EXPLORING THE REASONS WHY SCHOOL STUDENTS EAT OR SKIP BREAKFAST

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1 Art & science The research acute synthesis care of art and science is lived by the nurse in the nursing act JOSEPHINE G PATERSON EXPLORING THE REASONS WHY SCHOOL STUDENTS EAT OR SKIP BREAKFAST Mohammed ALBashtawy describes a study to determine whether sociodemographic factors affect the likelihood that children will consume or miss breakfast, and to examine how the chosen habitual behaviour correlates with nutritional status Correspondence mohammadbash@aabu.edu.jo Mohammed ALBashtawy is associate professor, vice-dean of faculty of nursing, Al-Mafraq, Jordan Date of submission February Date of acceptance May Peer review This article has been subject to open peer review and checked using antiplagiarism software Author guidelines journals.rcni.com/r/ ncyp-author-guidelines Abstract Background Breakfast is considered to be the most important meal of the day. It provides the essential nutrients needed for the day s activities. Aims To determine the prevalence of breakfast consumption and to assess the nutritional status of students aged years. Methods A school-based study carried out between September and October 2014 involved 1,303 school students from grades 7 to 12, aged 12 to 18 years, who completed a questionnaire on breakfast consumption. The chi-square test was used. An odds ratio and 95% confidence interval determined the predictive factors for skipping breakfast. Results The prevalence of breakfast consumption was 52.3%, statistically decreasing with age. Adjusted logistic regression analysis reflected a statistically high consumption among year olds, those with highly educated mothers and those with low family income. Conclusion For the target groups at risk, a community and school-based health education programme, conducted by school nurses and other healthcare providers, would be beneficial. Keywords Breakfast, child health, growth and development, nutritional intake, school health services, school nursing, students BREAKFAST IS considered the most important meal of the day, providing the essential nutrients for the day s activities for children, adolescents and adults (Nicklas et al 1993, Kleinman et al 2002, Kawafha 2013, Kawafheh et al 2014). Literature review Skipping breakfast is a worldwide phenomenon among school students, with many studies highlighting the issue and raising concerns. It is associated with many health problems and changes in various aspects of children s and adolescents lives, including psychosocial functions, cognitive functions, academic achievement and school attendance (Rampersaud et al 2005, Hoyland et al 2009, Smith et al 2010, Kawafheh et al 2014). A regular pattern of having breakfast on most days of the week has been associated with improving and enhancing general nutritional health and is linked to long-term health status. This may include: lower plasma cholesterol level; reduced risk of cardiovascular disease; improved absorption of vitamins, minerals and fibre; and a decreased likelihood of obesity and gastrointestinal disturbance (Nicklas et al 1993, Lien et al 2002, Timlin and Pereira 2007, Isaksson et al 2011, Zeng et al 2011). 16

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3 Art & science acute research care 18 Adolescence is a time of transition and fast growth. Moreover, during this period an individual s food habits are strongly influenced by their families and peer groups as they seek independence (Gikas et al 2003, ALBashtawy et al 2015). The adoption of bad food habits at this time, therefore, will have major long-term consequences, because this is likely to affect lifestyle and eating habits in adult life. Sociodemographic and economic transitions affecting many developing countries, including Jordan, are producing crucial changes in meals and nutritional habits that will have a serious effect on the general health of adolescents in the immediate future (Haddad et al 2009). In Jordan, nearly 40% of the population are below the age of 18 years (Department of Statistics and ICF Macro 2010), increasing pressure on health providers to develop suitable interventions for this age group. Several studies have shown a prevalence of breakfast skipping among adolescents of 20-55% (Haddad et al 2009, Kawafha 2013, El-Qudah 2014, Kawafheh et al 2014). Further investigation into this unhealthy habit among elementary (grade 7-10) and secondary (grade 11-12) students is needed. A comprehensive assessment will provide basic information for health providers in the Ministry of Health and the Ministry of Education to tackle this problem. Aims The aim of the research was to determine the prevalence of breakfast consumption and to assess the nutritional status of students aged years. Methods A cross-sectional school-based study was undertaken between September and October It was conducted in the north of Jordan in Mafraq Governorate. At the end of 2014, Mafraq had a population of nearly 128,000, and the number of students attending elementary and secondary school from grade 7 to 12 was nearly 23,500. Research questions The study aimed to explore the following issues: What is the prevalence rate of breakfast skipping among school students in relation to their general health, appetite, learning achievement and school attendance? What are the predictive factors for breakfast consumption among school students? What are the sources of information on breakfast habits among school students? Sampling A multistage random sample was used to select 18 public schools (nine boys and nine girls schools) to represent elementary and secondary school students, from a total of 48 schools in Mafraq. A minimum sample size was determined using the formula n=z21-α/2p (1-P)/ d2, where n is minimum sample size, Z21-α is the confidence level at 95%, P is the expected prevalence of breakfast consumption among students aged (0.5%) and d2 is the margin of error at 5% (Aday and Corvelius 2006). According to the equation, the sample size required for the study was 385 participants. All students in grades 7-12 were invited to take part and the minimum sample size of 385 was achieved. There was allowance for the withdrawal of students who did not get permission from their families or who refused to participate. Procedure The entire cohort of 1,540 students in grades 7 to 12 in the 18 selected schools was invited to participate. Each was given a file containing a consent letter and the study questionnaire to discuss with their families and to gain permission to participate; it was to be returned within one week. The study took place in the students classes. The researcher gave all subjects a full explanation of the meaning of breakfast consumption and skipping, and guided them on how to fill in their responses. Of the 1,540 students invited to participate, 237 either did not gain consent from their families, were absent on the day of data collection or refused to participate, leaving 1,303 (754 boys and 549 girls) who completed the questionnaire. The overall response rate was 84.6%. The study procedures involved no significant physical, verbal, emotional, social or other type of harm, and all students were guided and informed about their rights to withdraw at any time. The information obtained was anonymised. All the questionnaires were completed under the supervision of the researcher, who was able to offer any necessary clarification. Measures After searching the relevant literature about breakfast consumption and skipping the morning meal among children and adolescents, a questionnaire was modified from previous studies (Brugman et al 1998, Gikas et al 2003, Sun et al 2013, Kawafheh et al 2014); it was then revised by academic staff (five colleagues in public health and two nutritionists). They re-evaluated the study objectives and research questions, and conducted face and content validity of the questionnaire. A pilot study was undertaken with 54 students in four schools (two boys and two girls schools); the information obtained was excluded from the final analysis of data. The final draft of the

4 Table 1 Sociodemographic distribution of school students (n=1,303) Variable Number Percentage Mean (SD) Gender Boys Girls Total , Age by years 15.6 (5.7) Grade Mother s education Secondary or lower Higher than secondary Family income per month Less than $350 ( 227) $350 ( 227) or more questionnaire was developed according to the responses of the students in the pilot study. Individual students required minutes to complete all parts of the questionnaire. Study questionnaire This had three parts, containing a total of 11 questions. The first part, consisting of six questions, covered the participant s sociodemographic data, including school, gender, grade, age, mother s education and family income. The second part, consisting of four multiplechoice questions, comprised questions about general health, appetite, learning achievement and school attendance. The third part contained a single question asking about the source of students knowledge about breakfast habits. Operational definition Breakfast consumption was defined as any food or beverage consumption between awaking and 45 minutes after the start of school (Gleason 1995, Sun et al 2013). Subjects who did not consume breakfast on most days of the week, four out of seven, were categorised as breakfast skippers. Data analysis Data were entered, tabulated, coded, and analysed using the software package for the social sciences SPSS v20. Means, frequency and standard deviation (SD) were computed. The chi-square test was used to compare the differences between the variable of breakfast consumption. Odds ratio and 95% confidence interval were used to determine the predictive factors for breakfast skipping and the statistical significance was considered as P< Ethical considerations Permission for this study was granted by the ethical approval committee of the Princess Salma Faculty of Nursing, Al al-bayt University, Jordan, the district education office at Mafraq Qasba and the administrator of each selected school. Each school chose a suitable day and time to conduct the study. Results Table 1 shows the sociodemographic characteristics of 1,303 school students (754 boys, 549 girls). Their ages ranged from 12 to over 18 years, with a mean of More than one third of the mothers were educated beyond secondary level, 19

5 Art & science acute research care Table 2 Prevalence of breakfast consumption among school students (n=681) Variable Number Prevalence Gender Boys Girls Total Age by years Grade Mother s education Secondary or less More than secondary Family income per month Less than $350 ( 227) $350 ( 227) or more Table 3 Self-perception among breakfast eaters (n=681) Variable Number Percentage P-value General health Appetite Learning achievement in previous semester School attendance and more than 60% had a family income above $350 ( 227) a month. Table 2 portrays the prevalence of breakfast consumption at 52.3% (52.8% among boys and 51.5% among girls), without any significant differences. The highest prevalence was seen among grade 7 students (70.3%) and this statistically decreased with age. Students with mothers of high level of education and with low family income showed a high breakfast consumption rate. The prevalence of breakfast consumption among students with good general health, good appetite, good learning achievement and good school attendance showed a statistical relationship with consumption rate (Table 3). Adjusted logistic regression analysis reflected a statistically high consumption of breakfast among the following groups (Table 4): Age group Those with mothers educated to more than secondary level. Those with low family income. Table 5 highlights the main sources of information about breakfast habits: families, friends and peer groups, and internet and television. Discussion The sample group for this study was 1,303 students from elementary and secondary schools. The findings presented in this article show that the prevalence of breakfast consumption was 52.3% (four or more times a week), in line with other studies (Kawafha 2013, El-Qudah 2014, Kawafheh et al 2014). This figure is considered low compared with other studies conducted among adolescents in the United Arab Emirates and Saudi Arabia (81% and 83.3% respectively) (Abalkhail and Shawky 2002, bin Zaal et al 2009) and in developed countries (70-90%) (Murata 2000, Boo et al 2010, Sandercock et al 2010, Schusdziarra et al 2011, Bian et al 2012). The clear differences between these findings might be explained by different operational definitions of breakfast consumption and the different age groups studied by researchers, using a variety of study designs. In the current study, breakfast consumption appeared greater among boys than girls, although there is no statistically significant difference. This result was consistent with other studies (Brugman et al 1998, Haddad et al 2009, Kawafha 2013, Sun et al 2013), some of which showed breakfast consumption to be more common among boys, while others revealed no differences between boys and girls (Mcintyre 1993, Mcintyre and Horbul 1995, Yahia et al 2008). 20

6 This result could be explained by the likelihood that during adolescence most girls are concerned about their appearance and are independent in their behaviours, and diet to maintain what they consider to a suitable weight (Brugman et al 1998, ALBashtawy 2012, Khamaiseh and ALBashtawy 2013, ALBashtawy et al 2014). The current research showed that the occurrence of breakfast consumption decreased with age, similar to the findings of other studies (Brugman et al 1998, Gikas et al 2003, Kawafha 2013, Sun et al 2013). This might be explained by increasing peer-group pressure and imitation. It was also shown that students with higher family incomes were more likely to skip breakfast, which might be explained by the availability of money to spend on snacks and other fast foods, rather than having a nutritious breakfast at home (Sun et al 2013). In contrast, other studies (Mcintyre 1993, McIntyre and Horbul 1995, Liu et al 2006) did not find a relationship between income and breakfast skipping. Also, breakfast consumption increased significantly among students with better educated mothers, which is in accord with the findings of other studies that examined this phenomenon among children, adolescents and adults of both sexes (Brugman et al 1998, Liu et al 2006). The current findings indicate that the prevalence of breakfast consumption is significantly higher among students who perceived their general health, appetite, learning achievement and school attendance as good compared with their classmates. Moore et al (2009) and Sun et al (2013) state that this result indicates a vicious circle in which bad dietary habits and skipping breakfast affect general health, enhance appetite and decrease school attendance. Mhurchu et al (2010) and Kawafheh et al (2014) found that breakfast consumption had a positive effect on students academic performance, concluding that they were more willing to participate in learning activities when in good health. Other studies (Harada et al 2007, Nakade et al 2012, Sun et al 2013) discussed the effect of breakfast consumption on increasing the levels of tryptophan, which is metabolised to serotonin in the human body, enhancing the student s academic performance and indirectly maintaining a good morning diurnal rhythm and good general health. Cheng et al (2008) concluded that breakfast consumption and skipping were associated directly with parental emphasis on this meal, and that it is a social habit taught in the family. Finally, the current research revealed that the main sources of information about breakfast habits were families, friends and peer groups, emphasising the unique role of school nurses in conducting Table 4 Adjusted logistic regression of school students about breakfast consumption Variables OR 95% a health education programme for schoolchildren, teachers, parents and the whole community, covering the important issues about healthy food habits. Limitations The sample was limited to one governorate, Mafraq, and a sample size of 1,303 school students. Therefore, it may not reflect the likely responses and habits of other students in Jordan or worldwide. Also, there could be a difference between what was reported Adjusted odds ratio (OR) Confidence interval P-value Gender Boys Girls Age by years Mother s education Secondary or higher Higher than secondary Family income per month Less than $350 ( 227) $350 ( 227) or more 0.66 Table 5 Sources of information about breakfast habits (n=1,303) Source* Number Percentage Family Friends and peer groups Internet and television Books, newspapers and magazines School curricula Other sources *More than one response

7 Art & science research and the facts. The study used a cross-sectional school-based design, but a different design might identify the problem of breakfast skipping more accurately. Conclusion The research demonstrated that breakfast consumption among school students was initially low and skipping breakfast increased with age. A community and school-based health education programme conducted by school nurses and other health providers for the target groups at risk, or individuals who are more prone to breakfast skipping, would be beneficial. This should be supported by a collaborative national policy between the ministries of health and education, conducted to promote healthy eating habits in schools, universities, sports clubs, curricula, local communities and the community as a whole. Implications for practice School nurses and other health professionals should encourage students to have breakfast at school Health professionals should prepare health promotion programmes for students, teachers and families to encourage breakfast consumption. These should feature in the school curriculum, in lectures, scientific nutritional days, workshops, conferences, and the mass media Health and education ministries should collaborate in intervention programmes, and formulate policies and strategies to foster the roles of teachers and parents in fighting breakfast skipping School nurses and health providers play a vital role in the early assessment, data collection and analysis of information related to unhealthy nutritional habits, especially breakfast skipping Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared Acknowledgements Many thanks to all participants and their families, and to the school principals and teachers who helped conduct the study s Abalkhail B, Shawky S (2002) Prevalence of daily breakfast intake, iron deficiency anemia and awareness of being anaemic among Saudi school students. 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