Dietary habits and effect of two different educational tools on nutrition knowledge of school going adolescent girls in Hyderabad, India

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1 (2007) 61, & 2007 Nature Publishing Group All rights reserved /07 $ ORIGINAL ARTICLE Dietary habits and effect of two different educational tools on nutrition knowledge of school going adolescent girls in Hyderabad, India D Raghunatha Rao 1, T Vijayapushpam 1, GM Subba Rao 1, GM Antony 2 and KVR Sarma 1 1 Extension & Training Division, National Institute of Nutrition (ICMR), Jamai-Osmania, Hyderabad, Andhra Pradesh, India and 2 Division of Field Studies, National Institute of Nutrition (ICMR), Jamai-Osmania, Hyderabad, Andhra Pradesh, India Objectives: To assess dietary habits and nutrition knowledge levels of the adolescent girls from different schools and to study the efficacy of two different nutrition education tools in improving their nutrition knowledge in the classroom setting. Design: Purposive sampling technique was adapted for selecting the subjects in the study. Setting: Four secondary schools in Hyderabad, India. Subjects: In total, 164 adolescent girls belonging to eighth grade. Interventions: Two interventions (Intervention-1. Traditional method using print media such as folders leaflets and charts; Intervetion-2. Audio-visual CD) were carried out in a classroom setting for the experimental group. Results: FFQ data on dietary consumption of adolescent girls revealed more consumption of aerated drinks, bakery items, fast foods and less consumption of millets irrespective of their socio-economic conditions. However, consumption of vegetables, green leafy vegetables and fruits was moderate. A significant improvement in the nutrition related knowledge was observed among the experimental group after interventions-1 and -2 as compared to the baseline data. However, no significant difference in the improvement of nutrition knowledge levels was observed with the second intervention over the first intervention as already the children in the experimental group gained knowledge through print media. Conclusions: Education on ill effects of aerated drinks, fast foods and the importance of nutrition during the adolescent phase should be emphasized in future programmes. Sponsorship: The study was supported by the National Institute of Nutrition (Indian Council of Medical Research), Hyderabad from the intramural funds. (2007) 61, ; doi: /sj.ejcn ; published online 7 February 2007 Keywords: adolescent girls; food frequency questionnaire (FFQ); nutrition education; classroom-based education Introduction Correspondence: Dr D Raghunatha Rao, Extension & Training Division, National Institute of Nutrition (ICMR), Jamai-Osmania PO, Hyderabad , Andhra Pradesh, India. drr_rao@yahoo.com Guarantors: GM Antony, GMS Rao and KVR Sarma. Contributors: DRR and TV were the principal investigators; they devised the study protocol, secured funding and directed the over all programme. They also contributed in data collection, analyses and interpretation. DRR was responsible for the preparation of manuscript. GMSR assisted the principal investigators in preparation of the CD Rom intervention tool and the manuscript. GMA was responsible for data processing, statistical design and analyses. KVRS supervised the study. Received 31 May 2006; revised 20 November 2006; accepted 20 November 2006; published online 7 February 2007 Adolescents constitute one-fifth of the total population and about 84% of this population lives in developing countries. According to WHO, children in the age group of years are referred to as adolescents. Adolescence is the transitional phase of life from childhood to adulthood, during which period, growth spurt with rapid increase in height and weight, psychological and sexual maturity with cognitive development are observed among adolescents (NIN, 1998). Adolescence is a particularly unique period in life because it is a time of intense physical, psychosocial and cognitive development and therefore the caloric and protein requirements increase. The nutritional requirements such as

2 1082 macronutrients like proteins and micronutrients including vitamins and minerals are high during the puberty of adolescents to meet the demand of increased nutritional needs as the adolescents gain up to 50% of their adult weight and skeletal mass, more than 20% of their adult height during this period (Spear, 2002). In India, the nutritional needs of adolescent girls, in particular, are often neglected (Basu et al., 1986). Increased physical activity combined with poor eating habits, menstruation and adolescent pregnancy contribute to poor nutritional status of the population. According to the National Nutrition Monitoring Bureau (NNMB) Report (2003), the prevalence of anaemia is 69% among adolescent girls. Micronutrient deficiency disorders in the adolescent phase result in growth retardation, low immunity to disease and impaired reproductive functions that contribute to some pregnancy-related deaths or result in delivering low birth weight (LBW) babies, thus perpetuating the transgenerational cycle of malnutrition (Bhaskaram, 2001). Peer pressure, parents dietary habits and media exposure influence the dietary intake of this age group. Despite implementation of various National Nutrition Programmes at the community level for quite a long time, impact evaluations showed poor coverage, because of low-awareness among beneficiaries due to weak implementation of IEC (Information, Education and Communication) components in the programmes (Vijayaraghavan and Rao, 1982). According to NNMB Report, only 14% of adolescent population was exposed to nutrition education. Therefore, a study was carried out to assess the dietary habits and the nutrition knowledge levels of the adolescent girls from different schools of Hyderabad and also to study the efficacy of two different nutrition education tools (traditional and CD Rom-based) in improving the nutrition knowledge levels among the adolescent girls in the classroom setting. Materials and methods Selection of schools The study protocol and design were reviewed and approved by the institutional scientific advisory committee (SAC), which is the Institutional Review Board. The list of schools was obtained from the District Educational Officer, Hyderabad. There were 48 Government-aided Higher Secondary Schools in the new city of Hyderabad. Among these schools, 20 schools were contacted at random and the principals of these schools were explained about the objectives of the study. Out of these schools, the principals of four schools agreed to participate in the study. Informed consent was obtained from both principals and students of the participating schools. Study design and subjects Purposive sampling method was adopted to select adolescent girls studying eighth grade as study subjects as the content analysis of the eighth grade science curriculum revealed the lack of adequate lessons on nutrition in the science textbooks. A total number of 164 adolescent girls were recruited for the study. Baseline data A structured interview schedule was administered to find out the socio-demographic details of the study subjects. A pretested knowledge assessment questionnaire (KAQ) consisting of multiple-choice questions on various aspects of health and nutrition was administered to children. Similarly, data on food consumption were obtained from these children by administering a validated Food Frequency Questionnaire (FFQ) (Vijayapushpam et al., 2003). An Interview schedule was also administered to find out their food preferences. All answers were coded for data analysis. For the study, the baseline data were obtained from the participating schools to find out the homogeneity of the study subjects. Interventions After obtaining the baseline data, two schools were considered as control group while the other two were experimental group. The experimental group was given two nutrition education interventions while no intervention was given to the control group. In intervention-1, the experimental group was given nutrition education by the science teachers in the classroom setting in the traditional method using slides, charts and folders, which were developed based on the knowledge levels at baseline and also science curriculum up to eighth grade. The post-intervention data were obtained at two different points of time one immediately after the intervention and the second with a gap of 3 months from the experimental group to assess the knowledge improvement and retention after classroom intervention. For intervention-2, a Compact Disc (CD) with animated messages on Nutrition and Health was developed and pre-tested by the investigators. The impact of this new technology tool in improving knowledge over and above the first intervention was assessed separately by re-administering the same questionnaire. Data analysis Data collected from KAQ and FFQ of these girls (n ¼ 164) were analysed separately using SPSS Package (version 11.5). ANOVA test was performed (at 5% significance level) to determine differences in the nutrition knowledge levels between the control and experimental groups at baseline as well as after intervetion-1 and intervention-2. In order to determine the significance of difference in the increments of

3 knowledge between the interventions, paired t-test was performed. 80 INSTANT FOOD AERATED DRINKS BAKERY ITEMS Results 60 Socio-demographic characteristics The average monthly family income of 50% of the subjects was less than Rs. 6000, while it ranged from Rs to (1 Euro ¼ 58 Rupees approximately) for the rest. The education of fathers of 59% of the subjects was below 10th grade. However, about three-fourth of the mothers had education up to 10th grade Dietary habits Data analysis of FFQ revealed that 68% of the girls reported daily intake of breakfast, 24% had one or two times a week while the rest 8% never had breakfast. With regard to the consumption of energy foods such as cereals and millets, the consumption of rice was 100% while 52% of them included wheat also in their daily diet. As regards the consumption of millets, Jowar (Sorghum) was consumed daily by 7% of the girls while 15% of them consumed one/two times or four times a week. The rest 67% never consumed Jowar (Sorghum). Over 90% of the girls reported to consume roots and tubers daily. The daily consumption of proteins in the form of pulses was observed in 39% of the girls followed by three or four times a week by 20% of the girls. About 41% of the girls consumed either once or twice a week. Consumption of flesh foods including poultry eggs daily was repeated by 12% of the girls followed by three or four times a week by 6% of the girls. As regards the consumption of green leafy vegetables 36% of the girls indicated daily intake of green leafy vegetables while, 62% reported consumption either once or twice a week. Consumption of other vegetables was reported by 92% of the girls. However, daily fruit consumption was observed in 59% of the girls, while 35% reported consumption once or twice a week. Most of them consumed guava and banana as these fruits are available in plenty throughout the year at an inexpensive cost. Among these girls, 82% reported intake of milk everyday while, 8% of the rest reported consumption either once or twice a week or nil. With regard to the intake of instant foods, about 51% of the adolescent girls reported consumption three to four times a week, nearly 68% reported daily consumption of bakery items and 48% of the girls consumed aerated drinks one to two times a week (Figure 1) DAILY/4 TIMES/WEEK ONE OR TWO TIME/WEEK indicated that there was a significant improvement (Po0.001) in the knowledge levels of the experimental group after intervention-1 using folders, charts and slide show. An improvement in the mean scores from 46.7 to 58.8% in KAQ test was observed in the experimental group with an increment of 12.27% as against the increase from 46.8 to 49.7% in control group with an increment of 2.9%, which was not significant (P40.05). After a gap of 3 months, the same KAQ was re-administered to the experimental group and no significant (P40.05) difference was observed in the mean scores showing that there was retention of the knowledge gained through intervention-1. Then, intervention-2 was given with CD-Rom. After the intervention-2, the increase in the nutrition knowledge was observed from 46.7 to 56.9% in the experimental schools with an increment of 10.5%. Similar increase in the nutrition knowledge from 46.6 to 53.1% in the control schools with an increment of 6.4% was observed. However, the intervention-2 (using CD Rom) did not show any significant improvement in the nutrition knowledge in the experimental group over and above the knowledge gained and retained after intervention-1 (Table 1). 2.4 OCASSIONALLY/ SEASONALLY Figure 1 Frequency of intake of instant foods, aerated drinks and bakery items among adolescent girls of Hyderabad. Impact of nutrition education At the baseline, the average nutritional knowledge levels were not significantly different between the control and experimental groups (P40.05) indicating the homogeneity of the groups with regard to the awareness on nutrition and health. Post-intervention data analysis by ANOVA test Discussion Administration of FFQ offer the advantages of assessing the food habits of the community (Anderson et al., 1995). In the present investigation, data from FFQs indicated less consumption of millets like Jowar (Sorghum) and more

4 1084 Table 1 Impact of nutrition education on adolescent girls in Hyderabad Group No. of adolescent girls Mean7s.d. Before (baseline) Intervention-1 Intervention-2 % of marks Increment-1 % of marks Increment-2 Experimental NS Control F-value 13.88* 25.58** 2.26 NS 4.14* Abbreviations: NS, not significant; s.d., standard deviation. **Po0.001; *Po0.05. Note: Paired t-test indicated that no significant (P40.05) difference was observed in the knowledge increments between intervention-1 and intervention-2 improvement of knowledge levels. consumption of carbonated drinks, instant foods and bakery items among the adolescent girls. Similar findings with regard to consumption of carbonated drinks and instant foods among urban adolescents in Delhi were reported by Shaw et al. (1993). Bakery items are reported to have transfatty acids hence intake of bakery items should be discouraged by this group. Green leafy vegetables are good source iron and vitamin A and available throughout the year at an inexpensive cost as compared animal sources (NIN, 1998). In the present study, it was observed that most of the adolescent girls (62%) consumed green leafy vegetables at least once or twice a week, while one-third of the girls reported to consume daily. According to Ahmed et al. (1997), consumption of dark green leafy vegetables at least four times per week showed significantly higher serum vitamin A levels in the adolescent girls than the girls who consumed less. Nutrition education on the beneficial effects of greens and citrus fruits such as lemon and oranges that are rich in Vitamin C would help the children understand the importance of vitamin C for better absorption of dietary iron from green leafy vegetables. Nutrition education is an effective tool in promoting healthy eating habits among the adolescents (Leupker et al., 1996). School settings provide the most effective platform for nutrition education as the school children serve as change agents by spreading the messages to a large segment of population (Green and Iverson, 1982; Lionis et al., 1991). Creating awareness and empowering adolescent girls with the information on nutrition and health not only provides an opportunity to understand the importance of nutrition during this period but also help them to share their knowledge gained during the programme with their parents and peers. The study indicated a significant improvement in the nutrition knowledge levels of the adolescent girls after the first intervention, which was carried out using traditional media in the classroom setting through teachers. This observation was in conformity with similar studies carried elsewhere in the world (Rodrigo and Javier, 2001). Even though the benefits of using computer-based nutrition education tools in schools is widely documented, only a few studies have compared the efficacy of teaching tools in experimental designs. A study carried out by Turnin et al. (2001) concluded that using computer-based nutritional teaching method at school provides an additional and modern support to conventional teaching. Contrary to this observation, the present study proved that the CD-Rom intervention did not result in any further improvement in nutrition knowledge over the intervention-1. It has also been observed that during intervention-1, a majority of the adolescent girls paid attention to the classroom lecture given by the science teacher using folders, slides and charts and they interacted more with the teacher whereas, in intervention-2 with Audio-visual CD, the attention of the adolescent girls was very low indicating the effectiveness of traditional method that is, intervention through class teacher by using print media over the other method. This could be due to the reason that most of the girls viewed computers as entertainment devices than educational devices. However, improvement in the knowledge levels of the adolescent girls in the control group could be attributed to their exposure to media such as print, television and others (Katherine Clancy- Hepburn et al., 1974). Similar results in the improvement of nutrition knowledge of the schoolchildren through classroom-based education was reported by Vijayapushpam et al. (2003) and Subba Rao et al. (2006). However, understanding the perceived needs and barriers to healthy dietary behaviour contribute to develop appropriate educational programmes for the community (Nicklas et al., 1997). Hence studies like this can be taken up on a larger scale to develop and popularize effective nutrition education tools. Acknowledgements We thank all the principals and students of participating schools for their cooperation. We gratefully acknowledge with thanks the continuous encouragement given by Dr B Sivakumar, former Director, NIN/FDTRC/NNMB during this study. Thanks are also due to all the staff of Extension & Training Division of NIN for their support during the study.

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