A participatory framework for identifying and ranking multidimensional solutions to nutritional behavior issues in female school students: a stakeholder-based mixed-methods study.

BACKGROUND

Broad multisectoral collaboration among families, communities, schools, health services, and policymakers is essential for improving nutritional behaviors. Despite the increasing prevalence of poor dietary habits among adolescent girls, existing interventions often fail to address the complex social, cultural, and environmental determinants of nutritional behavior. This study aimed to develop a proposed solution to improve the nutritional behaviors of female school students aged 13-17 years in Khuzestan, Iran.

METHODS

This study employed a mixed-methodology approach, integrating qualitative exploration and stakeholder-driven prioritization. Phase 1 utilized directed qualitative inquiry with 17 school students to identify adolescent dietary challenges, while Phase 2 applied the Nominal Group Technique (NGT) and Analytic Hierarchy Process (AHP) to prioritize solutions through expert consensus and multicriteria evaluation. The AHP framework, which is supported by Expert Choice software, ensures rigorous weight assignment (CR < 0.1) as validated by independent expert review.

RESULTS

In Phase 1, directed content analysis of 17 student interviews yielded six overarching themes (e.g., "Self-Monitoring and Goal Setting," "Social Environmental Influences") and 15 subthemes, from which 121 candidate solutions were generated. During Phase 2, nine panelists (five nutrition experts and four stakeholders) applied the NGT: 74.4% (90/121) of the solutions met the ≥ 4.0 mean ranking threshold (on a 5-point scale), while 25.6% (31/121) were eliminated. The 90 retained solutions were then scored via the AHP across five criteria-effectiveness, feasibility, cost efficiency, sustainability, and cultural acceptability. Cultural acceptability received the highest weight (35.7%), followed by sustainability (18.1%), cost efficiency (20.2%), effectiveness (16.8%), and feasibility (12.1%). The consistency was excellent (CR = 0.003), and sensitivity analyses confirmed the stability of the rank order under ± 15% weight variation.

CONCLUSION

This stakeholder-driven framework highlighted balanced diet education during puberty, parental education sessions, and school nutrition campaigns as top-priority interventions, demonstrating excellent consistency (CR = 0.003). Future studies should pilot and rigorously evaluate these interventions in real-world school settings, assess their long-term impacts on dietary behaviors and health outcomes, analyze cost-effectiveness, and explore digital delivery platforms to increase adolescent engagement.