Journal of health research in community

Introduction
Nutrition in childhood and adolescence is essential for physical and mental health, growth, and optimal development [1]. Breakfast, as a key daily meal, supplies energy, improves cognitive function and academic performance, reduces risky behaviors, and supports mental health [2, 3]. Despite its importance, skipping breakfast is common worldwide (10–30% in various studies) [4–6] and in Iran (e.g., 2.4% of students reported no breakfast in the past month) [7]. Contributing factors include busy family lifestyles, nutritional misconceptions, low parental awareness, socioeconomic status, maternal employment, and negative attitudes [8, 9]. 
The Theory of Planned Behavior (TPB) explains behavior through attitude (evaluation of outcomes), subjective norms (social pressure from important others), and perceived behavioral control (ease/difficulty based on resources/barriers) [12]. These form intention, the strongest predictor of behavior, with control also directly affecting it. TPB has proven effective in nutrition, physical activity, and other health behaviors [13–16]. Individual studies conducted in Iran and other parts of the word have shown that TPB-based interventions improve breakfast consumption [17–21, 24, 27–31]. However, no systematic review has specifically assessed TPB-based educational interventions for breakfast in children/adolescents. This review addressed this gap to guide school-based programs.

Methods
This systematic review was conducted according to the PRISMA guidelines. A structured search was performed in PubMed, Scopus, Web of Science, Google Scholar, Scientific Information Database (SID), and Magiran databases for English and Persian articles published between 2000 and 2025. Main keywords included “Theory of Planned Behavior,” “Educational Interventions,” “Breakfast Consumption,” “Children,” and “Adolescents,” combined using AND/OR operators. Inclusion criteria comprised interventional educational studies based on TPB aimed at improving breakfast consumption in children and adolescents with full-text access. Exclusion criteria included a focus on other meals, the use of non-TPB theories, or a lack of educational intervention. After removing duplicates, title/abstract screening and full-text review were conducted independently by two researchers. Study quality was assessed using the JBI checklist for randomized controlled trials (score ≥7 out of 13). Extracted data included study characteristics, interventions, TPB constructs, and outcomes.

Results
Of the initial 532 articles, 12 interventional studies (9 from Iran [13-23], 1 from the USA [27], 1 from Australia [24], and 1 from Nepal [28]) were included in the analysis. Publication years ranged from 2010 to 2025, with the highest concentration occurring between 2013 and 2015 (Table 1).


All studies utilized interventional designs with control groups (quasi-experimental or randomized controlled trials), and sample sizes ranged from 88 to 378 (mean ≈200). The target population primarily consisted of elementary and middle/high school students aged 10–16 years, with most falling within the 12–14 years range.  
Interventions were multifaceted, including lectures, discussions, videos, booklets, PowerPoint presentations, and role-playing, along with implementation intentions. Five studies incorporated parent/teacher sessions [17, 18, 22, 29, 30]. Assessments were conducted using validated self-report TPB questionnaires, administered both before and 1–4 months after the intervention.  
Based on the results, attitudes increased significantly in 10 studies [17–20, 22, 29–31] , Perceived behavioral control improved in 10 studies [17–20, 22, 29–31], and subjective norms increased in 7 studies [17, 19, 20, 22, 30, 31], with no significant change observed in 4 studies [18, 27, 29]. A significant relationship for intention was found in 11 studies [17–20, 22, 27, 29–31]. Breakfast consumption behavior improved in 10 studies [17–20, 22, 27, 29–31], while the consumption of unhealthy snacks/beverages decreased in 2 studies [17, 18]. One study showed that TPB constructs explained 39.3% of the variance in intention [24].

Conclusion
This systematic review demonstrates the substantial effectiveness of TPB-based educational interventions in improving breakfast consumption and related dietary habits among children and adolescents. Consistent with TPB, attitude and perceived behavioral control showed significant improvements in 10 out of 12 studies, emerging as key drivers of behavioral intention and actual breakfast-eating behavior [12, 17–20, 22, 29–31]. 
Subjective norm effects were inconsistent, being significant in only 7 studies [17, 19, 20, 22, 30, 31]. This inconsistency might be due to cultural or family differences, or limited family involvement [45]. Interventions that included parent/teacher sessions reinforced norms and sustainability [39, 40]. Strengths of the reviewed studies include multifaceted designs and family-centered elements [41–44]. 
Despite the geographic concentration on Iran (75%) and limitations such as short-term follow-up, the use of self-reported tools, and limited sample sizes in some studies, the results align with the TPB framework and confirm the theory’s utility in designing dietary behavior change programs.
It is recommended that future programs be designed as multilevel interventions (individual, family, and school) incorporating multiple sessions, the integration of modern technologies, and long-term follow-up. Future studies should examine moderating factors (age, gender, and socioeconomic status), and include comparisons with complementary theories to enhance intervention effectiveness and generalizability. 

Ethical Considerations
Compliance with ethical guidelines
This study has been approved by Mazandaran University of Medical Sciences (Code: IR.MAZUMS.REC.1404.391).

Funding
This study was extracted from a Master’s thesis and supported by the Vice-Chancellor for Research and Technology, Mazandaran University of Medical Sciences (Grand No.: 22895).

Authors contributions
All authors contributed equally to this work.

Conflicts of interest
The authors declared no conflicts of interest.


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