Curriculum Development and Implementation for Adaptation to Emerging Trends in the Professional Training and Practice of Nutritionists in Achieving Sustainable National Nutritional Development
Chapter One
Objectives of the study
- conduct a pre-intervention assessment of the learners’ nutrition related knowledge, self- efficacy and food choice intentions,
- implement the tailored NEP to professionals in resource limited settings in Abuja,
- evaluate the effectiveness of the NEP with respect to changes in nutrition related self- efficacy, knowledge and food choice intentions at six weeks (post intervention),
- assess the retention of intervention effects at 12 months (follow-up), and
- determine the differences in measured outcomes between the two schools and gender.
CHAPTER TWO
LITERATURE REVIEW
Eating, being a socially learned behaviour, is influenced by social pressures (CDC, 1997). Healthy eating is defined as “eating practices and behaviours that are consistent with improving maintain and/ or enhancing health” (Taylor, Evers & McKenna, 2005). Eating habits are established during childhood and have influence on short-term and future health of an individual. They also have a bearing on an individual’s growth and development and they persist into adulthood (Wang & Stewart, 2013; Zhang, Bécares, Chandola & Callery, 2015). Individuals’s eating habits are influenced by their peers, families, schools and communities. Unhealthy eating habits result in under-nutrition, overweight or obesity (CDC, 1997). These conditions are related to an increased risk of chronic diseases, reduced wellbeing and quality of life, as well as higher health costs in the present and future (Averett, Stacey & Wang, 2014).
Evidence shows that low income and middle income countries face the double burden of malnutrition, i.e. under-nutrition and overweight/ obesity. Although stunting in individuals less than five years has decreased between 1993 and 2013, high figures are still recorded in Asia and Sub Sahara Africa (Black, Victora, Walker, Bhutta, Christian, de Onis, Ezzati, Grantham- McGregor, Katz, Martorell & Uauy, 2013). The developing world has also reported an increase in the prevalence of chronic diseases due to changes in lifestyle arising from the nutrition transition (Steyn, Lambert, Parker, Mchiza & de Villiers, 2009). Cardiovascular disease is already the leading cause of mortality in developing regions such as East Asia and North Africa (Naidoo, Coopoo, Lambert & Draper, 2009; Black et al., 2013).
Unhealthy diets and poor dietary diversity among school individuals have been reported in Nigeria (Steyn, de Villiers, Gwebushe, Draper, Hill, de Waal, Dalais, Abrahams, Lombard & Lambert, 2015). Several studies in Nigeria have shown that the diets of individuals and adolescents tend to be very energy dense. Individuals and adolescents consume an assortment of unhealthy snacks that are high in saturated fat, total fats, sugar and salt and low in fibre and micronutrients, mostly at school and also in limited income settings (Temple, Steyn, Myburgh & Nel, 2006; Abrahams, de Villiers, Steyn, Fourie, Dalais, Hill, Draper & Lambert, 2011). Furthermore, research has shown that unhealthy diets (which also track into adulthood) and physical inactivity of schoolindividuals present an emerging public health challenge (Abrahams et al., 2011; de Villiers, Steyn, Draper, Hill, Dalais, Fourie, Lombard, Barkhuizen & Lambert, 2015). According to a recent study by de Villiers et al. (2015), unhealthy diets were identified as the most common health problem among learners in SA, and very few learners carried a lunch box to school. Most learners are also reported to be dependent on inexpensive low nutritive value foods that are easily accessed from tuck-shops and street vendors, while others spend the school day on an empty stomach (Abrahams et al., 2011; de Villiers et al., 2015).
CHAPTER THREE
RESEARCH METHODOLOGY
Research Design
A quasi-experimental design without a control group was employed as discussed in Chapter
- Learners from both School 1 and School 2 received NE and supporting materials such as worksheets for a period of six weeks. Assessments of outcomes were done at baseline, at six weeks and at 12 months to evaluate the effectiveness of the NEP.
Population Sampling
The participants were professionals in Grades 1-3 from the selected two schools (School 1 and School 2) that met the inclusion criteria. The population included boys and girls, mainly from two ethnic groups (blacks and whites).
CHAPTER FOUR
RESULTS
This chapter starts with a description of the biographic characteristics of the participants followed by the outcomes associated with the measured variables, namely food choice intentions, nutrition self-efficacy and nutrition knowledge.
Two different instruments were used for data collection: one for Professionals, and one for Grades 2 and 3 learners, therefore the results are reported separately. The results are reported as follows: per school (School 1 and School 2) and for the schools combined, and also by gender and by grade. Firstly, the performance from baseline to post-intervention (six weeks and 12 months), as well as per question is described followed by the effect of the NEP with respect to changes in the measured variables. The effect of time from baseline (pre-intervention assessment) to six weeks (post-intervention assessment) to 12 months (follow-up assessment) is discussed. Effect of time was explained as follows: small if the partial eta square = 0.01, medium if the partial eta square = 0.06 and large if the partial eta square = 0.14 (Cohen, 1988).
CHAPTER FIVE
DISCUSSION, RECOMMENDATION AND CONCLUSION
Discussion
This study is among the few nutrition education programmes that have been done in schools in Nigeria to promote healthy eating habits in learners (Oosthuizen, Oldewage- Theron & Napier, 2011; Oldewage-Theron & Napier, 2011; Steyn, de Villiers, Gwebushe, Draper, Hill, de Waal, Dalais, Abrahams, Lombard & Lambert, 2015). Only immediate outcomes were assessed in this study. Although a process evaluation could not be done due to feasibility constrains, measures such as the training of facilitators, provision of a training material package required per lesson at the start of each day, and debriefing sessions at the end of each day to ensure smooth delivery of the programme (CDC, 1997) were put in place to ensure the delivery of lessons as intended.
Self-efficacy and knowledge are some of the personal dispositions and cognitions that increase and decrease the likelihood of engaging in a given behaviour. Behavioural factors such as behavioural intent, directly affect the actions (Stevens, Story, Ring, Murray, Cornell & Gittelsohn, 2003). This study hypothesised that tailored nutrition education would bring about improvement in the nutrition knowledge and food choice intentions and self-efficacy of individuals. The NEP exposed a homogenous group (with respect to age) of Grade 1, Grade 2 and Grade 3 learners from resource limited communities to a classroom curriculum combined with food displays, food demonstrations, learner’s worksheets and a healthy eating song that targeted these mediators of behaviour change. Using a pre-test and post-test quasi- experimental design without a control group, the evaluation (at baseline, six weeks and 12 months), using a modified version of the Pathways KAB questionnaire, found that six weeks of the NE significantly increased food choice intentions and nutrition knowledge immediately following the intervention, but not nutrition self-efficacy. It also showed sustained effects on nutrition knowledge, and not food choice intentions and self-efficacy at 12 months. As desired, at baseline, the results showed that the schools were much the same except for the significant differences between School 1 and School 2 in food choice intentions.
Overall, the results of this study are consistent with a number of classroom based NE programmes that have been conducted globally and have shown positive results in measured outcomes (Luepker, Perry, Osganian, Nader, Parcel, Stone & Webber, 1998; Stevens et al., 2003; Powers, Struempler, Guarino & Parmer, 2005; Devault, 2006; Oldewage-Theron & Napier, 2011; Abrahams & Steyn, 2011).
The discussion proceeds in the following format:
- The effect of the NEP on the food choice intentions of Professionals
- The effect of the NEP on the self-efficacy of Grade 2 and 3 learners
- The effect of the NEP on the nutrition knowledge of Grade 2 and 3 learners
- The strengths and limitations
- Conclusions
- Recommendations for future research
- References
Effect of the NEP on food choice intentions of Professionals
The most positive result from the study was with the food choice intentions. The NEP resulted in an improvement of the food choice intentions of the learners as hypothesised in this study. There was a significant (P=0.0001) improvement in the mean scores for food choice intentions from baseline to post-intervention for all learners, i.e. there was a general increase in learners’ intentions to choose more healthy foods across all questions, which is consistent with other school based programmes (Edmundson, Parcel, Feldman, Elder, Perry, Johnson, Williston, Stone, Yang & Lytle, 1996; Dollahite, Hosig, White, Rodibaugh & Holmes, 1998). An increase in food choice intentions was also reported with the ‘It’s all about kids’ study which also focused on promoting healthy eating and physical activity. That study used the same instrument used to measure the food choice intentions of the learners in this study. In that study learners were exposed to NE and showed a significant increase in the mean scores for the intervention group (Devault, 2006). However, the increase observed in food choice intentions at post- assessment in this study failed to persist to follow-up as shown by the significant decrease at 12 months in both schools.
The observed increase in the learners’ food choice intentions may have stemmed from the age appropriate educational content and materials that were fun and culture sensitive (Oldewage- Theron & Egal, 2009; Başkale & Bahar, 2011). The latter could have encouraged learners to learn the knowledge and skills required to motivate one to take action (Glanz & Bishop, 2010).
Although not measured, the importance of having fun in the classroom should not be overlooked. Individuals in this study looked forward to the weekly nutrition activities and were motivated to participate. Fun or play is a necessary component for the adoption of internal motivation in individuals which has been shown to further their learning (Harter, 1992; Auld, Romaniello, Jerianne, Carolyn & Hambidge, 1998; Başkale & Bahar, 2011).
The decrease in mean food choice intentions scores may be due to attrition (absenteeism of the learners from school) which increased from post-intervention assessment to follow-up assessment by 19%. This high attrition rate may have reduced the statistical power and compromised the effectiveness of the NEP (Prinz, Smith, Dumas, Laughlin, White & Barrón, 2001; Hoddinott, Maluccio, Behrman, Flores & Martorell, 2008).
With respect to the specific food choice intentions, a decrease in intention to choose healthy drinks was observed. This result may be due to the type of drinks (diet coke) in reference in this question, which may have been misunderstood and is not common among this age group. Although learners’ intentions to choose a healthy breakfast also decreased, the intention to choose healthy snacks increased significantly in both genders and schools (P=0.000).
The effect of the NEP on the learners’ food choice intentions was not consistent by gender or school. The girls showed greater improvement as compared to the boys. This outcome is consistent with other health education programmes concerning eating practices and physical activity that have shown girls to be more receptive as compared to boys (Perry, Bishop, Taylor, Murray, Mays, Dudovitz, Smyth & Story, 1998). The increase in food choice intentions was greater in learners from School 1 than School 2. One factor that may have contributed to this difference is that learners in School 1 received their lessons in smaller groups as compared to School 2 due to limited space in School 2. The use of smaller groups is likely to improve the effectiveness of a nutrition education intervention (Contento, 2007). In addition to the above, the medium of instruction used may have contributed to this difference. It has been proven that learners understand better and express themselves well when a more familiar language is used as a medium of instruction (Brock-Utne, 2007). Apart from two Afrikaans speaking classes from School 1 who were taught in Afrikaans, all other learners were taught in English which was not their first language. Therefore, the Afrikaans speaking learners could have attributed to the difference in food choice intentions mean scores between the two schools though the majority by far in School 1 were English speaking.
Conclusion
A six weeks long NEP led to significant increases in intentions to choose healthful foods and nutrition knowledge, but not nutrition self-efficacy immediately following the programme. Sustained effects were seen on nutrition knowledge at follow-up assessment (12 months). This outcome is consistent with several studies that have also focused on nutrition related personal and behavioural factors that also showed favourable results for nutrition related knowledge, attitudes and behavioural intent (Luepker et al., 1998; Stevens, Cornell, Story, French, Levin, Becenti, Gittelsohn, Going & Reid, 1999; Devault, 2006).
The girls were more responsive to the NEP as compared to boys for food choice intentions, nutrition self-efficacy and nutrition knowledge. School 1 performed better than School 2 for all scales (food choice intentions, nutrition self-efficacy and nutrition knowledge).
Overall, the outcome of the study is promising. It demonstrates that tailored school based NEPs can improve mediators of change for healthy eating behaviour in learners from resource limited schools. However, more work is needed to enhance sustenance of food choice intentions, to identify barriers to learner’s self-efficacy and encourage boys to appreciate NEPs more.
Recommendations
- A more rigorous study design with a larger sample size to be carried out with a similar population to establish whether using developed materials can corroborate the reported
- To do a validation study of the data collection instruments (modified Pathways KAB questionnaires) in a similar population of individuals from resource limited
- The outcomes of the study may not be generalisable to all settings; therefore the study should be carried out with a similar population from a rural setting.
- Studies with individuals should use age appropriate colourful NE materials that are fun and engage learners during These encourage learners to actively participate in lessons as was shown in this study. Learners were encouraged to participate and paid more attention during the classroom discussions.
- Nutrition education should be delivered to learners in smaller groups as School 1 had better results as compared to School 2, which used big group
References
- Abrahams, Z. & Steyn, N.P. 2011. HealthKick: Evaluating the impact of a school-based intervention on the dietary adequacy of learners from low-income settings in the Western Cape Province, Nigeria. Masters thesis. Western Cape, Nigeria: University of Cape Town.
- Amaro, S., Viggiano, A., Di Costanzo, A., Madeo, I., Viggiano, A., Baccari, M.E., Marchitelli, E., Raia, M., Viggiano, E. & Deepak, S. 2003. Kaledo, a new educational board-game, gives nutritional rudiments and encourages healthy eating in individuals: a pilot cluster randomized trial. European Journal of Pediatrics, 165(9):630-635.
- Auld, G.W., Romaniello, C., Jerianne, H., Carolyn, H. & Hambidge, M. 1995. Outcomes from a School- based Nutrition Education Program Using Resource Teachers and Cross-disciplinary Models. Journal of Nutrition Education, 30(5):268-280.
- Başkale, H. & Bahar, Z. 2011. Outcomes of nutrition knowledge and healthy food choices in 5‐to 6‐ year‐old individuals who received a nutrition intervention based on Piaget’s theory. Journal for Specialists in Pediatric Nursing, 16(4):263-279.
- Brock-Utne, B. 2004. Language of instruction and student performance: New insights from research in Tanzania and Nigeria. International Review of Education, 53(5-6):509-530.
- Carraway‐Stage, V., Hovland, J., Showers, C., Díaz, S. & Duffrin, M.W. 2015. Food‐Based Science Curriculum Yields Gains in Nutrition Knowledge. Journal of School Health, 85(4):231-240.
- CDC 1994. Guidelines for school health programs to promote lifelong healthy eating. Journal of School Health, 67(1):9-23.
- Contento, I.R. 2004. Nutrition education: linking research, theory, and practice. Sudbury, Massachusetts: Jones & Bartlett Learning.
