THE IMPLEMENTATION OF NUTRITION EDUCATION IN PRESCHOOLS IN MALAYSIA

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1 THE IMPLEMENTATION OF NUTRITION EDUCATION IN PRESCHOOLS IN MALAYSIA 1. INTRODUCTION Health has been the ultimate agenda to be acquired by most regions in the world for the coming millennium as emphasised in the "Alma Ata Declaration" that health should be accessible to all by year This declaration has strongly influenced the Malaysian government in her aims to promote health education and healthy lifestyle among the people. In line with this agenda, Malaysian Ministry of Health with the cooperation of both the private sector and public organization has conducted series of healthy lifestyle campaigns. In a survey reported in local newspaper (Berita Harian, 12 Oct.2000), in 1995, 21% of the Malaysian population are found to be overweight and 6.2% are obese. Overall, the urban population tends to be more overweight (17.5%) compared to the rural population (15.5 %) of Malaysia. In 1996 another survey was conducted, and out of the 80,000 people surveyed, it was found that 16.6% were overweight, and up to 4.4% reached the level of obeity, while 25.2% were reported to be under weight. Though the percentage in overweight and obesity cases have shown a decrease, the fact remains that health messages or campaigns has not yet reached the Malaysian population effectively, especially, the younger generation. Food is actually very closely related to our social and cultural lives. It forms an integral part of our family, religions and cultural celebrations. Many aspects of food are culturally determined: such as what parents think is appropriate to be eaten; how we eat (with fingers, spoon and forks, or chopsticks); with whom we eat, and when we eat throughout the whole day. Children, in particular, rely on their parents' and caregivers' attitude and behaviour in terms of providing the appropriate healthy choices of food, environment and living conditions. Teaching children to make healthy choices in the food they select is certainly a worthwhile goal and one that will affect their lives through adulthood. Children are building their bodies that are to last them a life-time, therefore they must know that the food they eat has a direct relationship to the quality of their health. They must be informed that consuming processed foods or foods high in sugar, salt and fat are physically detrimental. An intervention program in preschools is necessary to instill in children a positive attitude towards food. This paper, based on a research currently undertaken at the University of Science Malaysia (USM) funded by the Ministry of Science, Technology and Environment Malaysia, aims to promote healthy lifestyle among Malaysian children. This research is part of a bigger study conducted nationwide, in colaboration with the School of Medicine, USM. The study focuses on nutrition education in preschool children as we believe that children have much to learn about food and nutrition. Reaching children at this age is important because it is easier to encourage healthy habits during initial behaviour development than to alter existing behaviour (Vance, 1973). Moreover, nutrition education is essential for preschool children because the quality of their nutrition has a direct impact on their growth and development as well as their nutritional status throughout life. This paper will describe how the nutrition education in preschool in Malaysia is being implemented and how the children perceived the importance of foods and good eating habits.

2 2. RESEARCH PROBLEM A survey conducted by the Malaysian Ministry of Health in 1991 showed that most of Malaysian preschool children suffered from iron deficiency and malnutrition (Khairuddin, 1991), especially those in the rural areas. Due to the poor nutritional state, combined with frequent episodes of infections and intestinal parasitism, resulted in high rates of absenteesm in rural schools (Kandiah, 1991). However, the state of health has increased rapidly lately due to the great development in the health sector and in the economic achievement, increasing the quality of life, both in the urban and rural areas in Malaysia. The changing eating habits due to introduction of fast foods and the affluent lifestyle has given wide variety of selection of foods to children. A lot more choices are available and this causes children to be picky when it comes to food. Moreover, nowadays it is more difficult to remain aware of nutritional values of food because of prepackaging, vending machines and fast-food restaurants. More often than not, "formulated", fabricated, fake food are displacing wholesome foods in the diet, especially children's foods and snacks. Parents also wrongfully teach their children by using rewards to encourage their children to eat. Remarks such as "eat your rice and after that you can have your ice-cream" encourages children to want to eat more sweet and sugary foods. This indicates the lack of awareness and knowledge among children (and adults) regarding what is good food for healthy growth. The latest Trent among families in Malaysia is to have meals outside because working mothers do not have time to prepare home-cooked food. This "eating out" lifestyle further agravate the problems of unhealthy eating and unbalance diets. We find now, more and more children are eating foods bought from stalls along roadsides or from fast food restaurants. Hence, there is a real great need to educate children (as well as parents) on the importamce of good nutrition for healthy growth and for prevention of illness. 3. RESEARCH OBJECTIVES The main purpose of this study is to design a program, which helps children develop important concepts, attitudes and behaviour toward food. Nutrition education should take place through the child's actual experiences and be focused on attitudes and feelings as well as development of concepts. Children should be educated to be able to make wise choices about food on their own from the variety of foods available around them and to practice orderly meals and good eating habits. 4. METHODOLOGY 4.1 The Conceptual Framework Healthy lifestyle means positive health, and is defined as an above average status regarding the physiological, mental and social abilities as a human (WHO, 1990). According to WHO, "health is the status of full mental, physical and social well being and not merely an absence of illness and/or infirmaity". Therefore it is necessary to apply substantial effort to assure the full realization of the potential in all children, in order to develop them further through all available means. Healthy lifestyle in this study is defined as having correct knowledge, attitude and practices about food and eating habits.

3 The theoretical basis for behaviour modification and attitude changing in this study comes from "Orem Advanced Nursing Theories". This theory encompasses three sub theories, which explains people's attitudes of making healthy choices for themselves. This is followed by the demand of taking the right action in making choices and eventually the forces, which would drive them to take actions for practicing healthy choices throughout life. In the case of young children, they do not personally perform all action requirements within their therapeutic self-care demand, because parents and teachers are expected to provide the necessary structure and supervision so that the child's therapeutic self-care demand is met. Children need to be fostered in order to develop their self-care agency through the design of health education program that enables them to distinguish between healthy and unhealthy choices. Orem has theorized that self-care agency development is dependent upon three underlying components (Orem, 1995): foundational capabilities and dispositions (as "pre-action" capacities that influence the perception of health), and judgement about the need to take action. This development process according to the cognitive development theory is the learning process, which apprently goes through several stages: i.e., perception, attention, exercise or work, memory and learning. Taking this point into consideration, the intervention program designed in this study is made into an instructional mode with the integration of cognitive strategies in order to promote long term healthy behaviors and to guide lifestyle choices. 4.2 Research Design The study used a pretest/posttest quazi-experimental design in which six preschools were involved. All of the 6 preschools were from the urban area in Penang and they participated voluntarily in this project. 4.3 Sample Altogether 200 children age 5 to 6 year are involved and all of them are from averange income groups (SES) families. One hundred of them were in the experimental group and the other one hundred made up the control group. 4.4 The Intervention Program: The Nutrition Education The following conceptual framework is used for the development of intervention program on nutrition education in this study. Part of the concepts was adopted from the USDA Dietary Guidelines for Americans (1995). 1. Nutrition is a process by which food and other substances eaten to make the child grow, be healthy and to get energy to work and play. 2. Many kinds and combination of food can lead to a well-balanced diet 3. No food by itself has all the nutrients needed for full growth and health. 4. Eat plenty of grains products, vegetables and fruits. 5. Choose diet low in fat 6. Choose diet moderate in sugar and salt 7. Drink a lot of water and milk 8. The effects of unhealthy eating patterns include under nutrition, iron deficiency anemia and overweight and obesity. Nine modules were developed and used in this study: Module 1: Eat a wide variety of foods

4 Module 2: Eat plenty of fruits and vegetables Module 3: Importance of grain products Module 4: Drink a lot of water Module 5: Food Guide Pyramid for a balanced diet Module 6: Preparing and cooking our food Module 7: Choose Healthy Snacks Module 8: Milk for healthy and strong bones Module 9: What is good eating habits? These modules aims to To provide knowledge and understanding on the importance of eating variety of foods. To create positive attitude towards food To instill good eating habits and regular mealtime. To create awereness in the children to drink a lot of water, instead of sugary and carbonated drinks. To provide understanding on the importance of a balance-diet, and eating the amount according to the food guide pyramid To raise awereness among the children on the needs to drink milk for healthy development of bones, teeth and hair. To provide understanding on the importance of eating a lot of fruits and vegetables To instill awareness on the bad effects of junk-food The intervention was administered over seven month's period. During this time teachers were regularly trained to teach these modules as lessons to be taught on a schedule, as well as to integrate throughout the day and made a part of many activities. The integrated activities include listening to stories, singing, hands-on activities, game and play activities. In line with the modules, teachers were also asked to provide nutritious snacks, controling the amount of sugar in drinks, and reducing the amount of salt used in food cooked at the centers. They were also encouraged to include a lot of vegetables (fibers) in the children's afternoon meals, and teaching them good manners during eating time. Teachers were to stress the importance of cleanliness in staying healthy and teaching them to brush their teeth after eating. Children in the experimental groups were always reminded of the problems related to nutrition including tooth decay, obesity, weak and tired, unable to play and hypersensitivity to foods through the activities conducted. 4.4 Test Instruments (KAP Questionnaires) Three sets of tests were developed to measure knowledge (K), attitude (A) and practices (P) of children on their dietry habits, namely (i) The Children's Questionnaire, (ii) The Teacher's Inventory, and (iii) The Parents Inventory. The Children's Questionnaire was conducted using an interview method. A 15 minutes interview was conducted with each child over several consecutive days. The data from Parents' and Teachers' Inventories would be used to substantiate the children's questionnaire.

5 5. INITIAL RESULTS AND DISCUSSION Pretest results show that the level of understanding of children about the concept of 'food' is indeed very superficial and simplistic. Children perceived eating as a way to ward off "hunger", "not get hungry", "not get stomach ache", "to be healthy", "not to be sick", or "not to die". Only a very small percentage of children understood that eating is for "growth" and "to give energy for play" (Table 1, 2, and 3 in Appendix A). From this analysis, we can interprete that children still do not possess a clear grasp of the concept of 'eating'. To them, eating is only a spontaneous reaction to hunger. Table 4, and 5 show that majority of children (91%) indicated that they do like eating vegetables, however unclear of the reason why. Table 6 and 7 shows various answers given by children when asked why they need to eat a variety of foods. Regarding their favorite drink, 53% of the children says they like to drink Milo or milk (Table 8) but again they are not sure of why they have to drink a lot of water. These are some of the data from the pretest which show that the children do not yet comprehend the concept of nutrition. It is expected that after the intervention program, the children will develop a better understanding of the concept, acquire a positive attitude towards eating and able to incorporate this habit into their lifestyle. It is hoped that through the modules children would learn to eat a variety of foods, increasing their awereness of reasons for selecting certain foods, and helping them develop positive attitude about food. Children's fear of a certain food, example green vegetable, can be reduced by simply increasing exposure to the food. Early experiences of preparing, tasting and eating nutritious foods can have an impact on their long-term eating preferences and habit. To help children learn to appreciate food, we involved them in cooking experience as part of the intervention program. They were taught to prepare simple sandwiches: cut tomatoes and cucumber, spread butter on the bread and put a layer of tuna or sardine, or prepare fruit salad: cut fruits, squeeze salad dressing onto the salad and mixing the salad. 6. CONCLUSION Good nutrition is essential to proper growth during childhood. To grow up healthy, with vitality and energy, children need adequate nutrition. Their early experiences of eating nutritious food can have an impact on their long term eating preferences and habits (Cosgrove, 1991). This study seeks to prove that we can instill in children healthy eating habits through good nutrition education, that would hopefully be continued through their lives. Many other similar studies have been conducted, in particular, in the USA (Smith, 1976; Karsch, 1977, Essa, Read and Haney-Clark, 1988; Birch et al., 1994) all show that they successfully promoted food and nutrition education to the preschool children. We hope to be able to produce a blueprint of Nutrition Education Curriculum for the preschoolers in Malaysia as a result of this study.

6 7.0 REFERENCES Eliason C. and Jenkins, L (1994, 5 th ed.). A Practical Guide to Early Childhood Curriculum. New York: Macmillan College Pub. Brewer, J.A. (1992) Introduction to Early Chidhood Education: Preschool Through Primary Grades. Allen and Bacon. Cosgrove, M.S. (1991) Cooking in the classroom. Young Children. 46 (3), Smith, J.M. (1976). "Parthways to Preschool Nutrition Education", Health Education, vol.7, Karsch, B.B. (1977), "Nutrition Education in Day Care", Journal of Home Economics. Vol.69, Essa, E.L., Read, M and Haney-Clark, R. (1988) "Effects of Parent Augmentation of Preschool Childrens Knowledge Scores". Child Study Journal, Vol. 18 (3), Birch, L.L. (1994). "How Kids Choose Foods". Research presented at International Conference on Gastronomy. Monterey, CA. March 11, Khairuddin Yusuf (1991). The Child, Health and ChildCare. University of Malaya, Kuala Lumpur. Kandiah, M. (1991). Ecology og Young Child Nutrition in Malaysia. University of Malaya, Kuala Lumpur. WHO (1990). Diet, Nutrition and The Prevention of Chronic Disease, Tech Rep. Ser.No. 797 WHO: Geneva

7 APPENDIX A TABLE 1 TABLE 2 Q: Why do you thing you have to eat in the Morning? Q: What will happen if we do not eat regularly the whole day? No. % No % Not to be hungry No answer Not to get stomach ache Don't know Not to be sick Sick/not well To be healthy Become thin To go to school Stomach ache To get fat Hungry To be strong Vomit To be clever Will die Don't know No answer

8 TABLE 3 TABLE 4 Q: Why do we have to eat everyday? Q: Do you like to eat vegetables? No. % No. % No answer No answer Do not know Don't know Stomach ache Yes To grow No For energy Hungry For health For beauty Become thin

9 TABLE 5 TABLE 6 Q: Why do you need to eat vegetables? Q: What type of food do we have to eat a lot of? No. % No % No answer No answer Don't know Don't know For good eyesight Grains For strength Fruit and vegetables To become healthy Fish and meat To have good skin Fatty food Lots of vitamins Others To become smart To grow

10 TABLE 8 TABLE 9 Q: What is your favourite drink? Q: Why do we have to drink a lot of water? No. % No % No answer No answer Don't know Don't know Milo/milk Thirsty Tea/coffee For strength Plain water For health Soft drinks Not to fall sick To be full To lose weight No worms To be smart 1 0,5 Hot To grow Choke To grow tall Will not die To be fat