Results
The exploratory factor analysis indicated that 64% of the variance in the DOHaD awareness scale was explained by two factors. Table 1 shows EFA factor loadings and 20 Likert-type items. The KMO value with a lower limit of 0.50 was found to be 0.890, and the Bartlett’s test of sphericity was found to be P < 0.05. It was determined that the scale is suitable for factor analysis. In the factor analysis conducted, it was determined that 64% of the scale could be explained under two factors. In the scale modeled as two factors, items numbered 1, 2, 3, 4, 5, 6, 7, 9, 10, 18 measure the importance of health and wellness components and 8, 11, 12, 13, 14, 15, 16, 17, 19, 20 numbered items measure the effect of nutrition on fetal programming. The Cronbach’s alpha of the scale was found to be 0.953, indicating a classification of ‘very reliable’. The scale appears suitable for assessing DOHaD-related awareness in the target population, though additional testing across diverse groups is warranted. Table 2 shows Cronbach’s alpha coefficient and ICC of the DOHaD awareness scale and item-total statistics, respectively.

Note:

Questions 1, 2, 3, 4, 5, 6, 7, 9, 10 and 18 placed in factor “health” and questions 8, 11, 12, 13, 14, 15, 16, 17, 19 and 20 placed in factor “nutrition”.

As shown in Table 3 , the majority of the anthropometric measurements changed after the intervention period. The values of body weight, BMI, waist circumference, hip circumference, mid upper arm circumference, waist/height ratio, body fat mass and total body water measured 6 months after the intervention were significantly lower than the pre-intervention values ( P < 0.001). These anthropometric parameters did not indicate a significant difference when the values of 6 weeks after intervention compared to the pre-intervention values ( P > 0.05). According to the partial eta squared values, the findings of the study demonstrate significant changes over time in measurements such as body weight and BMI, with substantial effects attributed to the independent variable (0.367 for body weight and 0.366 for BMI). Other measurements also exhibited similar effectiveness, with the effects of changes in waist circumference and body fat identified as 0.291 and 0.272, respectively. The interventions were associated with notable changes in participants’ anthropometric values, although further studies are needed to confirm these effects.

Notes:

Repeated measures ANOVA (*) and Friedman test (#) indicated significantly different scores of DOHaD Awareness Scale at pre-intervention, 6 weeks after intervention and 6 months after intervention.

The partial eta squared values represent the effect size of the differences observed, indicating the proportion of variance in the dependent variable that can be attributed to the independent variable.

Figure 1 shows the comparison of component scores of HEI-2015 recorded during the pre-intervention, 6 weeks after intervention and 6 months after intervention. Accordingly, participants consumed significantly more total fruit ( P < 0.001) and whole fruit ( P < 0.001) after the intervention period. Although scores were higher at 6 months after intervention, the difference between the scores of 6 weeks and 6 months after intervention did not reach to a statistically significant difference. Similarly, scores of total vegetables significantly increased both in 6 weeks ( P < 0.001) and 6 months ( P < 0.001) after intervention period. The consumption of greens & beans only increased during the period of 6 weeks after intervention significantly ( P < 0.05) and then decreased at the end of the 6 months after intervention phase. The strongest impact of the intervention was observed on the scores of whole grains and dairy since the consumption of these groups continued to increase significantly both in 6 weeks and 6 months after intervention phase. Total protein foods consumed more only during the 6 months after intervention period ( P < 0.001). Despite these significant alterations in the component scores of HEI-2015, the intervention did not influence the scores of seafood & plant proteins, fatty acids and saturated fats ( P > 0.05). Refined grains were the only increased component of HEI-2015 at both phases in the current study. Although the scores of sodium and added sugars seemed to be reduced during the 6 weeks after intervention, they significantly increased at the end of the study period ( P < 0.001).

Figure 2 demonstrates the average physical activity duration (min/day) of the participants. In addition, moderate exercise duration significantly increased both at 6 weeks ( P < 0.05) and 6 months ( P < 0.05) after intervention. On the other hand, duration of vigorous exercise did not exhibit a significant change in all phases of the study ( P > 0.05).

The effect of the educational intervention on the participants’ DoHaD awareness scale scores has been investigated, and the results are presented in Table 4 . The scores of the questions that are related to the concepts of DOHaD mostly (Q5. “How much does your current exercise level affect your future health?”; Q6. “How important is nutrition during pregnancy?”; Q8. “How much does being breastfed affect your future health?”; Q9. “How much does a woman’s general health and pre-pregnancy well-being affect the fetus during pregnancy?”; Q10. “How much does a man’s general health and general condition before pregnancy affect the fetus during his partner’s pregnancy?”; Q11. “How much does a pregnant woman’s nutrition during pregnancy affect the health of the fetus?”; Q12. “How much does a pregnant woman’s nutrition during pregnancy affect the health of the fetus in childhood?”; Q13. “How much does a pregnant woman’s nutrition during pregnancy affect the health of the fetus in adulthood?”; Q14. “How much does a pregnant woman’s nutrition during pregnancy affect the health of the fetus in elderly?”; Q15. “How much does a child’s nutrition up to the age of two affect the child’s health later in life?”; Q16. “How much does a child’s nutrition up to the age of two affect the child’s health in adulthood?”; Q17. “How much does a person’s diet affect the risk of developing non-communicable diseases such as cancer, heart diseases, type 2 diabetes etc .?”; Q18. “How important are the first 1,000 days of life in the programming of health and disease?”; Q19. “To what extent does inadequate and unbalanced nutrition of a pregnant woman cause permanent changes in the metabolism of the fetus?”; Q20. “How much can a pregnant woman’s nutritional status during pregnancy affect the health of the next generations by changing gene functioning?”) significantly increased at 6 weeks ( P < 0.001) and 6 months ( P < 0.001) after the intervention. The scores obtained at 6 weeks and 6 months after the intervention did not differ significantly.

Notes:

Friedman test indicated significantly different scores of DOHaD Awareness Scale at pre-intervention, 6 weeks after intervention and 6 months after intervention.

The results obtained from the GEE analysis indicated that the DoHaD awareness scale and HEI-2015 scores, along with their interaction, were significant predictors for all dependent variables ( P < 0.001), and the AR(1) correlation structure exhibited the best model fit for most variables, as evidenced by the lowest QIC values. However, since the findings were evaluated without a control group, it is not possible to determine the effect of the educational module on the results independently of other external factors. The results of the GEE analysis are presented in Table 5 . The multivariate regression analysis presented in Table 6 indicates that the waist-to-height ratio is a significant variable influencing DOHaD awareness ( F = 3.718, P = 0.038), while no other anthropometric variables or HEI scores were significantly associated with DOHaD awareness. Additionally, the time variable did not exhibit a statistically significant effect ( F = 0.438, P = 0.594), indicating that time does not have a notable impact on DOHaD awareness.