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research-article2014
PED0010.1177/1757975914552914Original ArticleW. Zhou/X. Xu et al.
Original Article Effectiveness of a school-based nutrition and food safety education program among primary and junior high school students in Chongqing, China Wen-jie Zhou1*, Xiang-long Xu1*, Ge Li1, Manoj Sharma2, Ya-Ling Qie1 and Yong Zhao1
Abstract: Background: Health behavioral patterns, especially eating patterns, established in childhood often carry over into adulthood, and some of the unhealthy ones are later associated with adult morbidity and mortality. Recently, a few nutrition and food safety education programs have been implemented in primary and junior high schools in China. Purpose: This study aims to examine the effectiveness of a school-based nutrition and food safety education program among primary and junior high school students in China. Methods: A mixed study design incorporating an intervention study and a quantitative survey was conducted for this research. With stratified cluster sampling, students from the 5th and 6th grade in one primary school and the 7th and 8th grade in one junior high school in Chongqing, China, were all selected and separated randomly into an intervention group (n = 501) and a control group (n = 522). Effectiveness evaluation investigations were performed at the initial time and nine-month follow-up (n = 472), respectively. Effectiveness of pre-/post-intervention and nine-month follow-up changes in scores of nutrition knowledge and food safety was assessed using a two-tailed t-test and analysis of variance. Results: Nutrition knowledge scores for the intervention group were mean 9.03, SD±2.75 at the baseline, and 14.70±3.28 after intervention. There was a significant improvement (t = 29.78, p < 0.01). The nine-month follow-up knowledge scores of the intervention group were 12.35±2.89, which were lower than the immediately after the intervention group (t = 12.40, p 0.05).
Questionnaires Based on a related literature questionnaire on nutrition and food safety knowledge among primary and junior high school students, the questionnaire used throughout this study, which was self-designed, had good validity, reliability, and readability (18,19). The questionnaire was based on the KAP model,
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designed specifically for the target population, and completed after repeated discussions and pre-survey, which included four sections: basic information; nutrition knowledge; eating habits, attitude, and behavior; and food safety knowledge.
Ethics This study was approved by the Ethics Committee, Chongqing Medical University. Written informed consent was obtained from all participants.
Procedures Our educational interventions consisted of both lectures and a prize quiz game about nutrition and food safety. Lectures about nutrition education On the basis of the baseline assessment and input from experts, professors, and students of the department of nutrition and food hygiene of Chongqing Medical University, the lectures were jointly designed with contents of nutrition and food safety knowledge. The main content of the lectures included nutrition knowledge, good personal eating habits, the prevention of nutrient deficiency diseases, food safety issues, etc. Nutrition lectures were given to the six intervention groups by six senior medical college students, whose major was nutrition and had been strictly trained (we drafted a slideshow and a prospectus to guide the undergraduates in how to give the lectures) many times. Lectures were planned for 30 minutes; in addition, each class was arranged by two supervisors and had finished a preceding evaluation. At the same time, the control groups did not receive any intervention.
Survey implementation Before measures were taken, we launched a presurvey among 220 school students in each grade, and just selected one class from every grade for the survey. According to this survey, we found that students had poor knowledge of nutrition and food safety, suggesting that measures should be taken to control this particular troublesome situation. After the pre-survey, an investigation was carried out after an explanation of the purpose of the research by investigators who had undergone unified rigorous training for two years, and were familiar with the objectives and methodology. The questionnaire was executed after the intervention. Each class was allocated two investigators who had received instruction regarding the questionnaire for six hours and the investigators were standardized in answering any of the students’ questions if explanations were needed. Another two well-trained supervisors assessed the process of the intervention and investigation in the class. It took about 20 minutes to complete the questionnaires.
Assignment method of nutrition knowledge scores The questionnaire on nutrition knowledge, which contained 16 questions in total (13 solo choice items and three multiple choice items), was used to comprehensively assess the level of students’ nutritional knowledge. Each item had one score. As to the three multiple-choice items, all responses were structured in different ways according to how each question was answered, and each question had four distinct responses, with the score ranging from zero to three. Maximum score of nutrition cognition was 22.
Prize quiz game
Assignment method of the food safety knowledge scores
After the lecture, two nutrition-related prize quiz games were organized in each class, including a game of Chinese food guide pyramid, good personal eating habits, and a game of the prevention of nutrient deficiency diseases, food safety issues. Each game was scheduled for 10 minutes and two supervisors as reviewers were assigned to grade the answers. Depending on the students’ scores, the two supervisors gave out the awards.
The part on food safety knowledge consisted of eight questions in total. An assignment method was used to arrive at the comprehensive score of the students’ food safety knowledge. Each question could be directly judged as true or false; the correct answer was assigned two points, and wrong or no answers were assigned 0 points. If the subject’s answers were progressive relations, 1, 2, or 3 were assigned according to the progressive relationship; IUHPE – Global Health Promotion Vol. 23, No. 1 2016
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Table 1. The demographic characteristics of the intervention group and the control school students, China, 2011. Variables
Age (year) ≤10 11 12 13 14 ≥15 Gender Boy Girl Nationality Han Others The only child Yes No
Primary school students (n = 518) Intervention
Control
96 116 48 3 0 0
100 115 33 5 2 0
134 129
123 132
241 3
249 6
176 79
146 99
Junior high school students (n = 505)
χ2
p
4.34
0.23
0.38
–
4.84
Intervention
Control
1 5 77 115 38 2
0 5 73 117 64 8
122 116
138 129
227 3
263 2
148 80
154 107
0.54
0.51
0.03a
χ2
p
7.72
0.05
0.01
0.92
–
0.67
1.80
0.18
aThe
difference between the intervention group of primary school students and the control group was statistically significant (p < 0.05).
did not know or no answer were assigned 0 points. Finally, the investigators calculated the total score so as to comprehensively evaluate the nutrition knowledge level of participants. The total score of this section was 19.
Data analyses Data from the questionnaire-based inquiry were stored, after a strict sorting and data cleaning, and analyses were performed by statistical analysis system software (version 9.0; SAS Institute, Cary, NC). Missing data were excluded and all data entries were double-checked to avoid errors. Outcomes were evaluated at baseline, at postintervention, and at follow-up. Demographic characteristics of participants, awareness rate of nutrition knowledge, and the section on eating habits used χ2 tests. Evaluation of before/after and nine-month follow-up changes in scores of nutrition knowledge and food safety were performed by a two-tailed t-test and analysis of variance (any two groups compared with LSD method). All the statistics were predetermined as p-value < 0.05 for statistical significance.
Results Sample demographics A total of 1023 participants were organized into intervention (n = 501) and control (n = 522) groups. The demographic characteristics of the participants are presented in Table 1. There was one significant difference between groups (single child status in the primary school group) (χ2 = 4.84, p = 0.03). There were no significant differences with respect to participants’ age, gender, nationality, and sibling numbers between the intervention group and control group of study students.
Nutrition knowledge Immediately after the intervention, most of the awareness rates of nutrition knowledge improved significantly, with more than 10% having some knowledge of nutrition, such as about fats, proteins, and calcium. Moreover, awareness rates of the question ‘what kind of disease is salt ionization used to prevent’ rose to 70.30% (χ2 = 306.66, p < 0.01) (Table 2). The most significant improvement was the students’ understanding of the Chinese food guide pyramid.
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I (255) 0.47* 0.89 0.820 0.19 0.28 0.22 0.24* 0.13 0.24 0.42 0.26* 0.15 0.37
B (242) 0.52 0.92 0.89 0.24 0.28 0.22 0.19 0.18 0.34 0.27 0.15 0.09 0.25
I (238) 0.53 0.92 0.84 0.40* * 0.43* * 0.53* * 0.55* * 0.43* * 0.70* * 0.91* * 0.83* * 0.71* * 0.85* *
L (219) 0.67* * 0.94 0.93* 0.41* * 0.45* * 0.34* * 0.30* * 0.29* * 0.69* * 0.75* * 0.64* * 0.50* * 0.69* *
B (269) 0.37 0.87 0.862 0.18 0.26 0.20 0.15 0.12 0.19 0.38 0.19 0.12 0.34
B (273) 0.49 0.89 0.90 0.24 0.26 0.23 0.18 0.08 0.23 0.43 0.25 0.11 0.37
L (253) 0.57* * 0.95* 0.95* 0.24 0.44* * 0.32* * 0.32* * 0.18* * 0.78* * 0.80* * 0.53* * 0.28* * 0.76* *
Intervention group
Control group
Intervention group I (263) 0.63* * 0.92 0.90 0.39* * 0.48* * 0.48* * 0.67* * 0.55* * 0.91* * 0.94* * 0.90* * 0.62* * 0.86* *
Junior high school students
Primary school students
B (274) 0.51 0.94 0.91 0.18 0.28 0.20 0.16 0.17 0.31 0.31 0.15 0.07 0.29
I (267) 0.53 0.94 0.90 0.21 0.29 0.20 0.18 0.18 0.39* 0.33 0.17 0.10 0.31
Control group
B: Baseline, I: Instant, L: Long-term; : The difference between the baseline intervention group of primary school students and the baseline intervention group of junior high school students was statistically significant(χ2 = 7.37, p < 0.01); * : Before-after comparison of the instant intervention group and baseline intervention group, and the long-term intervention group and baseline intervention group (p < 0.05,* * p < 0.01); : Comparison of the baseline intervention group and baseline control group, and the baseline intervention group and instant intervention group (p < 0.05, p < 0.01); a : The difference between instant intervention group of primary school students and long-term intervention group was not statistically significant; b: The difference between instant intervention group of junior high students and long-term intervention group was not statistically significant (p > 0.05).
Proteina b Fatb Vitamin Ca b Calcium b Coronary disease (fat)a Anemia (Ferrum) Rickets (Vitamin D) Scurvy (Vitamin C) Goiter (iodine)b Diet pagoda Five layers pagoda The bottom layer Best amount of fat
Nutrition knowledge
Table 2. Comparison of the awareness rate of nutrition among the intervention group and the control group, China, 2011–2012.
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Table 3. Comparison of the average knowledge scores of nutrition among the intervention group and control group (x±s), China, 2011–2012. Period Group Primary school students Boy n B I L
Int Con Int Con Int
Secondary school students
Girl Scores
n
142 8.86±3.02a 132 8.85±3.07a 134 14.91±3.21* 123 9.89±3.42 132 11.62±2.67
Boy Scores
131 8.69±2.60b 137 9.09±3.49b 129 14.90±2.88* 132 10.05±2.95 121 12.91±2.58
n
Total
Girl Scores
126 8.91±2.56 141 9.94±3.62c 122 13.89±3.81* 138 10.59±3.03c 103 12.52±3.50
n
Scores
116 9.75±2.67d 133 9.70±2.60d 116 15.04±3.09* 129 10.60±2.87 116 13.27±2.46
n
Scores
515 9.03±2.75e 543 9.40±3.25e 501 14.70±3.28* 522 10.29±3.08 472 12.35±2.89
B: Baseline, I: Instant, L: Long-term, Int: intervention group, Con: control group; The knowledge scores of both transverse and longitudinal groups were also compared using analysis of variance (any two groups compared with LSD method); *:In five longitudinal groups, the instant intervention group had the highest scores, and the difference was statistically significant (p < 0.01). : In five transverse groups, the scores of the long-term intervention group were lower than the instant intervention group’s, but higher than the other three groups (p < 0.01). a, b, c, d, e: With five longitudinal groups, any two groups compared with LSD method, and the differences were not statistically significant (p > 0.05). : In 5 transverse baseline intervention groups, the secondary school girls group had the highest scores, and the difference was statistically significant (p < 0.05).
Those nutrition questions marked ‘a’ showed that the awareness of nutrition knowledge between the instant intervention group and long-term intervention group in primary school was not statistically significant. Those nutrition questions marked ‘b’ showed that the awareness of nutrition knowledge between the instant intervention group and long-term intervention group in junior high school was not statistically significant. However, the intervention group and control group in the baseline were high (p < 0.05). A comparison of the average knowledge scores of nutrition between the intervention group and the control group is shown in Table 3. The nutrition knowledge scores were from mean 9.03, SD±2.75 points (before the intervention) to 14.70±3.28 points (immediately after the intervention), and the differences were statistically significant (t = 29.78, p < 0.01). There were statistically significant differences between before and after the intervention in primary boys, primary girls, junior boys, and junior girls (t = 16.15, p < 0.01; t = 18.29, p < 0.01; t = 12.05, p < 0.01; t = 13.97, p < 0.01, respectively). The increase in amplitude was highest for primary girls (6.20 points), ahead of primary boys (6.05 points), junior
girls (5.29 points), and junior boys (4.98 points), respectively. The nutrition knowledge score of the long-term intervention group was 12.35±2.89. It was lower than for the immediately after intervention group (t = 12.40, p < 0.01), but higher than baseline (t =18.04, p < 0.01) and control groups. Nutritional knowledge scores were different between the long-term intervention group and instant intervention group. The primary boys, primary girls, junior boys, and junior girls scored 3.29, 1.99, 1.36, and 1.77, respectively. Boys in primary school recorded the fastest decline in score than others. Most importantly, the difference was statistically significant (p < 0.01).
Diet and behavior habits There were no statistically significant differences between baseline and control groups (p > 0.05) (Table 4).
Knowledge of preference for certain foods and picky eating habits Intervention can effectively alter the behavior of any preference for certain foods and picky eating habits.
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Table 4. Comparison of the eating habits between instant intervention and long-term intervention groups. Question Are you willing to change your picky eating habits from now on Are you willing to change your habit of eating high energy snacks from now on Are you willing to increase the frequency of eating breakfast from now on What is your first consideration on food choice aThe
χ2
p
No 34 17
14.09
0.05).
leak in Japan’ between immediately after and nine months later (χ2 = 10.28, p < 0.05). The knowledge scores on food safety among primary and secondary school students are shown in Table 6. The immediately after intervention group achieved higher scores than those of other groups (p < 0.01). There were significant differences between instant and nine months later intervention groups (t = 2.00, p < 0.05). There was no significant difference between different schools and different gender (p > 0.05). There were significant differences between before and instant primary boys and secondary girls (t = 2.99, p < 0.01 and t = 2.349, p < 0.01, respectively). The primary boys, primary girls, junior high boys, and junior high girls scored 1.50, 0.52, 0.76, and 1.13, respectively.
Discussion The means of medical university-based nutrition education At present, nutrition education in primary and secondary schools is deficient, which has led to primary and secondary school students’ lack of basic understanding of nutrition knowledge in China (9). Therefore, to help students develop lifelong healthy habits, more holistic health and nutrition curricula are needed that not only teach students health knowledge at the cognitive level but
also improve the nutritional status of school-age children and adolescents. It is urgent for schools and related departments to enhance nutrition education in primary and secondary schools, and to explore various ways to improve the young generation’s nutrition KAP at the same time. Inclusion of nutritional education in primary and secondary school curricula is one effective way (10,14). To participate in the work of popular science, there is a tremendous need for more professionals to be devoted to it; the development of college students’ science associations and students’ science and technology organizations (9,11) is a reciprocal choice. Through these organizations, science and technology activities have started to enter into the school lives of primary and secondary school students in recent years. Many nutritional science research studies focus on theoretical topics and are restricted to the laboratory in China (4). Few of them pay much attention to popular science activities, even on nutrition and food hygiene in schools, and few evaluations on the effects immediately after and in the longer term have been conducted. This is the theme of our study, and the issue to which this study seeks to draw more attention. We encourage nutrition undergraduates to serve schools with their professional skills, including the development of nutrition education. This could provide opportunities for them to practice their professional theories in the real world and help them find their own goal at the same time. IUHPE – Global Health Promotion Vol. 23, No. 1 2016
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Immediate and long-term effect evaluations were carried out to provide a theoretical basis for nutrition education involved in primary and secondary school education. The results prove that this intervention appeared to be effective and that it is worth exploring. Further schoolbased nutrition education efforts should focus on culturally and geographically appropriate, multicomponent approaches that actively involve family members, schools and teachers, community members, and health and nutrition experts (26). We also recommend that nutrition-information interventions can be more effective when using nutrition information that is generally liked by the target population in combination with an educational intervention to increase objective nutrition knowledge. We can use active learning strategies include simulations and learning games, teacher and peer modeling, role-playing, and so on.
The effectiveness of medical college-based nutrition education for primary and junior high school students’ nutrition KAP In this study, the scores illustrated that knowledge of nutrition and food safety among primary and junior high school students was seriously lacking, which was similar to the findings of other reports (17,27–29). Nevertheless, after this intervention, the awareness scores of nutrition and food safety knowledge were higher than before, and effectiveness continued to nine months later, which was similar to the results of other reports (30–36). Especially, the awareness of ‘the association between microelements and disease’ (18,33), ‘Chinese food guide pagoda’, ‘spoiled food’, and ‘the problem of hot food’ was significantly different before and after the interventions. In addition, the majority of the students under intervention indicated that they would pay more attention to food, but no difference was found in the control group. To some extent, through the contrast before and after intervention, the nutrition and food safety information acquired in this education program indicates that the students’ knowledge of nutrition has improved. All the things we have mentioned demonstrate that this program was effective, feasible, and worthy of being popularized.
The effectiveness of medical university-based nutrition education interventions for changing eating behavior among primary and junior high school students Healthy eating in childhood and adolescence is important for proper growth and development and can prevent health problems such as obesity, dental caries, iron deficiency, and osteoporosis (37,38). It is generally known that health promotion is a transformation process of knowledge, attitude, and behavior (11–13,20,27). The awareness of nutrition plays a vital role in shaping healthy eating behavior; meanwhile, the change of attitude is the principal element to lead to changing behavior (9). Thus, besides enhancing the awareness of nutrition and food safety among primary and junior high students, healthy eating behavior is also important. A study has shown that dietary intentions and planning are assumed to be primary predictors of dietary changes (39). Most health behavior models share the assumption that the intention to change is a predictor of actual behavior (40,41). Based on the results of this investigation, the majority of the school students were willing to change their bad eating behaviors after intervention, such as picking food, eating junk food, and not having breakfast every day, which was similar to the results of earlier reports (9,18,31,34–39). However, the change of attitude was not significantly different nine months later, which may be due to lack of continuous intervention. Moreover, this result may demonstrate that the effect of this intervention is limited on the change of attitude, and more effective intervention will be needed in the future. In addition, changes in behavior also need to be evaluated in further research. Food choice patterns established during youth will likely influence long-term behaviors (42). The use of food safety information when people select food products should decrease food risk as well as consumers’ concerns when selecting food.
The future of medical college-based nutrition education interventions Compared with the control group, the intervention was impactful. The study shows that nutritional knowledge scores were different between long-term and instant intervention groups. Schools have an
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important role to play in equipping children with the knowledge, attitudes, and skills they need in order to protect their health. Young persons need nutrition education to assist them to develop lifelong eating patterns consistent with the Dietary Guidelines for Chinese Food Guide Pyramid. This was the first time that we were able to cooperate with the students’ association and organizations of a medical college, and implement the program via a medical collegebased nutrition education method for primary and secondly school students. College students, especially medical university students, should take more responsibility for nutrition and health knowledge communication and popularization. Meanwhile, we have built a long-term cooperation mechanism with primary and secondary schools on nutrition education. Comparison of the difference between long-term and immediate intervention groups revealed the need to constantly develop nutrition knowledge by strengthening the consciousness of students, otherwise they will gradually forget.
Daily consumption of breakfast In recent years, many primary and middle school students in China often do not eat breakfast for reasons such as lack of time or parents who are busy working. Although some are eating breakfast, energy intake is inadequate and quality is poor. Several studies have reported that breakfast consumption is linked to some aspects of brain function, such as neural network activity and cognitive performance (43,44). Studies have shown that regularly skipping breakfast is closely linked to increased rates of obesity in all age groups (45–49). Our research shows that the length of the intervention time has not affected the effect of the interventions on breakfast. Increasing frequency of breakfast was positively correlated with students’ performance in both male and female healthy adolescents (4).
period that affected children’s knowledge, but there was no way of seeing this. If there were sufficient time to organize more activities, the effect of intervention may be better. Secondly, we only selected one primary school and one middle school and random selection was not done. Extrapolation to other schools’ students remains to be further validated. Furthermore, the effect of this intervention is limited to the change of attitude; eating habits were self-reported rather than measured in a more objective way. Nevertheless, this intervention trial could be easily reproduced in other regions. Course topics and the content of the nutrition lecture can be applied to other places. In the future, different areas can replicate the intervention trial, in order to have a better study about the influence factors of the intervention effect. More effective intervention will be needed in the future.
Conclusions School-based nutrition and food safety education intervention resulted in a significant impact on students’ nutrition knowledge. The present study found that the nutrition and food safety education program were beneficial and effective for primary and junior high school students. This program seemed to be applicable, feasible, and is worth exploring further. Acknowledgements The authors thank the project sponsors, the China Association for Science and Technology Graduate science research capability class project for providing college graduate project funding and technical guidance. Thanks also to Hua-Ping Wang, Jing-Qiu Wang, Kun Li, Zhi-Jiao Zhang, Huan Zeng, Hong Wang, Yong Zhang, and Tao Gong in Chongqing Medical University for their active participation. Thanks to Professor Jianfei Guo in University of Cincinnati for the language polishing.
Conflict of interest The authors declare no conflict of interests.
Limitations
Funding
There are several limitations to this study. Firstly, the time for the program was short; students only engaged in one activity as a result of limited time and material resources. There was no control group at nine months follows up. Other changes might have occurred in the schools during the nine month
Contibutorship statement
This research received funding from the China Association for Science and Technology through its graduate student scientific research project funds.
All authors contributed to the design of the study. Wen-Jie Zhou and Xiang-long Xu were responsible for literature IUHPE – Global Health Promotion Vol. 23, No. 1 2016
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searches, the interpretation of the results, and writing the manuscript. Ge Li, Xiang-Long Xu, Ya-Ling Qie, and Yong Zhao participated in the development of the study protocol, data collection, and analysis. Yong Zhao, Ge Li, and Manoj Sharma contributed to the drafting of the manuscript. Yong Zhao was responsible for the conception of the study and overall supervision of the data collection and analysis, the interpretation of the results, and manuscript preparation. All authors have read and approved of the final manuscript.
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28. Wojtaś M, Kołłajtis-Dołowy A. Level of knowledge on food and nutrition among groups of pupils of the last class of secondary schools. Rocz Panstw Zakl Hig. 2012; 63: 213–217. 29. Takeda S, Akamatsu R, Horiguchi I, Marui E. Relationship among food-safety knowledge, beliefs, and risk-reduction behavior in university students in Japan. J Nutr Educ Behav. 2011; 43: 449–454. 30. Yusoff H, Daud WN, Ahmad Z. Nutrition education and knowledge, attitude and hemoglobin status of Malaysian adolescents. Southeast Asian J Trop Med Public Health. 2012; 43: 192–200. 31. Morgan PJ, Warren JM, Lubans DR, Saunders KL, Quick GI, Collins CE.The impact of nutrition education with and without a school garden on knowledge, vegetable intake and preferences and quality of school life among primary-school students. Public Health Nutr. 2010; 13: 1931–1940. 32. Wall DE, Least C, Gromis J, Lohse B. Nutrition education intervention improves vegetable-related attitude, selfefficacy, preference, and knowledge of fourth-grade students. J School Health. 2012; 82: 37–43. 33. Aldinger C1, Zhang XW, Liu LQ, Pan XD, Yu SH, Jones J, et al. Changes in attitudes, knowledge and behavior associated with implementing a comprehensive school health program in province of China. Health Educ Res. 2008; 23: 1049–1067. 34. Shi L, Zhang J, Wang Y, Caulfield LE, Guyer B. Effectiveness of an educational intervention on complementary feeding practices and growth in rural China: a cluster randomised controlled trial. Public Health Nutr. 2010; 13: 556–565. 35. Friel S, Hope A, Kelleher C, Comer S, Sadlier D. Impact evaluation of an oral health intervention amongst primary school children in Ireland. Health Promot Intervention 2002; 17: 119–126. 36. Watts SO, Piñero DJ, Alter MM, Lancaster KJ. An assessment of nutrition education in selected counties in New York State elementary schools (kindergarten through fifth grade). J Nutr Educ Behav. 2012; 44: 474–480. 37. Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010 to the Secretary of Agriculture and the Secretary of
Health and Human Services. Washington, DC: US Department of Agriculture; 2010. 38. CDC. Recommendations to prevent and control iron deficiency in the United States. MMWR 1998; 47: 1–29. 39. Schwarzer R. Modeling health behavior change: how to predict and modify the adoption and maintenance of health behaviors. Appl Psychol. 2008; 67: 1–29. 40. Ajzen I. The theory of planned behavior. Organiz Behav Hum Decisi Processes. 1991; 50: 179–211. 41. Maddux JE, Rogers RW. Protection motivation and selfefficacy: a revised theory of fear appeals and attitude change. J Exp Social Psychol. 1983; 19: 469–479. 42. Kelder SH, Perry CL, Klepp KI, Lytle LL. Longitudinal tracking of adolescent smoking, physical activity, and food choice behaviors. Am J Public Health. 1994; 84: 1121–1126. 43. Pivik RT, Tennal KB, Chapman SD, Gu Y. Eating breakfast enhances the efficiency of neural networks engaged during mental arithmetic in school-aged children. Physiol Behav. 2012; 106: 548–555. 44. Hoyland A, Dye L, Lawton CL. A systematic review of the effect of breakfast on the cognitive performance of children and adolescents. Nutr Res Rev. 2009; 22: 220–243. 45. Ma Y, Bertone ER, Stanek EJ 3rd, Reed GW, Hebert JR, Cohen NL, et al. Association between eating patterns and obesity in a free-living US adult population. Am J Epidemiol. 2003; 158: 85–92. 46. Cho S, Dietrich M, Brown CJ, Clark CA, Block G. The effect of breakfast type on total daily energy intake and body mass index: results from the Third National Health and Nutrition Examination Survey (NHANES III). J Am Coll Nutr. 2003; 22: 296–302. 47. Sjöberg A, Hallberg L, Höglund D, Hulthén L. Meal pattern, food choice, nutrient intake and lifestyle factors in the Göteborg Adolescence Study. Eur J Clin Nutr. 2003; 57: 1569–1578. 48. Berkey CS, Rockett HR, Gillman MW, Field AE, Colditz GA. Longitudinal study of skipping breakfast and weight change in adolescents. Int J Obes Relat Metab Disord. 2003; 27: 1258–1266. 49. So W-Y. Association between frequency of breakfast consumption and academic performance in healthy korean adolescents. Iranian J Publ Health. 2013; 42: 25–32.
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PED0010.1177/1757975914552914Original ArticleW. Zhou/X. Xu et al.
Original Article Effectiveness of a school-based nutrition and food safety education program among primary and junior high school students in Chongqing, China Wen-jie Zhou1*, Xiang-long Xu1*, Ge Li1, Manoj Sharma2, Ya-Ling Qie1 and Yong Zhao1
Abstract: Background: Health behavioral patterns, especially eating patterns, established in childhood often carry over into adulthood, and some of the unhealthy ones are later associated with adult morbidity and mortality. Recently, a few nutrition and food safety education programs have been implemented in primary and junior high schools in China. Purpose: This study aims to examine the effectiveness of a school-based nutrition and food safety education program among primary and junior high school students in China. Methods: A mixed study design incorporating an intervention study and a quantitative survey was conducted for this research. With stratified cluster sampling, students from the 5th and 6th grade in one primary school and the 7th and 8th grade in one junior high school in Chongqing, China, were all selected and separated randomly into an intervention group (n = 501) and a control group (n = 522). Effectiveness evaluation investigations were performed at the initial time and nine-month follow-up (n = 472), respectively. Effectiveness of pre-/post-intervention and nine-month follow-up changes in scores of nutrition knowledge and food safety was assessed using a two-tailed t-test and analysis of variance. Results: Nutrition knowledge scores for the intervention group were mean 9.03, SD±2.75 at the baseline, and 14.70±3.28 after intervention. There was a significant improvement (t = 29.78, p < 0.01). The nine-month follow-up knowledge scores of the intervention group were 12.35±2.89, which were lower than the immediately after the intervention group (t = 12.40, p 0.05).
Questionnaires Based on a related literature questionnaire on nutrition and food safety knowledge among primary and junior high school students, the questionnaire used throughout this study, which was self-designed, had good validity, reliability, and readability (18,19). The questionnaire was based on the KAP model,
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designed specifically for the target population, and completed after repeated discussions and pre-survey, which included four sections: basic information; nutrition knowledge; eating habits, attitude, and behavior; and food safety knowledge.
Ethics This study was approved by the Ethics Committee, Chongqing Medical University. Written informed consent was obtained from all participants.
Procedures Our educational interventions consisted of both lectures and a prize quiz game about nutrition and food safety. Lectures about nutrition education On the basis of the baseline assessment and input from experts, professors, and students of the department of nutrition and food hygiene of Chongqing Medical University, the lectures were jointly designed with contents of nutrition and food safety knowledge. The main content of the lectures included nutrition knowledge, good personal eating habits, the prevention of nutrient deficiency diseases, food safety issues, etc. Nutrition lectures were given to the six intervention groups by six senior medical college students, whose major was nutrition and had been strictly trained (we drafted a slideshow and a prospectus to guide the undergraduates in how to give the lectures) many times. Lectures were planned for 30 minutes; in addition, each class was arranged by two supervisors and had finished a preceding evaluation. At the same time, the control groups did not receive any intervention.
Survey implementation Before measures were taken, we launched a presurvey among 220 school students in each grade, and just selected one class from every grade for the survey. According to this survey, we found that students had poor knowledge of nutrition and food safety, suggesting that measures should be taken to control this particular troublesome situation. After the pre-survey, an investigation was carried out after an explanation of the purpose of the research by investigators who had undergone unified rigorous training for two years, and were familiar with the objectives and methodology. The questionnaire was executed after the intervention. Each class was allocated two investigators who had received instruction regarding the questionnaire for six hours and the investigators were standardized in answering any of the students’ questions if explanations were needed. Another two well-trained supervisors assessed the process of the intervention and investigation in the class. It took about 20 minutes to complete the questionnaires.
Assignment method of nutrition knowledge scores The questionnaire on nutrition knowledge, which contained 16 questions in total (13 solo choice items and three multiple choice items), was used to comprehensively assess the level of students’ nutritional knowledge. Each item had one score. As to the three multiple-choice items, all responses were structured in different ways according to how each question was answered, and each question had four distinct responses, with the score ranging from zero to three. Maximum score of nutrition cognition was 22.
Prize quiz game
Assignment method of the food safety knowledge scores
After the lecture, two nutrition-related prize quiz games were organized in each class, including a game of Chinese food guide pyramid, good personal eating habits, and a game of the prevention of nutrient deficiency diseases, food safety issues. Each game was scheduled for 10 minutes and two supervisors as reviewers were assigned to grade the answers. Depending on the students’ scores, the two supervisors gave out the awards.
The part on food safety knowledge consisted of eight questions in total. An assignment method was used to arrive at the comprehensive score of the students’ food safety knowledge. Each question could be directly judged as true or false; the correct answer was assigned two points, and wrong or no answers were assigned 0 points. If the subject’s answers were progressive relations, 1, 2, or 3 were assigned according to the progressive relationship; IUHPE – Global Health Promotion Vol. 23, No. 1 2016
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Table 1. The demographic characteristics of the intervention group and the control school students, China, 2011. Variables
Age (year) ≤10 11 12 13 14 ≥15 Gender Boy Girl Nationality Han Others The only child Yes No
Primary school students (n = 518) Intervention
Control
96 116 48 3 0 0
100 115 33 5 2 0
134 129
123 132
241 3
249 6
176 79
146 99
Junior high school students (n = 505)
χ2
p
4.34
0.23
0.38
–
4.84
Intervention
Control
1 5 77 115 38 2
0 5 73 117 64 8
122 116
138 129
227 3
263 2
148 80
154 107
0.54
0.51
0.03a
χ2
p
7.72
0.05
0.01
0.92
–
0.67
1.80
0.18
aThe
difference between the intervention group of primary school students and the control group was statistically significant (p < 0.05).
did not know or no answer were assigned 0 points. Finally, the investigators calculated the total score so as to comprehensively evaluate the nutrition knowledge level of participants. The total score of this section was 19.
Data analyses Data from the questionnaire-based inquiry were stored, after a strict sorting and data cleaning, and analyses were performed by statistical analysis system software (version 9.0; SAS Institute, Cary, NC). Missing data were excluded and all data entries were double-checked to avoid errors. Outcomes were evaluated at baseline, at postintervention, and at follow-up. Demographic characteristics of participants, awareness rate of nutrition knowledge, and the section on eating habits used χ2 tests. Evaluation of before/after and nine-month follow-up changes in scores of nutrition knowledge and food safety were performed by a two-tailed t-test and analysis of variance (any two groups compared with LSD method). All the statistics were predetermined as p-value < 0.05 for statistical significance.
Results Sample demographics A total of 1023 participants were organized into intervention (n = 501) and control (n = 522) groups. The demographic characteristics of the participants are presented in Table 1. There was one significant difference between groups (single child status in the primary school group) (χ2 = 4.84, p = 0.03). There were no significant differences with respect to participants’ age, gender, nationality, and sibling numbers between the intervention group and control group of study students.
Nutrition knowledge Immediately after the intervention, most of the awareness rates of nutrition knowledge improved significantly, with more than 10% having some knowledge of nutrition, such as about fats, proteins, and calcium. Moreover, awareness rates of the question ‘what kind of disease is salt ionization used to prevent’ rose to 70.30% (χ2 = 306.66, p < 0.01) (Table 2). The most significant improvement was the students’ understanding of the Chinese food guide pyramid.
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I (255) 0.47* 0.89 0.820 0.19 0.28 0.22 0.24* 0.13 0.24 0.42 0.26* 0.15 0.37
B (242) 0.52 0.92 0.89 0.24 0.28 0.22 0.19 0.18 0.34 0.27 0.15 0.09 0.25
I (238) 0.53 0.92 0.84 0.40* * 0.43* * 0.53* * 0.55* * 0.43* * 0.70* * 0.91* * 0.83* * 0.71* * 0.85* *
L (219) 0.67* * 0.94 0.93* 0.41* * 0.45* * 0.34* * 0.30* * 0.29* * 0.69* * 0.75* * 0.64* * 0.50* * 0.69* *
B (269) 0.37 0.87 0.862 0.18 0.26 0.20 0.15 0.12 0.19 0.38 0.19 0.12 0.34
B (273) 0.49 0.89 0.90 0.24 0.26 0.23 0.18 0.08 0.23 0.43 0.25 0.11 0.37
L (253) 0.57* * 0.95* 0.95* 0.24 0.44* * 0.32* * 0.32* * 0.18* * 0.78* * 0.80* * 0.53* * 0.28* * 0.76* *
Intervention group
Control group
Intervention group I (263) 0.63* * 0.92 0.90 0.39* * 0.48* * 0.48* * 0.67* * 0.55* * 0.91* * 0.94* * 0.90* * 0.62* * 0.86* *
Junior high school students
Primary school students
B (274) 0.51 0.94 0.91 0.18 0.28 0.20 0.16 0.17 0.31 0.31 0.15 0.07 0.29
I (267) 0.53 0.94 0.90 0.21 0.29 0.20 0.18 0.18 0.39* 0.33 0.17 0.10 0.31
Control group
B: Baseline, I: Instant, L: Long-term; : The difference between the baseline intervention group of primary school students and the baseline intervention group of junior high school students was statistically significant(χ2 = 7.37, p < 0.01); * : Before-after comparison of the instant intervention group and baseline intervention group, and the long-term intervention group and baseline intervention group (p < 0.05,* * p < 0.01); : Comparison of the baseline intervention group and baseline control group, and the baseline intervention group and instant intervention group (p < 0.05, p < 0.01); a : The difference between instant intervention group of primary school students and long-term intervention group was not statistically significant; b: The difference between instant intervention group of junior high students and long-term intervention group was not statistically significant (p > 0.05).
Proteina b Fatb Vitamin Ca b Calcium b Coronary disease (fat)a Anemia (Ferrum) Rickets (Vitamin D) Scurvy (Vitamin C) Goiter (iodine)b Diet pagoda Five layers pagoda The bottom layer Best amount of fat
Nutrition knowledge
Table 2. Comparison of the awareness rate of nutrition among the intervention group and the control group, China, 2011–2012.
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Table 3. Comparison of the average knowledge scores of nutrition among the intervention group and control group (x±s), China, 2011–2012. Period Group Primary school students Boy n B I L
Int Con Int Con Int
Secondary school students
Girl Scores
n
142 8.86±3.02a 132 8.85±3.07a 134 14.91±3.21* 123 9.89±3.42 132 11.62±2.67
Boy Scores
131 8.69±2.60b 137 9.09±3.49b 129 14.90±2.88* 132 10.05±2.95 121 12.91±2.58
n
Total
Girl Scores
126 8.91±2.56 141 9.94±3.62c 122 13.89±3.81* 138 10.59±3.03c 103 12.52±3.50
n
Scores
116 9.75±2.67d 133 9.70±2.60d 116 15.04±3.09* 129 10.60±2.87 116 13.27±2.46
n
Scores
515 9.03±2.75e 543 9.40±3.25e 501 14.70±3.28* 522 10.29±3.08 472 12.35±2.89
B: Baseline, I: Instant, L: Long-term, Int: intervention group, Con: control group; The knowledge scores of both transverse and longitudinal groups were also compared using analysis of variance (any two groups compared with LSD method); *:In five longitudinal groups, the instant intervention group had the highest scores, and the difference was statistically significant (p < 0.01). : In five transverse groups, the scores of the long-term intervention group were lower than the instant intervention group’s, but higher than the other three groups (p < 0.01). a, b, c, d, e: With five longitudinal groups, any two groups compared with LSD method, and the differences were not statistically significant (p > 0.05). : In 5 transverse baseline intervention groups, the secondary school girls group had the highest scores, and the difference was statistically significant (p < 0.05).
Those nutrition questions marked ‘a’ showed that the awareness of nutrition knowledge between the instant intervention group and long-term intervention group in primary school was not statistically significant. Those nutrition questions marked ‘b’ showed that the awareness of nutrition knowledge between the instant intervention group and long-term intervention group in junior high school was not statistically significant. However, the intervention group and control group in the baseline were high (p < 0.05). A comparison of the average knowledge scores of nutrition between the intervention group and the control group is shown in Table 3. The nutrition knowledge scores were from mean 9.03, SD±2.75 points (before the intervention) to 14.70±3.28 points (immediately after the intervention), and the differences were statistically significant (t = 29.78, p < 0.01). There were statistically significant differences between before and after the intervention in primary boys, primary girls, junior boys, and junior girls (t = 16.15, p < 0.01; t = 18.29, p < 0.01; t = 12.05, p < 0.01; t = 13.97, p < 0.01, respectively). The increase in amplitude was highest for primary girls (6.20 points), ahead of primary boys (6.05 points), junior
girls (5.29 points), and junior boys (4.98 points), respectively. The nutrition knowledge score of the long-term intervention group was 12.35±2.89. It was lower than for the immediately after intervention group (t = 12.40, p < 0.01), but higher than baseline (t =18.04, p < 0.01) and control groups. Nutritional knowledge scores were different between the long-term intervention group and instant intervention group. The primary boys, primary girls, junior boys, and junior girls scored 3.29, 1.99, 1.36, and 1.77, respectively. Boys in primary school recorded the fastest decline in score than others. Most importantly, the difference was statistically significant (p < 0.01).
Diet and behavior habits There were no statistically significant differences between baseline and control groups (p > 0.05) (Table 4).
Knowledge of preference for certain foods and picky eating habits Intervention can effectively alter the behavior of any preference for certain foods and picky eating habits.
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Table 4. Comparison of the eating habits between instant intervention and long-term intervention groups. Question Are you willing to change your picky eating habits from now on Are you willing to change your habit of eating high energy snacks from now on Are you willing to increase the frequency of eating breakfast from now on What is your first consideration on food choice aThe
χ2
p
No 34 17
14.09
0.05).
leak in Japan’ between immediately after and nine months later (χ2 = 10.28, p < 0.05). The knowledge scores on food safety among primary and secondary school students are shown in Table 6. The immediately after intervention group achieved higher scores than those of other groups (p < 0.01). There were significant differences between instant and nine months later intervention groups (t = 2.00, p < 0.05). There was no significant difference between different schools and different gender (p > 0.05). There were significant differences between before and instant primary boys and secondary girls (t = 2.99, p < 0.01 and t = 2.349, p < 0.01, respectively). The primary boys, primary girls, junior high boys, and junior high girls scored 1.50, 0.52, 0.76, and 1.13, respectively.
Discussion The means of medical university-based nutrition education At present, nutrition education in primary and secondary schools is deficient, which has led to primary and secondary school students’ lack of basic understanding of nutrition knowledge in China (9). Therefore, to help students develop lifelong healthy habits, more holistic health and nutrition curricula are needed that not only teach students health knowledge at the cognitive level but
also improve the nutritional status of school-age children and adolescents. It is urgent for schools and related departments to enhance nutrition education in primary and secondary schools, and to explore various ways to improve the young generation’s nutrition KAP at the same time. Inclusion of nutritional education in primary and secondary school curricula is one effective way (10,14). To participate in the work of popular science, there is a tremendous need for more professionals to be devoted to it; the development of college students’ science associations and students’ science and technology organizations (9,11) is a reciprocal choice. Through these organizations, science and technology activities have started to enter into the school lives of primary and secondary school students in recent years. Many nutritional science research studies focus on theoretical topics and are restricted to the laboratory in China (4). Few of them pay much attention to popular science activities, even on nutrition and food hygiene in schools, and few evaluations on the effects immediately after and in the longer term have been conducted. This is the theme of our study, and the issue to which this study seeks to draw more attention. We encourage nutrition undergraduates to serve schools with their professional skills, including the development of nutrition education. This could provide opportunities for them to practice their professional theories in the real world and help them find their own goal at the same time. IUHPE – Global Health Promotion Vol. 23, No. 1 2016
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Immediate and long-term effect evaluations were carried out to provide a theoretical basis for nutrition education involved in primary and secondary school education. The results prove that this intervention appeared to be effective and that it is worth exploring. Further schoolbased nutrition education efforts should focus on culturally and geographically appropriate, multicomponent approaches that actively involve family members, schools and teachers, community members, and health and nutrition experts (26). We also recommend that nutrition-information interventions can be more effective when using nutrition information that is generally liked by the target population in combination with an educational intervention to increase objective nutrition knowledge. We can use active learning strategies include simulations and learning games, teacher and peer modeling, role-playing, and so on.
The effectiveness of medical college-based nutrition education for primary and junior high school students’ nutrition KAP In this study, the scores illustrated that knowledge of nutrition and food safety among primary and junior high school students was seriously lacking, which was similar to the findings of other reports (17,27–29). Nevertheless, after this intervention, the awareness scores of nutrition and food safety knowledge were higher than before, and effectiveness continued to nine months later, which was similar to the results of other reports (30–36). Especially, the awareness of ‘the association between microelements and disease’ (18,33), ‘Chinese food guide pagoda’, ‘spoiled food’, and ‘the problem of hot food’ was significantly different before and after the interventions. In addition, the majority of the students under intervention indicated that they would pay more attention to food, but no difference was found in the control group. To some extent, through the contrast before and after intervention, the nutrition and food safety information acquired in this education program indicates that the students’ knowledge of nutrition has improved. All the things we have mentioned demonstrate that this program was effective, feasible, and worthy of being popularized.
The effectiveness of medical university-based nutrition education interventions for changing eating behavior among primary and junior high school students Healthy eating in childhood and adolescence is important for proper growth and development and can prevent health problems such as obesity, dental caries, iron deficiency, and osteoporosis (37,38). It is generally known that health promotion is a transformation process of knowledge, attitude, and behavior (11–13,20,27). The awareness of nutrition plays a vital role in shaping healthy eating behavior; meanwhile, the change of attitude is the principal element to lead to changing behavior (9). Thus, besides enhancing the awareness of nutrition and food safety among primary and junior high students, healthy eating behavior is also important. A study has shown that dietary intentions and planning are assumed to be primary predictors of dietary changes (39). Most health behavior models share the assumption that the intention to change is a predictor of actual behavior (40,41). Based on the results of this investigation, the majority of the school students were willing to change their bad eating behaviors after intervention, such as picking food, eating junk food, and not having breakfast every day, which was similar to the results of earlier reports (9,18,31,34–39). However, the change of attitude was not significantly different nine months later, which may be due to lack of continuous intervention. Moreover, this result may demonstrate that the effect of this intervention is limited on the change of attitude, and more effective intervention will be needed in the future. In addition, changes in behavior also need to be evaluated in further research. Food choice patterns established during youth will likely influence long-term behaviors (42). The use of food safety information when people select food products should decrease food risk as well as consumers’ concerns when selecting food.
The future of medical college-based nutrition education interventions Compared with the control group, the intervention was impactful. The study shows that nutritional knowledge scores were different between long-term and instant intervention groups. Schools have an
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important role to play in equipping children with the knowledge, attitudes, and skills they need in order to protect their health. Young persons need nutrition education to assist them to develop lifelong eating patterns consistent with the Dietary Guidelines for Chinese Food Guide Pyramid. This was the first time that we were able to cooperate with the students’ association and organizations of a medical college, and implement the program via a medical collegebased nutrition education method for primary and secondly school students. College students, especially medical university students, should take more responsibility for nutrition and health knowledge communication and popularization. Meanwhile, we have built a long-term cooperation mechanism with primary and secondary schools on nutrition education. Comparison of the difference between long-term and immediate intervention groups revealed the need to constantly develop nutrition knowledge by strengthening the consciousness of students, otherwise they will gradually forget.
Daily consumption of breakfast In recent years, many primary and middle school students in China often do not eat breakfast for reasons such as lack of time or parents who are busy working. Although some are eating breakfast, energy intake is inadequate and quality is poor. Several studies have reported that breakfast consumption is linked to some aspects of brain function, such as neural network activity and cognitive performance (43,44). Studies have shown that regularly skipping breakfast is closely linked to increased rates of obesity in all age groups (45–49). Our research shows that the length of the intervention time has not affected the effect of the interventions on breakfast. Increasing frequency of breakfast was positively correlated with students’ performance in both male and female healthy adolescents (4).
period that affected children’s knowledge, but there was no way of seeing this. If there were sufficient time to organize more activities, the effect of intervention may be better. Secondly, we only selected one primary school and one middle school and random selection was not done. Extrapolation to other schools’ students remains to be further validated. Furthermore, the effect of this intervention is limited to the change of attitude; eating habits were self-reported rather than measured in a more objective way. Nevertheless, this intervention trial could be easily reproduced in other regions. Course topics and the content of the nutrition lecture can be applied to other places. In the future, different areas can replicate the intervention trial, in order to have a better study about the influence factors of the intervention effect. More effective intervention will be needed in the future.
Conclusions School-based nutrition and food safety education intervention resulted in a significant impact on students’ nutrition knowledge. The present study found that the nutrition and food safety education program were beneficial and effective for primary and junior high school students. This program seemed to be applicable, feasible, and is worth exploring further. Acknowledgements The authors thank the project sponsors, the China Association for Science and Technology Graduate science research capability class project for providing college graduate project funding and technical guidance. Thanks also to Hua-Ping Wang, Jing-Qiu Wang, Kun Li, Zhi-Jiao Zhang, Huan Zeng, Hong Wang, Yong Zhang, and Tao Gong in Chongqing Medical University for their active participation. Thanks to Professor Jianfei Guo in University of Cincinnati for the language polishing.
Conflict of interest The authors declare no conflict of interests.
Limitations
Funding
There are several limitations to this study. Firstly, the time for the program was short; students only engaged in one activity as a result of limited time and material resources. There was no control group at nine months follows up. Other changes might have occurred in the schools during the nine month
Contibutorship statement
This research received funding from the China Association for Science and Technology through its graduate student scientific research project funds.
All authors contributed to the design of the study. Wen-Jie Zhou and Xiang-long Xu were responsible for literature IUHPE – Global Health Promotion Vol. 23, No. 1 2016
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searches, the interpretation of the results, and writing the manuscript. Ge Li, Xiang-Long Xu, Ya-Ling Qie, and Yong Zhao participated in the development of the study protocol, data collection, and analysis. Yong Zhao, Ge Li, and Manoj Sharma contributed to the drafting of the manuscript. Yong Zhao was responsible for the conception of the study and overall supervision of the data collection and analysis, the interpretation of the results, and manuscript preparation. All authors have read and approved of the final manuscript.
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