order to increase the variance rate , and was based on factor analysis , copied from the main form .
it has four scales , with seven questions in each scale , including physical symptoms , anxiety , depression , and disorder in social function .
the ghq 's non - traditional method of scoring is the same as the likert method in which scoring of each test is with four degrees ,  0 , 1 , 2 , and 3, and thus the total score of each individual varies from 0 to 84 . in this
study the cut off point was considered to be 22 for the student population and for both sexes , so , persons with scores less than 22 were considered to have optimal mental health .
several studies conducted on this questionnaire indicated and showed the high validity and reliability of the questionnaires . for conducting the educational - participatory program based on the precede model , focus group discussion ( fgd ) intervention
was designed and performed on 12-person subgroups during 12 thirty - to - forty minute sessions for each one , by using life skills training separately , such as , problem - solving , confidence , decision - making , and critical thinking , by one of the researchers .
after three months from the pre - test , the questionnaires were completed by the case and control groups .
the data were analyzed separately by the spss-11.5 software and anova , regression , pearson correlation coefficient , paired - t , and independent - t - test .
in order to prepare this section of instruments , after a literature review on information resources , a questionnaire was designed . for assessing the predisposing factors ,
the questions were designed in three parts : ( a ) demographic data ; ( b ) knowledge including a 10-item , three - choice option questions with 
yes ,  no , and  somewhat answers , with a possible range score from 0 to 20 ( example
: do you know the conflicts of the situations you encounter ? ) ; and ( c ) attitude including an 18-item scale ( six points that included ,  disagree a little ,  disagree , 
agree ,  completely agree ) with a possible range score of 6 to 36 .
( example : the best way to prevent getting sick , i see the physician regularly ) . for assessing the enabling factors a 10-item , three - choice option questions with 
somewhat answers were designed , related to economic , religious , and environmental factors , with a possible range of score from 0 to 20 ( example : do you think economic conditions are involved in predicting health behaviors , particularly in your mental health ? ) . for assessing the reinforcing factors
somewhat as answers ( example : have you been encouraged by others such as family , teachers , classmates , friends , etc ? ) for determining the content validity of the tools , the questionnaires were given to seven faculty members in the related subjects .
after the announcement of their viewpoints and after resolving the problems and reforming the faults , they were submitted to 50 medical students , for reviewing and verifying from the sentences , matching points of view , with implementation , purposes , and aims of the scale producer , and resolving any objection or challenge regarding the understanding of the same concept from each question , by the students . after reviewing and correction of the cases ,
the reliability of the questionnaire was estimated for 188 students , using the internal consistency and test  retest .
the cronbach 's alpha coefficients for internal consistency of the scales were 0.74 , 0.78 , and 0.78 , respectively , and after three weeks of test  retest , the reliability coefficients were 0.80 , 0.77 , and 0.77 , respectively .
this known and standard tool , which was developed by rosenberg ( 1989 ) , includes 10 questions , and each question is scored based on a four - choice options scale , from  quite agree to  disagree , with divers scoring for question numbers 9 , 6 , 5 , and 2 .
hemmati has reported a cronbach 's alpha coefficient of 0.78 for the farsi translation of this questionnaire .
the general health questionnaire-28 is the most recognized screening tool in psychiatry and mental health status , and has had dramatic effects on the development of researches .
the 28-item questionnaire was made in order to increase the variance rate , and was based on factor analysis , copied from the main form .
it has four scales , with seven questions in each scale , including physical symptoms , anxiety , depression , and disorder in social function .
the ghq 's non - traditional method of scoring is the same as the likert method in which scoring of each test is with four degrees ,  0 , 1 , 2 , and 3, and thus the total score of each individual varies from 0 to 84 . in this
study the cut off point was considered to be 22 for the student population and for both sexes , so , persons with scores less than 22 were considered to have optimal mental health .
several studies conducted on this questionnaire indicated and showed the high validity and reliability of the questionnaires . for conducting the educational - participatory program based on the precede model , focus group discussion ( fgd )
intervention was designed and performed on 12-person subgroups during 12 thirty - to - forty minute sessions for each one , by using life skills training separately , such as , problem - solving , confidence , decision - making , and critical thinking , by one of the researchers .
after three months from the pre - test , the questionnaires were completed by the case and control groups .
the data were analyzed separately by the spss-11.5 software and anova , regression , pearson correlation coefficient , paired - t , and independent - t - test .
in this study , in both groups , 69.8% were girls and 30.2% were boys , with a mean age of 20.6  1.95 years . before performing the program on the case group ,
the variables affecting the mental health of the students , including the predisposing , enabling , and reinforcing factors , and particularly self - esteem were analyzed by the linear regression test , with controlling of the confounding factors in which self - esteem , examination times , and knowledge and attitude of significant variables were introduced [ table 1 ] .
the statistical test showed predictors , or on the other hand , variables affecting the mental health of the students , to fully explain the process and for effective intervention in accordance with the educational - ecological models level , for the researchers .
multiple regression of self - esteem , knowledge , attitude , examination , and family on the mental health one - way anova analysis showed no significant relationship between the demographic characteristics , including marital or single status of the top students , or even sex with self - esteem and / or mental health , before their performances .
also , according to table 2 , a significant correlation was obtained based on the polychoric correlation coefficient before intervention in the experimental ( case ) group , between the predisposing and enabling factors and self - esteem and mental health , and it was significant even after intervention , so that the correlation between mental health and self - esteem ( p < 0.0001 ) , and mental health and knowledge ( p < 0.008 ) was at a significant level of 0.01 , and also between self - esteem and knowledge ( p < 0.02 ) , self - esteem and attitude ( p < 0.01 ) , and mental health and attitude ( p < 0.03 ) was obtained at a significant level of 0.05 , respectively , even when such a status was not observed in the samples of the control group .
matrix of polychoric correlation coefficient of variables in experimental group before intervention according to table 3 , an independent t - test showed that there were no significant differences between mental health , self - esteem , predisposing , enabling , or reinforcing factors in the case and control groups before the intervention ( participatory - educational program based on the precede model ) .
comparison of study variables based on independent t- test before intervention after intervention using an independent t - test , a significant difference had emerged between the mental health , self - esteem , predisposing , enabling , and reinforcing factors in the case and control groups [ table 4 ] . comparing tables 3 and 4 , the findings indicated the program efficacy on the students of the experimental group rather than the control group .
the aim of the research was to determine the effect of a participatory - educational program based on the precede model to promote the self - esteem and mental health of the students .
in short , the research findings introduced self - esteem , examination times , knowledge , and attitude as the significant and affecting variables on the mental health of students . there was also a significant difference between the predisposing , enabling , and reinforcing factors , self - esteem , and ultimately the students mental health , in the case group and the control group , after the intervention .
a significant correlation was observed between mental health and self - esteem , mental health and knowledge , self - esteem and knowledge , self - esteem and attitude , and mental health and attitude in the case group after intervention , while such a correlation was not seen in the control group . in the study ,
the mental health status showed no significant difference between single and married students , but in fakhraei 's study , the psychological disorder status was reported to be significant in single students .
fakhraei , ziaei and his colleagues , and faraji did not show any relationship between marital states and psychological disorders .
ildarabadi , et al . reported that the depression in married students was higher than in single students .
it is also important to note that the length of the education period in the university , especially in medical sciences , varies in different subjects and this can cause variations in the prevalence rate of mental disorders in the students of those fields .
the results before intervention indicated the influence and close relationship of knowledge , attitude , and self - esteem with mental health .
meanwhile , the regression analysis test introduced the self - esteem , knowledge , and attitude variables as significant variables affecting the students mental health .
the results were considered to be the base and foundation of the design and implementation of the intervention programs based on the model , hence , they were highlighted in the focus group discussions ( fgd ) among students , and its effectiveness was identified in the intervention program process after implementation on the case group , rather than on the control group .
it also showed significant differences in the correlation between self - esteem and mental health , correlation of mental health with knowledge and attitude , and correlation of self - esteem with knowledge and attitude ; so self - esteem and the mental health status of the samples were better with increase in knowledge and a positive attitude level .
the promotion of students mental health was observed as their self - esteem increased and that coordinated with the results of this research and many other texts , such as , those by mann and colleagues , mohair , and moshki et al .
particularly , the significance of these factors , after performing the program , indicated a confirmation of compliance with the study findings and reports of pope , botvin , and talebpour , et al .
the influence of knowledge and attitude status from the predisposing factors has been emphasized on mental health and self - esteem , and also a significant correlation between the variables of knowledge , attitude , economic , religious , and environmental factors has been confirmed in the related literature , with self - esteem and their mental health .
meanwhile , the role of self - esteem as a variable of an impressive predictor correlated with mental health has been explained in the studies of mann and his colleagues , quoted by tudor , furnham and cheng zimmermann .
even krueter and green have noted and expressed the influencing role of self - esteem based on the model and have mentioned it specifically and implicationally in the training - ecological stage of the model .
its efficacy can show the power of the model , which can facilitate the exact determining of the study aims , through community participation and empowerment .
it can not be achieved , except through the process of community assessment , using evidence based on community - based participatory approaches , capacity building , and correcting the contributing factors during a review , and regular and continuous evaluation in the form of this model .
it is possible that the significant increasing factor of self - esteem and especially mental health , is the use of the educational - participatory program based on the precede model in the case group rather than in the control group . using this model as a framework of an intervention , to reduce mental health problems ,
confirms the study findings in relation to the predisposing factors ( knowledge and attitudes ) , enabling factors ( educational resources and skills ) , and reinforcing factors ( social support ) , with the results of other related researches , including the use of the precede model in anxiety reduction of the tehran fire fighters , the impact of education on depression in bypass heart surgery patients , and in accordance with the precede model in isfahan , the development and evaluation of community mental health with public awareness based on the precede  proceed model in australia . phoenix and winnie utilized the predisposing , reinforcing , and enabling factors in the educational diagnosis of the precede model , to examine their effects on the mental well - being and quality of life among adults in hong kong .
structural equation modeling showed that the sense of coherence ( predisposing factor ) , social support ( reinforcing factor ) , and daily hassles ( enabling factor ) were significantly related to mental health promoting behaviors , which were associated with the mental well - being .
we also found a significant relationship between mental health and the mentioned factors of the precede model in this study .
wright and colleagues showed that mental health campaigns were differently higher in the target region .
it meant that the object of the enabling factor which was to make mental health information more available was accessed .
they also stated that suicide beliefs associated with depression and psychosis increased or stabilized in the target region , while it declined in the comparison region .
skarsater , et al . indicated that if mental health was well - designed as an intervention it could empower individuals to take responsibility for adopting mental health promoting behaviors .
they also recommended the precede model as a useful framework for understanding factors involved with mental health promoting behaviors , among a large number of their samples .
considering the effect of the predisposing , enabling , and reinforcing factors of the educational  ecological model on self - esteem and the students mental health at first glance , and as the ultimate goal , the cumulative effect of related variables with each of the factors , and during implementation of the educational - participatory programs is matched and has conformity with the precede model .
this model provides some steps for policy development , implementation , and evaluation of an educational program process , because a health education program is a process that is presented in regular consecutive stages .
it is clear that the samples of this study can not be a representative of the country 's student population because of the wide extent and the different distribution of cultural , social , and ethnic characteristics . on the other hand the study samples
are limited to the study subjects in two universities of medical sciences , and certainly more studies are needed among students in other subjects across the country , iran , as also in the state universities , non - profit , and even non - governmental universities
. however , may different factors such as individual ethnicity , customs and habits of the students that are effective on students self - esteem and their mental health and similar researches should be conducted and expanded in different parts of the country to observe how they work and impact .
this study is a part of an extensive and innovative project , using internationally recognized standards of a health promotion program model to promote self - esteem and mental health in the iran students community .
the study also offers confidence to researchers in this manner to use approved skills and training methods with student empowerment and participation based on the precede model , which finally leads to health promotion in a part of the community .
in fact , this pattern can provide a clear concept of designing an effective program through community awareness about mental health , so that it can have the ability to comply with all areas , problems , and mental disorders . in the same manner , and with the help of health education ,
we should step on the path to promote personal and social confidence and empower people to participate in health promotion . to promote mental health
in fact , this strategy shows that even educated people of the society should strive to rely on their own resources . to achieve such self - confidence ,
people should be informed adequately about having the accurate attitude and sufficient skill to participate in the planning , implementation , and evaluation of health interventions .
the goal will be effectively achieved only through appropriate educational activities intending to empower people to protect their health , family , and community in which they live .
 background : the students vulnerability to different problems can have an impact on their mental health . regarding the lack of evidence on the effectiveness of interventional programs based on health education planning models in this area in developing countries , an educational - participatory program based on the precede model was used , to promote the medical science students self - esteem and mental health status , in iran.methods:in this experimental study , 154 students from the universities of medical sciences in the north east of iran were selected by stratified random sampling method . 
 then , they were randomly assigned to two groups of case and control . 
 the questionnaires , including the enabling , reinforcing , and predisposing factors , the rosenberg self - esteem scale , and the ghq-28 were used for data collection . 
 then , an intervention plan , including focus group discussions and training of selected life skills , based on the precede model , was conducted for the case group.results:the predisposing , reinforcing , and enabling factors , and the self - esteem and mental health of the students showed a significant difference between the case and control groups . 
 the pearson correlation coefficient showed that there was a correlation between mental health and knowledge ( p = 0.008 ) , between self - esteem and knowledge ( p = 0.02 ) , self - esteem and attitude ( p = 0.01 ) , and mental health and attitude ( p = 0.03).conclusion : health promotion planning by using life skills training based on the precede model can result in participation and empowerment , in order to promote the self - esteem and mental health of the students . 
INTRODUCTION
METHODS
Predisposing, enabling, and reinforcing factors questionnaire (PRECEDE model constructs)
Rosenberg self-esteem scale
General Health Questionnaire (GHQ-28)
RESULTS
DISCUSSION
CONCLUSION