Percentage RESULTS (Unpublished Data) Comparative Analysis of Baseline, Intermediate and End line Data - Knowledge, Attitude and Practice (KAP) Survey The impact of two year intervention was assessed through repeated surveys (KAP) with the study participants before the beginning of the intervention (baseline survey), at the midpoint of the intervention (intermediate survey) and after completion of the intervention (end line survey). 1. SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE PARTICIPANTS The analysis was based on 2263 students who participated in atleast one of the surveys in the study (baseline, intermediate and end line). The socio-demographic characteristics of these students is depicted in Figure 1. Out of 2263 students, 63% represent boys and 37% represent girls. The study participants varied from different age groups, with 8.6% of 10 years and below, 39.6% of 11 years, 35.4% of 12 years and 16.4% of 13 years and above. School type wise, 56.7% of study participants were from private schools, which cater to middle and high socio-economic status (SES) and 43.3% from government schools, which cater to middle and low SES. 70 63.0 60 56.7 50 40 37.0 39.6 35.4 43.3 42.0 46.0 30 20 16.4 10 8.6 5.5 6.5 0 Boys Girls 10 11 12 13 Private Government 6th 7th 8th 9th Gender Age (Years) School Type Class Figure 1: Socio-demographic characteristics of the students (n= 2263) 1
2. MEASURES Knowledge about eating habits, overweight/obesity and diabetes, average serving per day of food items and physical activity were main outcome variables. Variables related to students attitude, practice towards their eating and physical activity behaviours were also considered as outcomes. The socio-demographic variables analysed were gender, age, school-type and class. A summative scale score was also created for knowledge level of students that included 20 questions on diet, physical activity, overweight/obesity and diabetes. These questions were recoded as 0 for wrong answer, and 1 for Don t know/not Sure and 2 for correct answer. Only those students, who answered for atleast 80% questions, were considered for the analysis. Values of Cronbach s alpha were calculated to check the consistency of the scales (alpha for knowledge at baseline = 0.66, at intermediate = 0.70 and at end line = 0.65). The values of Cronbach s alpha suggest that all the knowledge scales were fairly consistent. Responses of practice and attitude related questions like, How often do you eat breakfast?, During the lunch break at school, I usually have food from, We eat out in a restaurant or order food from outside, I eat vegetables and fruits, Every day I do physical activity/ exercise of play for, were recoded as ordinal variables (the options are rearranged in ascending order). Also responses of questions, During my leisure time, I mostly, During the games period in schools, I mostly, If the meal is tasty, I prefer to eat even if my stomach feels full, I like to have all meals at a fixed time, I feel it is OK to have fried snacks in between main meals, etc. were converted into binary variables. For individual knowledge related questions only the correct answers are presented in the results. Frequency table is provided for the questions included in the end line survey only. 3. DATA ANALYSIS Descriptive statistics were calculated for the demographic distribution of the data. Per day serving for all food items was calculated. All the students who participated in the study over three years were included in the analysis. Since, some of the students were not present in all the three surveys, generalized linear models were applied to compare the proportion of students at each survey who had correct knowledge about each item related to healthy diet, physical activity, overweight/obesity and diabetes. 95% confidence intervals (CI) were also provided for these proportions. To assess the trend in overall mean knowledge per student over the three years the same model was used. Students practice and attitude related questions were compared through Generalized Estimating Equations (GEE) using ordinal logit function for ordinal data and simple logit function for binary responses. For the ease of interpretation, students responses at each time point were presented in percentages instead of the results obtained from the GEE, though p values from GEE were presented to show the statistical significance of the change in students practice and attitude. Here, the percentages were not directly compared. Change in mean per day servings of food items consumed by students were compared through generalized linear models. Only descriptive 2
Mean Knowledge Score statistics were provided for Section D (Advocacy for adopting healthy lifestyle practices) which is included only in the end line survey. All the comparisons were considered significant at 5% level of significance. All the analysis was done using SAS V9.1. 3.1 KNOWLEDGE Figure 2 show the comparison of knowledge scores of students between baseline, intermediate and end line survey. Overall the mean knowledge score was significantly higher at end line (15.48) than at intermediate (14.99) and at baseline (13.95) (p<0.001). This significant increasing trend in knowledge score from baseline to end line was observed across all the sub-groups of different socio-demographic variables. The change in knowledge score among girls was significantly more than boys. Also, the change in knowledge score among private school students was significantly more than government school students. 18 16 14 12 10 8 6 4 2 0 Overall Boys Girls 10 11 12 13 Private Government 6th 7th Gender Age (Years) School Type Class Baseline Intermediate End line Figure 2: Comparison of mean knowledge scores of students between Baseline, Intermediate and End line (n= 2263) 3.1.1. Knowledge about dietary/eating habits Overall, 88.3% of students at baseline reported that having a balanced diet is essential while 95.7% of the students reported the same at end line (p<0.001). At end line, significantly 5.1% more students from government schools in comparison to baseline reported that having a balanced diet is essential (p<0.001). 79.7% students at end line as compared to 76.4% at baseline reported that whole grains, cereals and whole pulses are good sources of fibre (p<0.001). 3
3.1.2. Knowledge about Physical Activity Though the proportion of students who reported that being active and doing regular exercise keeps a person fit and healthy was quite high at baseline (93.8%), however a significant 4.8% increase was observed in the proportion of students reporting the same at end line (98.6%) (p<0.001). Significantly 5.2% more students at end line (94.5%) in comparison to 89.3% at baseline reported that all types of physical activities (cycling, climbing stairs, dancing, cleaning the house, exercise, yoga, etc.) are beneficial (p=0.004). 3.1.3. Knowledge about overweight/obesity 12.8% more students at end line (89.6%) as compared to baseline (76.8%) reported that not only overweight people should exercise (p<0.001). Significantly, more students at end line (78.3%) than baseline (75.5%), reported that obesity is the presence of excess fat in the body (p=0.049). 3.1.4 Knowledge about diabetes (Figure 3) Higher proportion of students at end line (71.7%) reported that high level of glucose in blood (blood sugar) is diabetes than at baseline (61.6%) (p<0.001). Significantly, 10% more girls (74.5% at end line vs. 64.5% at baseline) (p=0.005) reported the same. 20.6% more students at end line (94.7%) in comparison to baseline (74.1%) reported that diabetes does not affect only adults (p<0.001). Significantly, 23.7% more students at end line (86.5%) in comparison to 62.8% at baseline reported that unhealthy eating habits can put one at risk for diabetes (p<0.001). 12.2% more students at end line (59.2%) vs. 47% at baseline, significantly reported that being overweight or obese in the present are related to getting diabetes in the future (p=0.033). Higher proportion of students at end line (66.8%) reported that being physically inactive or not doing regular exercise can put one at risk of diabetes, in comparison to baseline (48.9%) (p<0.001). 59.8% students at end line reported that having a family history of diabetes increases the chance of getting diabetes while at baseline 49.8% students felt the same (p=0.018). Significantly, 12.7% more boys at end line (61.6%) in comparison to baseline (48.9%) reported the same (p=0.013). In addition, 12% more private school students at end line (63.9%) in comparison to baseline (51.9%), reported the same (p<0.001). Significantly, 27.9% more boys (68.6% at end line vs. 40.7% at baseline), and 26.7% more girls (67.5% at end line vs. 40.8% at baseline), reported that the risk of diabetes is higher in tobacco users as compared to non-tobacco users than reported at the 4
baseline level (p<0.001, for both). In addition, significantly, 20.4% more private school students at end line (65.4%) than at baseline (45%), (p<0.001), also, 37.4% more government school students, showed significantly higher responses at end line (71.7%) than 34.3% at baseline (p<0.001) for the same. Figure 3: Knowledge regarding the risk factors of Diabetes (n=2263) The proportion of students who reported that Type 2 diabetes is preventable was high at end line level (55.4%) than seen at baseline (44%) (p=0.001). Significantly more students (10.7%) at end line reported that exercise and healthy eating can prevent diabetes in comparison to baseline (p<0.001). More students (75.8%) at end line than at baseline (67.4%) reported that people with diabetes are more likely to develop heart disease, stroke, kidney and eye problems (p=0.004). 3.2. PRACTICES 3.2.1. Practices related to dietary/eating habits Results from the baseline and intermediate level revealed that 42% and 38.2% students, respectively eat out in a restaurant or order food from outside sometimes, while at end line, this proportion was 37% (p=0.001). The daily intake of vegetables significantly increased at end line (76.9%) in comparison to 61.2% at baseline and 65.8% at intermediate (p<0.001). This increase was significantly observed in all sub-groups (among boys, girls, private and government school students) at end line than at baseline (p<0.001, for all subgroups). 5
Food Items Also, a significant increase in the daily consumption of milk and milk products was seen at end line (78.3%) vs. baseline (68%) and intermediate (67.9%) (p=0.003). A significant decrease in consumption of carbonated drinks, traditional Indian sweets and non-indian sweets was reported at end line vs. at baseline (p<0.01). The daily consumption of traditional Indian sweets among girls, significantly reduced at end line (5.8%), than at baseline (10.6%) and intermediate (6.6%) (p=0.042). The overall mean serving per day for consumption of whole fruit (1.56), vegetables (1.84) and milk and milk products (1.83) significantly increased in comparison to both baseline and intermediate survey. The mean serving per day of carbonated drinks, fried snacks, traditional Indian sweets, and packed chips, etc were reported to have significantly decreased at end line in comparison to baseline (Figure 4). Milk and milk products Egg and meat products Packed chips Non-Indian sweets Traditional Indian sweets Fried snacks Carbonated drinks Fruit juices Vegetables Whole fruit 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 Mean serving per day End line Intermediate Baseline Figure 4: Mean serving per day of food items at Baseline, Intermediate and End line (n=2263) 3. 2.2. Practices related to physical activity patterns 52.6% students at end line in comparison to 34.9% at baseline and 45.3% students at intermediate reported that during their leisure (free) time they mostly go out and play with friends, while the proportion of students, who did sedentary activities during their leisure (free) time was less at end line (47.4%) than at intermediate (54.7%) and baseline survey (65.1%) (p<0.001). Significantly, 88.9% students at end line vs. 84.4% at baseline and 87.3% at intermediate reported mostly playing games in the playground, or mostly doing physical activity during the games period in school (p<0.001). 6
Percentage (%) At end line, 74% of students reported walking while going to a market nearby their house than reported at baseline (67.4%). At end line, majority of the students reported to watch television for 1-2 hours (73.7%) and use computer for 1-2 hours (65.7%) while only 3.4% students and 1.9% of students reported to watch television and use computer, respectively for more than 4 hours. More than fifty percent of students (53.4%) reported that they never play videogames. The proportion of students who reported doing physical activity/ exercise or play for more than 60 minutes (more than 1 hour) every day increased at end line (44.3%) in comparison to baseline (34.2%) and intermediate (39.1%) (p<0.001). Higher proportion of students at end line in comparison to baseline level reported doing physical activities on a daily basis such as brisk walking (50.6% vs. 44.7%), cycling (33.5% vs. 28.2%), running/jogging (45.8% vs. 39.6%) and playing outdoor games like cricket/ football/ badminton/ hockey/ volley ball, basket ball, etc. (65.5% vs. 60%). 3.3. ATTITUDE 3.3.1. Attitude related to physical activity pattern Significantly, higher proportion of students at end line (71.5%) than baseline (56.2%) and intermediate (69%) reported climbing stairs when going to somebody s house located anywhere between 2 nd floor and 5 th floor of a building (p<0.001). 3.3.2. Attitude related to dietary/eating habits Significantly increase in healthy food choices were reported by the students at end line than at baseline and intermediate survey. Higher proportion of students at end line vs. baseline preferred lemonade (80.1% vs. 66.6%), fruit chaat (75.4% vs. 65.7%), vegetable poha (69.1% vs. 54.9%) and rajma rice (71.4% vs. 60.6%) (Figure 5). 90 80 70 60 50 40 30 20 10 0 Lemonade vs. Cold Drinks Whole Fruit vs. Fruit Juice Fruit Chaat vs. Aloo Tikki Vegetable Poha vs. Samosa Rajma Rice vs. Chole Bhatura Baseline Intermediate End line Healthy food options chosen Figure 5: Proportion of students who chose healthy food options at Baseline, Intermediate and End line (n=2263) 7
3.4. ADVOCACY FOR ADOPTING HEALTHY LIFESTYLE PRACTICES 95.7% of students agreed that the programme, helped them to learn and understand the benefits of healthy eating, 96.1% students agreed that it helped them to understand the importance of regular physical activity and 93.2% agreed that it helped them realize or recognize the importance of leading a healthy lifestyle to prevent diabetes through this programme. 91.5% of students were motivated to work to make their school healthy, out of which, 69.6% students reported this could be achieved by creating awareness on the importance of healthy diet and being physically active, 57.3% reported that by encouraging their school students to participate enthusiastically in games period in the school and 57.2% felt by demanding healthier and nutritious food options in their school canteen/nearby their school campus. In addition, 8.3% students also reported that by increasing the frequency and duration of the physical activity periods, introducing yoga, martial arts, cricket, etc. availability of more sports equipment, regular checking of the student s tiffin boxes, creating health clubs, etc. were a few interesting ways to make their school healthy. Higher proportion of students (95.8%) reported that they would work to keep their home healthy. Out of these, 69% of students reported this could be achieved by avoiding bringing and preparing of junk/unhealthy foods in their home and 66.7% reported by being physically active for atleast 60 minutes (1 hour) daily. Regarding the students acceptance of junk food/unhealthy food, a higher percentage of students (79.4%) reported that they will say No to junk food/unhealthy food if offered to them by anyone (apart from their family members), 73.1% students reported that they will refuse to take from their friends and 60.3% reported they will refuse accepting junk food/unhealthy food when offered by their family members. 69.8% students reported that they will say No to their friend(s), if he/she asked them to sit and talk during the games period, instead of playing. 8