Recommendations for future research

As the present study was the only study of its kind in the Pakistan context, there is need for further research to substantiate these findings. This is advised in order to ascertain whether similar findings will be found using other computer-based nutrition education programs. Due to the time and resource constraints, the study did not attempt to explore the effects of nutrition knowledge on change in dietary behavior. Future studies are highly recommended in order to explore this aspect.

The future studies to determine the effectiveness of computer-based nutrition education should include varied time spans for the intervention. Further research needs to be conducted, which addresses the effectiveness of computer-based nutrition education among other age groups (adolescent, elderly) and children in different settings (public schools). Follow-up after one or two year’s duration should be conducted to determine the effect of computer-based education on knowledge gain. Future studies need to explore the nexus between nutrition knowledge, attitudes and dietary behavior specifically in the Pakistani population. There is also need to explore the relationship between parental nutrition knowledge and children nutrition knowledge and dietary habits.

9 Summary

The purpose of the present study was twofold. It aimed to implement and evaluate a computer-based nutrition education intervention in the primary schools of Pakistan and to explore the acceptability of such a program in the Pakistani context. Secondly, the study attempted to compare results of the present study with the study results of ‘Cool Food Planet Kidz’ (Kreisel K, 2004). A total of 11 schools (344 children) including 4 intervention (147 children), 5 comparison (156 children) and 2 control (41 children) schools completed the study. Schoolchildren of 8-10 years of age participated in the study.

The study was carried out during the two-week practical experience of student teachers in Lahore, Pakistan. The comparison group received nutritional education through worksheets, board and card games. The intervention group used the computer-based tool (Cool Food Planet Kidz) along with worksheets, board and card games. The control group received no nutrition education. The nutrition knowledge was measured at baseline (t0), post-intervention (t1) and three-months’ follow-up (t2) with the help of the validated Nutrition Knowledge Questionnaire. In addition to the Nutrition Knowledge Questionnaire, focus group discussions, observation of the nutrition lessons and evaluation questionnaires were also employed to gather data.

The nutrition knowledge increased significantly from baseline to post-intervention in both post-intervention and comparison groups (p<0.001). No tangible difference was observed at post-intervention and follow-up between the two groups indicating that the computer-based tool did not support additional learning in children. The intervention effect was significantly maintained at three months’ follow-up, indicating the retention of nutrition knowledge gained. Younger children (8-9 years old) significantly (p=0.045)

retained more nutrition knowledge at three months follow-up as compared to the older children (10-11 years old) implying that nutrition intervention is more advantageous when started at an early age. Long-term knowledge gain and retention of knowledge is significantly higher among girls as compared to boys (Mann Whitney-U test p=0.025, p=0.024 respectively). Higher retention of nutrition knowledge in girls as compared to boys could be associated to the fact that girls found nutrition knowledge more relevant to their future prospective role as homemaker and caretakers.

Nutrition knowledge in all children was strongly associated with the indicators of socio-economic status i.e. occupational level of the father and the mother and Family Affluence Scale. No difference was detected in nutrition knowledge with regard to different levels of mother and father occupation and Family Affluence Scale between intervention and comparison groups. This suggests that computer-based tool did not prove beneficial concerning the socio-economic status.

Children and teachers both enjoyed learning and teaching nutrition concepts through computers. Nevertheless, Student teachers highlighted many important factors that need to be taken into account in order to integrate computer-assisted education in Pakistani primary schools successfully.

The comparison with the Vienna study revealed that at baseline, nutrition knowledge (mean number of correct answers) of Vienna children was higher as compared to the Lahore children, indicating that nutrition knowledge of Pakistani children is very low as compared to the children in Vienna study. It signifies the inadequacy of Pakistani school curricula in particular and society in general in providing knowledge related to nutrition and healthy eating to children. At three months’ follow-up children in the Vienna study notably retained more nutrition knowledge as compared to the Lahore children

suggesting that children in Vienna have more opportunities to get nutrition-related information from their environment.

The study results have provided a strong foundation for incorporating nutrition education intervention in primary schools. Computer-based tools were found helpful in disseminating nutrition education. However, they were not the panacea. Other creative mediums were almost equally effective in disseminating nutrition knowledge. The low level of nutrition knowledge urgently demands incorporation of nutrition education in the school curriculum.

10 Zusammenfassung

Das Ziel der Studie war einerseits die Einführung und Evaluierung einer computergestützten Interventionsmaßnahme im Bereich der Ernährungsbildung in pakistanischen Grundschulen und andererseits die Prüfung der Akzeptanz eines Programms dieser Art. Weiters wurden die Ergebnisse der vorliegenden Studie mit den Resultaten des Projektes „Cool Food Planet Kidz“ (Kreisel K, 2003) verglichen. An der Studie nahmen insgesamt 11 Schulen (344 Kinder) teil, wobei 4 Schulen als Interventionsgruppe (147 Kinder), 5 Schulen als Vergleichsgruppe (156 Kinder) sowie 2 Schulen als Kontrollgruppe (41 Kinder) dienten. Das Alter der teilnehmenden Kinder lag zwischen 8 und 10 Jahren.

Die Studie wurde während einer zweiwöchigen Praxis von Lehramtsstudenten in Lahore, Pakistan durchgeführt. Der Vergleichsgruppe wurde Ernährungsbildung mittels Arbeitsblättern sowie Brett- und Kartenspielen vermittelt. Die Interventionsgruppe verwendete begleitend zu den Arbeitsblättern, Brett- und Kartenspielen das computergestützte Programm. Die Kontrollgruppe erhielt keine Ernährungsbildung. Das Ernährungswissen wurde zu Beginn (t0), nach der Intervention (t1) und nach drei Monaten (t2) anhand eines validierten Fragebogens zum Ernährungswissen getestet. Zusätzlich zum Fragebogen wurden Gruppendiskussionen, Beobachtungen der Ernährungserziehung sowie ein Evaluierungsfragebogen eingesetzt, um Daten zu erfassen.

Sowohl in der Interventions- als auch in der Vergleichsgruppe stieg das Ernährungswissen nach Intervention signifikant an (p<0,001). Allerdings konnten zwischen den beiden Gruppen keine relevanten Unterschiede sowohl nach Intervention als auch beim Follow-Up festgestellt werden. Das computergestützte Programm führte somit zu keinem zusätzlichen Lerneffekt bei den Schülern. Beim Follow-Up wurden der Interventionseffekt und somit

das erworbenen Ernährungswissen signifikant aufrechterhalten. Jüngere Kinder (8-9 Jahre) konnten beim Follow-Up nach drei Monaten signifikant mehr (p=0,045) vom erworbenen Ernährungswissen wiedergeben als ältere Kinder (10-11 Jahre), was bedeutet, dass Ernährungsbildung von größerem Nutzen ist, wenn sie in einem jüngeren Alter begonnen wird. Eine längerfristige Steigerung und Beibehaltung des Wissens waren bei Mädchen signifikant höher als bei Buben (Mann-Whitney-U-Test p=0,025, bzw.

p=0,024). Die bessere Beibehaltung des Wissens bei Mädchen könnte mit der Tatsache in Zusammenhang stehen, dass Mädchen Ernährungswissen für ihre angehende Rolle als Hausfrauen und Mütter für relevanter erachteten.

Bei allen Kindern war Ernährungswissen stark mit dem sozioökonomischen Status (z.B. Beruf von Vater und Mutter, Wohlstand der Familie) assoziiert.

Zwischen Interventions- und Vergleichsgruppe konnten keine Unterschiede im Ernährungswissen in Bezug auf Beruf der Eltern sowie Familienwohlstand gefunden werden. Somit zeigte der sozioökonomische Status keine Auswirkungen auf die Vorteile der Anwendung des computergestützten Programms.

Die Anwendung des Computers in der Ernährungsbildung wurde von den Kindern, wie auch von den Lehrern gut angenommen. Nichtsdestotrotz zeigten die Lehramtsstudenten viele relevante Punkte auf, die in Erwägungen gezogen werden müssen, um computerunterstützten Unterricht erfolgreich in den pakistanischen Grundschulen integrieren zu können.

Der Vergleich der Baselineergebnisse mit den Resultaten der „Cool Food Planet Kidz“-Studie zeigte, dass das Ernährungswissen (durchschnittlich Anzahl an korrekten Antworten) bei den Kindern aus Wien wesentlich besser war als bei den Kindern aus Lahore. Dies hebt die Unzulänglichkeit in der pakistanischen Gesellschaft im Allgemeinen und insbesondere die Unzulänglichkeit der Bildungsinhalte an pakistanischen Schulen hervor,

Kindern Wissen über gesunde Ernährung zu vermitteln. Beim Follow-Up nach drei Monaten zeigte sich, dass die Kinder der Wiener Studie deutlich mehr Ernährungswissen behalten konnten als die Kinder aus Lahore, was darauf zurückführen sein könnte, dass Kinder in Wien mehr Möglichkeiten haben, in ihrem Umfeld zu ernährungsbezogenen Informationsquellen zu gelangen.

Die Ergebnisse dieser Studie bilden ein solides Fundament für die Einführung von Interventionsmaßnahmen im Bereich Ernährungsbildung in Grundschulen. Computerunterstützte Programme wurden als hilfreich angesehen, um Ernährungsbildung zu verbreiten. Jedoch sind diese kein Wundermittel. Andere kreative Medien waren beinahe ebenso effektiv in der Verbreitung von Ernährungswissen. Das niedrige Niveau des Ernährungswissens erhebt dringenden Anspruch auf die Berücksichtigung von Ernährungsbildung in den Lehrplänen.

11 References

Abdollahi M, Amini M, Kianfar H, Dadkhah-Piraghag M, Eslami-Amirabadi M, Zoghi T, Assasi N and Kalantari N. (2008). Qualitative study on nutritional knowledge of primary-school children and mothers in Tehran.

Eastern Mediterranean Health Journal, 14(1): 82-89.

Agha DA, Maqbool S and Anwar S. (2005). Is poverty or lack of nutrition awareness the main cause of malnutrition in children? Pakistan Paediatrics Journal, 29: 63-67.

Amaro S, Viggiano A, Di Costanzo A, Madeo I, Viggiano A, Baccari ME, Marchitelli E, Raia R, Viggiano E, Deepak S, Monda M and De Luca B.

(2006). Kalèdo, a new educational board-game, gives nutritional rudiments and encourages healthy eating in children: a pilot cluster randomized trial.

European Journal of Pediatrics, 165(9): 630–635.

Andrabi T, Das J, Khwaja AI, Vishwanath T and Zajonc T. (2007) Learning and Educational Achievements in Punjab Schools (LEAPS): Insights to inform the education policy debate. LEAPS project publications.

Auld G W, Romaniello C, Heimendinger J, Hambidge C, and Hambidge M. (1998). Outcomes from a school-based nutrition education program using resource teachers and cross-disciplinary models. Journal of Nutrition Education, 30(5): 268-280.

Baig-Ansari N, Rahbar MH, Bhutta ZA, and Badruddin SH. (2006). Child’s gender and household food insecurity are associated with stunting among young Pakistani children residing in urban squatter settlements. Food Nutrition Bulletin. 27(2): 114-127.

Bamji MS and Murthy PV. (2006). Promotion of the Feeding Minds and Fighting Hunger initiative in selected rural schools in Andhra Pradesh, India.

Food and Nutrition Bulletin, 27(2): 105-113.

Baranowski T, Baranowski JC, Cullen KW, Marsh T, Islam N, Zakeri I, Honess-Morreale L, deMoor C. (2003). Squire’s Quest! dietary outcome evaluation of a multimedia game. American Journal of Preventive Medicine, 24(1): 52-61.

Baranowski T, Davis M, Resnicow K, Baranowski J, Doyle C, Lin LS, Smith M and Wang DT. (2000). Gimme 5 fruit, juice, and vegetable for fun and health: outcome evaluation. Health Education and Behavior, 27(1): 96-111.

Beerman K, Brown G and Evans M. (1998). Interactive CD study modules in food science and human nutrition: assessing technology-enhanced study programs. Journal of Educational Multimedia and Hypermedia, 7(4): 365-374.

Benjamin SE, Tate DF, Bangdiwala SI, Neelon BH, Ammerman AS, Dodds JM and Ward DS. (2008). Preparing Child Care health Consultants to address childhood overweight: a randomized controlled trial comparing web to in-person training. Maternal and Child Health Journal, 12(5): 662–669.

Bergen D. (1993). Authentic performance assessment. Childhood Education, 70:99-101.

Berkman, DS, Lescano AG, Gilman RH, Lopez SL and Black MM. (2002).

Effects of stunting, diarrhoeal disease, and parasitic infection during infancy on cognition in late childhood: a follow-up study. The Lancet, 359(9306): 564-571.

Bhatnagar S and Taneja S. (2001). Zinc and cognitive development. British Journal of Nutrition, 85(2):139-145.

Bhutta ZA, Gupta I, de Silva H, Manandhar D, Awasthi S, Hossain SMM and Salam MA. (2004). Maternal and child health: is South Asia ready for change? British Medical Journal, 328(7443):816-819.

Birch LL and Fisher JO. (1998). Development of eating behaviors among children and adolescents. Pediatrics, 101(3), 539-549.

Birch LL, Fisher JO, Grimm-Tomas K, Markey CN, Sawyer R and Johnson SL. (2001). Confirmatory factor analysis of the Child Feeding Questionnaire: a measure of parental attitudes, beliefs and practices about child feeding and obesity proneness. Appetite, 36(3):201-210.

Birch LL. (1999). Development of food preferences. Annual Review of Nutrition, 19:41–62.

Black MM and Hurley KM. (2007). Helping children develop healthy eating habits. Rev.ed. In: Trembley RE, Barr RG, Peters RDeV, Boivin M, eds.

Encyclopedia on early childhood development. Centre of excellence for early childhood development, 1-10. Retrieved September 2009, from

http://www.child-encyclopedia.com/documents/Black-HurleyANGxp_rev-Nutrition.pdf

Block SA. (2007). Maternal nutrition knowledge versus schooling as determinants of child micronutrient status. Oxford Economic Papers, 59(2):

330-353.

Bryan J, Osendarp S, Hughes D, Calvaresi E, Baghurst K, and van Klinken JW. (2004). Nutrients for cognitive development in school-aged children. Nutrition Reviews, 62(8): 295–306.

Bryce J, Coitinho D, Darnton-Hill I, Pelletier D and Pinstrup-Andersen P.

(2008). Maternal and child under nutrition: effective action at national level.

Lancet, 371(9611): 510–526.

Bukhari SKH and Sikander U. (2007). Poverty, income and social development in Lahore. Lahore School of Economics: Third annual conference on management of Pakistan economy: economic reforms. May 2-3 2007.

Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D and Tyrer P. (2000). Framework for design and evaluation of complex interventions to improve health. British Medical Journal, 321(7262):694-696.

Centers for Disease Control and Prevention. (2006). Overweight and obesity: Childhood overweight. Atlanta, GA: Department of Health and Human Services.

Chang CY. (2002). Does computer-assisted instruction + problem solving = improved science outcomes? A pioneer study. The Journal of Educational Research, 95(3): 143–151.

Choi ES, Shin NR, Jung EI, Park HR, Lee HM and Song KH. (2008). A study on nutrition knowledge and dietary behavior of elementary school children in Seoul. Nutrition Research and Practice, 2(4): 308-316.

Cohen J. (1998). Statistical power analysis for the behavioral sciences, Lawrence Erlbaum Ass, Hillsdale, New Jersey.

Contento IR, Blach GI, Bronner YL, lytle LA, Malnowy SK,Olson CM, and Swadener SS. (1995). The effectiveness of nutrition education and implications for nutrition education policy, programs and research-a review of research. Journal of Nutrition Education, 27: 279–418.

Contento IR, Randell JS and Basch CE. (2002) Review and analysis of evaluation measures used in nutrition education intervention research.

Journal of Nutrition Education and Behavior, 34(1): 2–25.

Contento IR. (2008). Nutrition education: linking research, theory and practice. Asia Pacific Journal of Clinical Nutrition, 17(1):176-179.

Cooke LJ and Wardle J. (2005). Age and gender differences in children’s food preferences. British Journal of Nutrition, 93: 741–746.

Cooke LJ, Wardle J, Gibson EL, Sapochnik M, Sheiham A and Lawson M. (2003). Demographic, familial and trait predictors of fruit and vegetable consumption by preschool children. Public Health Nutrition, 7(2): 295–302.

Crites SL Jr and Aikman SN. (2005). Impact of nutrition knowledge on food evaluations. European Journal of Clinical Nutrition, 59(10): 1191–1200.

Cullen KW, Baranowski T, Owens E, Marsh T, Rittenberry L and de Moor C. (2003). Availability, accessibility, and preferences for fruit, 100% fruit juice, and vegetables influence children’s dietary behavior. Health Education and Behavior, 30(5): 615-626.

Cullen KW, Baranowski T, Rittenberry L, Cosart C, Hebert D, and de Moor C. (2001). Child-reported family and peer influences on fruit, juice and vegetable consumption: Reliability and validity of measures. Health Education Research, 16(2): 187-200.

Cullen KW, T. Baranowski, T. Baranowski, L. Rittenberry and N. Olvera.

(2000). Social environmental influences on children’s diets: results from focus groups with African, Euro and Mexican American children and their parents.

Health Education Research, 15(5): 581-590.

Currie C, Molcho M, Boyce W, Holstein B Torsheim T and Richter M.

(2008). Researching health inequalities in adolescents: the development of the Health Behavior in School-Aged Children (HBSC) family affluence scale.

Journal of Social Science and Medicine, 66(6):1429-1436.

Currie CE, Elton RA, Todd J and Platt S. (1997). Indicators of socioeconomic status for adolescents: the WHO Health Behaviour in School-aged Children Survey. Health Education Behavior, 12(3): 385-397.

Das J, Pandey P and Zajonc T. (2006). Learning Levels and Gaps in Pakistan World Bank Policy Research Working Paper No. 4067. Retrieved June 2009, from http://ssrn.com/abstract=944668

De Bourdeaudhuij I and Van Oost P. (2000). Personal and family determinants of dietary behavior in adolescents and their parents. Psychology and Health, 15(6): 751-770.

De Bourdeaudhuij I, Van Cauwenberghe E, Spittaels , Oppert, J-M, Rostami C, Brug J, Van Lenthe F, Lobstein T and Maes L. (2010). School-based interventions promoting both physical activity and healthy eating in

Europe: a systematic review within the HOPE project. Obesity Reviews, DOI: 10.1111/j.1467-789X.2009.00711.x

de Castro Ribas R and Bornstein MH. (2005). Parenting Knowledge:

Similarities and differences in Brazilian mothers and fathers. Interamerican journal of Psychology, 39(1): 5-12.

DeWalt DA and Hink A. (2009). Health literacy and child health outcomes: a systematic review of the literature. Pediatrics, 124(3): 265-274.

Edward N, Mill J, and Kothari A. (2004). Multiple intervention research programs in community health. Canadian journal of Nursing Research, 36 (1):

40-55.

Elmadfa I, Meyer A, Nowak V, hasenegger V, Putz P et al. (2009).

European nutrition and health report. Forum of Nutrition, 62

Ellis RM and Ellis RT. (2007). Impact of a traffic light nutrition tool in a primary school. The Journal of the Royal Society for the Promotion of Health, 127(1): 13-21.

Erdfelder E, Faul F, Buchner A (1996). G*Power: a general power analysis program. Behavior Research Methods Instruments, & Computers, 28:1-11.

Fančovičová J, Prokop P and Uşak M. (2010). Web-site as an educational tool in biology education: a case of nutrition issue. Educational Sciences:

Theory & Practice, 10(2): 907-921.

Fikree FF, Rahbar MH and Berendes HW. (2000). Risk factors for stunting and wasting at age six, twelve and twenty-four months for squatter children of Karachi, Pakistan. Journal of the Pakistan Medical Association, 50(10): 341-348.

Fitzgerald A, Heary C, Nixon E and Kelly C. (2010). Factors influencing the food choices of Irish children and adolescent: a qualitative investigation.

Health Promotion International, 25(3): 289-298.

Florence MD, Asbridge M and Veugelers PJ. (2008). Diet quality and academic performance. Journal of School Health, 78(4): 209-215.

French SA, Jeffrey RW, Story M, Breitlow KK, Baxter JS, Hannan P and Snyder MP (2001). Pricing and promotion effects on low-fat vending snack purchases: the CHIPS study. American Journal of Public Health, 91(1): 112-117.

Gable S and Lutz S. (2000). Household, parent and child contributions to childhood obesity, Family Relations 49(3): 293–300.

Galobardes B, Morabia A and Bernstein MS. (2001). Diet and socioeconomic position: does the use of different indicators matter?

International Journal of Epidemiology, 30(2): 334-340.

Gentile DA, Welk G, Eisenmann JC, Reimer RA, Walsh DA, Russell DA, Callahan R, Walsh M, Strickland S and Fritz K. (2009). Evaluation of a multiple ecological level child obesity prevention program: Switch® what you Do, View, and Chew. BMC Medicine, 7:49.

Gnavi R, Spagnoli TD, Galotto E, Pugliese E, Carta A and Cesari L.

(2000). Socioeconomic status, overweight and obesity in prepuberal children:

a study in an area of Northern Italy. European Journal of Epidemiology, 16(9):

797-803.

Gorely T, Nevill ME, Morris JG, Stensel DJ and Nevill A. (2009). Effect of a school-based nutrition education intervention to promote healthy eating in 7-11 year old children. International Journal of Behavioral Nutrition and physical Activity, 6:5. DOI; 10.1186/1479-5868-6-5

Gortmaker SL, Cheung LWY, Peterson KE, Chomitz G, Cradle JM, Dart H, Fox MK, Bullock RB, Sobol AM, Colditz G, Field AE and Laird N.

(1999). Impact of a school-based interdisciplinary intervention on diet and physical activity among urban primary school children: eat well and keep moving. Archives of Pediatrics and Adolescent Medicine, 153(9): 975-983.

Government of Pakistan (1998a). National education policy 1998-2010.

Islamabad; Ministry of Education, Pakistan.

Government of Pakistan. (1998b). 9th Five-Year Plan. Islamabad; Planning Commission of Pakistan.

Grantham-McGregor S and Ani C. (2001). A review of studies on the effect of iron deficiency on cognitive development in children. Journal of Nutrition, 131(2S-2): 649-668.

Grantham-McGregor S. (2005). Can the provision of breakfast benefit school performance? Food Nutrition Bulletin, 26(2): 144–158.

Grønhøj A and Ölander F. (2007). A gender perspective on environmentally related family consumption. Journal of Consumer Behaviour, 6 (4): 218–235.

Gupta N and Kochar GK. (2009). Role of nutrition education in improving the nutritional awareness among adolescent girls. The Internet Journal of Nutrition and Wellness, 7(1). Retrieved December 2009, from

http://www.ispub.com/journal/the_internet_journal_of_nutrition_and_wellness/

volume_7_number_1_21/article/role_of_nutrition_education_in_improving_th e_nutritional_awareness_among_adolescent_girls.html

Hakeem R, Asar F and Shaikh AH. (2004). Socioeconomic differences in housewife's ability to take nutritional care. Journal of Pakistan Medical Association, 54(7): 382-390.

Hakeem R, Thomas J, and Badruddin SH. (2002). Food habits and nutrient density of diets of Pakistani children living in different urban and rural settings.

Journal of health, Population and Nutrition, 20(3):255-263.

Hall A, Khanh LN, Son TH, Dung NQ, Lansdown RG, Dat DT, Hanh NT, Moestue H, Khoi HH andBundy DA. (2001). An association between chronic undernutrition and educational test scores in Vietnamese children.

European Journal of Clinical Nutrition, 55(9): 801-804.

Hancock T. (1993). Health, human development and community ecosystem:

three ecological models. Health promotion International, 8(1): 41-47.

three ecological models. Health promotion International, 8(1): 41-47.

In document Comparative analysis of computer-based nutrition education in primary schools of Lahore and Vienna (Page 120-144)