NSM-NCD2013 Symposium 2a - Healthy Kids Programme - Development and evaluation of Nutrition...

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Healthy Kids Programme Development and Evaluation of Nutrition Education Package for

Primary School Children

Dr Zawiah Hashim Dr Tee E Siong

Prof Dr Norimah A Karim Dr Chin Yit Siew

Expert Panel, Healthy Kids Programme Nutrition Society of Malaysia

Presented @ NCD conference, Renaissance Hotel KL, March 26, 2013

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Healthy Kids Programme (HKP) in Malaysia

• Aim to improve nutrition knowledge and promote healthy lifestyle among school children

• Consists of two main components

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Jointly implemented by

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Overview of Activities

HKP (2011-2013)

A. AWARENESS (On-going)

Parent & Children

- Website: Monthly upload on healthy eating & physical activity content (article & interactive tools)

B. RESEARCH (2011 – 2013)

A longitudinal (2010-2013) intervention study to develop, implement and evaluate the nutrition education modules appropriate for primary school children

Ultimate goal at the end of 3-year study is to develop interactive nutrition modules that the MOE can implement in all primary schools

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A. Awareness Component (Education on healthy eating & active living)

Parent – Children Website

www.healthykids.org.my

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http://www.healthykids.org.my/

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Website for Parents & Children

• Online resource on nutrition for school going children anywhere in the country

• Target audiences:

o Children and parents

• Dedicated website

• No mention of brands /products except for corporate logo

• Contents: o Parents:

• Healthy eating (snacking tips, food pyramid)

• Meal planning (+ planner)

• Measuring child’s BMI (+ BMI tool)

• Exercising with children

• Understanding nutrition information panel and food labels

• Easy recipes

o Children: • Understanding pyramid, digestive

system

• Interactive games on various sports

• Choosing healthy snacks

• Easy recipes

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www.healthykids.org.my

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http://www.healthykids.org.my/

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Website Highlights (1): Interactive Tools (For Parents)

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Website Highlights (2): Interactive Tools (For Parents)

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TM Website Highlights (3): Interactive Tools (For Children)

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TM Website Highlights (4): Interactive Tools (For Children)

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Website Highlights (5): Interactive Tools (For Children)

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Website Highlights (6): Articles for Parents

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Website Highlights (7): Articles for Children

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TM Website Highlights (5): Recipes for Parents

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B. Research Component

Longitudinal Study to Develop and Evaluate

Nutrition Education Package For

Primary School Children

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The Need to Conduct this Research

• Important to increase awareness of teaching nutrition knowledge

• HKP aims to develop a set of educational materials for this purpose

• A longitudinal intervention progamme to:

o Develop appropriate educational modules

o Evaluate effectiveness of these modules

• The findings will demonstrate the effectiveness of interactive nutrition education sessions to improve nutrition knowledge and attitude of the children.

• Lack of appropriate

educational module

• Insufficient

emphasis by school

authorities, parents

Lack of

teaching of

healthy eating

and physical

activity

Alarming

nutritional

problems –

obesity on

the rise

Healthy lifestyle

promotion

among school

children is

important

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Our Goals 1. To develop appropriate modular educational

materials to facilitate teaching of nutrition to primary school children

2. To share with the Ministry of Education the developed educational materials for teaching of nutrition in all primary schools in the country

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4 Key Objectives of the Research 1. To determine the level of knowledge, attitude and practices

on nutrition and physical activity

2. To determine the nutritional status through body mass index (BMI) measurements.

3. To develop modular educational materials to improve nutrition and physical activity knowledge and practices

4. To evaluate the effectiveness of these educational interventions.

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Research Framework

Expert Committee Develop research questionnaire &

educational materials tools to

improve KAP

Conduct “Educational” Intervention

(every 2 weeks, 6 times per year)

Conduct KAP survey &

measure BMI (end of the year)

Selection of 6 intervention schools

(~ total of 200 subjects)

Repeat for 2nd & 3rd Year.

Data analysis

Baseline data Collection :

Conduct KAP survey & measure BMI (beginning of

the year)

Intervention (2011-2013)

Step 1

Step 2

Step 3 Step 4

Step 5

Step 6

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Research Method

1. Study subjects and study duration (3 years)

2. Sample Size (Random sampling)

2011 207 students from 6 schools

Standard 3

(2011)

Standard 4

(2012)

Standard 5

(2013)

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2012 189 students from 6 schools

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Research Method (cont’d)

3. Questionnaire for beginning and at the end of the year (KAP) • Part A : Socio Demographic Data • Part B : Nutrition Knowledge • Part C : Nutrition Attitude • Part D : Nutrition Practice • Part E : Anthropometry Data

4. Questionnaire before and after each educational sessions 5. Data analysis

• Using SPSS version 15

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Knowledge, Attitude & Practice Survey – at the Beginning & End of Each Year

• Conducted at the beginning of year (Feb) and at the end of year (Oct)

• 26 questions to determine status of nutrition knowledge, attitude and practices (KAP) among subjects.

Nutrition Knowledge

• Covering healthy habits, food pyramid, function of food group, healthier food choices, physical activity and hygiene

Nutrition Attitude

• Perception of what is healthy and unhealthy lifestyle habits

Nutrition Practice

• Questions on students eating habits (eg. breakfast consumption) as well as physical activity

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Intervention (Educational) Sessions: Standard Module

• 6 sessions per year conducted • Students are given a set of educational materials after each session

“Engagement” Session

(Learning Through Games, Q&A)

Introduction & Refresher Sessions

(Going Through Worksheets Of Previous Topic)

Immediate Impact Survey on

Knowledge (5Q) Before intervention

“Educational” Session (Short PPT To Recap Messages Based On “Engagement” Session

Briefing & Dissemination of materials

(Worksheets, Goal Cards & Leaflet For Parents)

7 mins 5 mins 15 mins

5 mins 5 mins 5 mins

Immediate Impact Survey on

Knowledge (5Q) After intervention

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No Educational Area

TOPICS

2011 (Standard 3) 2012 (Standard 4) 2013 (Standard 5)

1 Health/ Nutrition 1

Healthy Habits Cereals & Cereal Products for Energy

Healthy Cooking Methods

2 Nutrition 2 Food Pyramid Fruits And Veggies For Health Read Food Labels And Choose Wisely

3 Nutrition 3 Eating Regular Meals Grow Stronger with Fish, Meat, Poultry, Milk & Dairy Products

Eating Out Healthily

4 Nutrition 4 Choosing Healthier Meals

Limit Fats, Sugar & Salt Eating Problems And Its Implications

5 Physical Activity

Be Active Everyday

Let’s Exercise & Participate in Sports (5- 6 X A Week)

Increase Strength & Flexibility

6 Food Safety & Hygiene

Personal Hygiene Prepare And Consume Safe & Clean F&B

Recap of 3 Years Topics

Educational Modules: Topics Year 1:

Laying the foundation on healthy eating (& keeping active)

Year 2: Understanding functions of

various food group (& active in sports)

Year 3: Applying healthy eating

in daily life (& increase strength)

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YEAR 1 & 2: 2011 -2012 Pictorial Report Props for Engagement Sessions

Worksheets, Goal cards & Parent’s Leaflets

Photos during beginning of the year survey

Photos during intervention sessions

Photos during at the end of the year survey

Results overview

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Props for Engagement Session Year 1 (2011)

Topic 1 Topic 2

Topic 3

Note: No props developed for Topic 5

Topic 4

Topic 6

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Props for Engagement Session Year 2 (2012)

Topic 1

Topic 3

Topic 4

Note: No props developed for Topic 2, 5 & 6

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Worksheets for Children Year 1 (2011)

Topic 2

Topic 1

Topic 3

Topic 4

Topic 5

Topic 6

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Topic 2

Topic 1

Topic 3

Topic 4

Topic 5

Topic 6

Worksheets for Children Year 2 (2012) TM

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Goal Cards for Children Year 1 (2011) Topic 1

Topic 2

Topic 3

Topic 4

Topic 5

Topic 6

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Topic 1

Topic 2

Topic 3

Topic 4

Topic 5

Topic 6

Goal Cards for Children Year 2 (2012)

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Leaflet for Parents Year 1 (2011) Topic 1

Topic 3 Topic 2

Topic 4

Topic 6 Topic 5

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Topic 1 Topic 3 Topic 2

Topic 4 Topic 6 Topic 5

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Leaflet for Parents Year 2 (2012)

Folder of HKP Educational Modules

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Photos: Survey at the Beginning of the Year

Weight and Height Measurement Session KAP Survey

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Photos: Intervention Session Year 1 (2011) TM

Engagement sessions 2011

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Photos: Intervention Session Year 2 (2012) TM

Engagement sessions 2012

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Photos: Intervention Session Year 1 & 2 (2011 - 2012) TM

Power Point Presentation and Q & A session

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Briefing on worksheets & goal cards

Photos: Intervention Session (2011 -2012)

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Weight and Height Measurement Session KAP Questionnaire Session

Photos: Survey at the End of the Year

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Year 1 & 2: 2011-2012 Results

1. Nutritional Status (BMI-for-age)

2. Immediate Impact Survey on Knowledge (before

and after each intervention sessions)

3. Nutrition Knowledge, Attitude & Practices (KAP)

Results (year 2011 - 2012)

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1. Nutritional Status

Weight and height measurement (BMI)

conducted at the beginning and

at the end of the year

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Figure 1.1: Nutritional status of intervention (n=153) and control (n=116) groups in year 2011 and 2012

Prevalence of overweight and obesity was high, but the control group was higher than intervention group.

Note: BMI at 2011 was collected in Feb 2011; BMI at 2012 was collected in Sept-Nov 2012.

2. Immediate Impact Survey on Knowledge for Year 1 and Year 2 Topics

Knowledge survey conducted before and

after each intervention sessions

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Module Topic Mean Score Mean Difference

(Increment) Before edu session After edu session

2011

1. Healthy Habits (n=187) 87.2 95.6 8.4

2. Food Pyramid (n=189) 77.6 85.1 7.5

3. Eating Regular Meals (n=180) 86.4 88.6 4.6

4. Choosing Healthier Meals (n=189) 77.4 78.7 1.3

5. Be Active Everyday (n=187) 87.4 98.2 9.8

6. Personal Hygiene (n=194) 87.0 90.1 3.1

2012

1. Grains & Tubers for Energy (n=182) 85.6 (19.8) 87.4 (17.0) 1.8

2. Fruits & Vegetables for Health (n=170) 77.5 (15.1) 90.8 (13.6) 13.3

3. Grow stronger with Protein Food (n=165) 64.7 (17.8) 80.5 (14.7) 15.8

4. Limit Fats, Sugar & Salt Intake (n=167) 61.8 (15.3) 80.0 (18.9) 18.2

5. Let’s Exercise & Participate in Sports (n=158) 85.8 (16.3) 88.5 (13.8) 2.7

6. Consume Safe & Clean F & B (n=155) 92.1 (18.2) 93.3 (12.7) 1.2

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Table 2.1: Mean of knowledge survey score before and after intervention in year 2011 and 2012

Increased in mean IIS score after intervention session for all modules.

3. Nutrition Knowledge, Attitude & Practices (KAP) Results

KAP survey conducted at the beginning of

the year and at the end of the year

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Figure 3.1: Mean Knowledge score of intervention and control groups from year 2011 to 2012

There was a significant improvement in mean knowledge score in both groups. The improvement among intervention group was significantly higher than control.

The mean knowledge score of the intervention group is always higher than that of the control group.

Within group F(55.7), p<0.001

Between group F(4.9), p<0.01

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Figure 3.2: Mean Attitude score of intervention and control groups from year 2011 to 2012

There was no significant difference in attitude score between both group. The mean attitude score among the intervention group was higher than control group.

Within group F(1.9), p=0.13

Between group F(1.7), p=0.17

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Figure 3.3: Mean Practice score of intervention and control groups from year 2011 to 2012

There was a significant improvement in mean practice score in both groups. The mean practice score of the intervention group is always higher than that of the control group

Within group F(37.8), p<0.001

Between group F(1.7), p=0.18

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No. Intervention (n=151) Frequency

n (%) Control (n=121)

Frequency n (%)

Beginning of the year 2011

1. Snacks (chips, keropok,kerepek) 81 (53.6) Snacks (chips, keropok,kerepek) 89 (73.6)

2. Sweets 42 (27.8) Sweets 28 (23.1)

3. Ice-cream 37 (24.5) Chocolate 25 (20.7)

End of the year 2012

1. Snacks (chips, keropok,kerepek) 114 (75.5) Snacks (chips, keropok,kerepek) 119 (98.3)

2. Biscuit 46 (30.5) Chocolates 24 (19.8)

3. Bread 42 (27.8) French fries 22 (18.2)

Table 3.1: Top 3 most favourite snacks in year 2011 and 2012

• Improvement of snack option (bread, biscuit) among the intervention group. • Intervention group had better snack option than the control group.

Note: KAP at 2011 was collected in Feb 2011.; KAP at 2012 was collected in Sept-Nov 2012.

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Table 3.2: Top 3 most purchased food from canteen in year 2011 and 2012



Frequency n (%)


1. Nasi lemak 72 (47.7) Nasi lemak 41 (33.9)

2. Sausage 38 (25.2) Sausage 22 (18.2)

3. Nugget 33 (21.9) French Fries 22 (18.2)


1. Nasi lemak 81 (53.6) Nasi lemak 45 (37.2)

2. Sausage 39 (25.8) Nugget 39 (32.2)

3. Fried noodle 31 (20.5) Bread 38 (31.4)

Nasi lemak and sausage remained as the most purchased food in year 2012 for intervention group.


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Table 3.3: Top 3 most frequent drinks in year 2011 and 2012



Frequency n (%)


1. Cordial drinks 109 (72.2) Plain water 77 (63.6)

2. Plain water 104 (68.9) Cordial drinks 69 (57.0)

3. Milo 65 (43.0) Milo 49 (40.5)


1. Plain water 96 (63.6) Cordial drinks 74 (61.2)

2. Milo 83 (55.0) Plain water 71 (58.)

3. Cordial drinks 60 (39.7) Milo 57 (47.1)

• Percentage of student in intervention group drinking cordial drinks has decreased tremendously. • Intervention group children showed better drink option than control group.


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Table 3.4: Top 3 most consumed breakfast in year 2011 and 2012



Frequency n (%)


1. Bread 86 (57.0) Bread 80 (66.1)

2. Sandwich 43 (28.5) Cereals 22 (18.2)

3. Cereals 40 (26.5) Biscuit 21 (17.4)


1. Bread 98 (64.9) Bread 75 (62.0)

2. Biscuit 49 (32.5) Cereals 36 (29.8)

3. Cereals 41 (27.2) Fried rice 29 (24.0)

• Increased in percentage of bread and cereals consumption among intervention group. • Percentage of bread and cereals consumption among intervention group was higher than the

control group.


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Table 3.5: Top 3 most favourite leisure time activities in year 2011 and 2012



Frequency n (%)


1. Football 71 (47.0) Football 53 (43.58

2. Badminton 58 (38.4) Badminton 47 (38.8)

3. Cycling 54 (35.8) Cycling 45 (37.2)


1. Badminton 78 (51.7) Badminton 62 (51.2)

2. Football 65 (43.0) Football 52 (43 .0)

3. Cycling 62 (41.1) Cycling 43 (35.5)

Increased in percentage of choosing badminton, football and cycling as their leisure time activities among the intervention group


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Summary of Main Findings

Year 1 & Year 2 (2011 – 2012)

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Main Findings

• High prevalence of overweight and obesity among the students.

o Overweight & obese child will most likely to become overweight teenager and if not curb, will become a overweight adult and at risk of chronic diseases (hypertension, heart disease, diabetes, etc)

o There is an urgent need to promote healthy eating and active living practices among school children.

• Nutrition knowledge score increased in all 12 topics after each intervention.

o This shows that the children in the intervention group learned from each educational session.

• Nutrition knowledge, attitude and practices scores improved after 2 years.

o The knowledge gain should be put into daily practice and should benefit the children in many years to come.

o With better nutritional status, children’s health will improve, school performance also will improve as they will pay attention better, less absenteeism.

o In summary, the educational modules have shown some benefit and the study should be continued to the final year (year 3).

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YEAR 3: 2013 Intervention Session

Topic of the modules

Objectives of the topics

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2013 Intervention Modules TM

Topics Healthy

Food Preparation

Read Food Labels and

Choose Wisely

Eating Out Healthily

Problems Related to Nutrient

Imbalance

Increase Strenght and

Flexibility

Recap of Year 1 – Year 3

Modules

Objectives

To educate

students on

healthy cooking

methods /

preparation

To educate

students to

make use of the

information on

food labels

when choosing

packaged foods

To educate

students on

healthier

food choice

while eating

out

To educate

students on the

problems related

to nutrient

imbalances and

the implications

To educate

students and

encourage them

to participate in

activities that

increase

flexibility and

strength

To recap the

topics learnt

by the

students from

year 1 to year

3

• Learning through fun and engaging games

• Worksheets to reinforce messages

• Letter-cum-leaflet to parents to encourage home practice

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End

Thank You

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NSM-NCD2013 Symposium 2a - Healthy Kids Programme - Development and evaluation of Nutrition...

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