Introduction
Based on the results of Nutrition and Health Surveys in Taiwan, the consumption of sugar-sweetened beverages, insufficient consumption of vegetables and fruits, and insufficient intake of dairy products among schoolchildren constitute pressing nutritional issues. Dietary intake has a profound impact on children’s development and health and may further affect their health conditions in adulthood.(Reference Murimi, Moyeda-Carabaza, Nguyen, Saha, Amin and Njike1) Imbalanced nutrition intake is considered to be closely related to childhood obesity which can lead to an increased incidence of CVD, diabetes, asthma, and sleep apnoea.(Reference Lloyd, Langley-Evans and McMullen2–Reference Bacha and Gidding6) The necessity and benefits of preventing and controlling childhood obesity has been suggested in literatures.(Reference Pandita, Sharma, Pandita, Pawar, Tariq and Kaul7) A survey study in Taiwan revealed that the frequency of vegetable consumption in overweight schoolchildren was lower than that of students with normal body weight.(Reference Chou and Chen8) Excessive consumption of sugar-sweetened beverages(Reference Malik, Pan, Willett and Hu9–Reference Leung, DiMatteo, Gosliner and Ritchie11) and skipping breakfast in schoolchildren are also unhealthy lifestyles which have been linked to increased risk of obesity and CVD.(Reference Adolphus, Lawton, Champ and Dye12–Reference Shang, Li, Xu, Zhang, Hu and Liu14)
The school-based health interventions have demonstrated results of developing healthy behaviours among elementary students.(Reference Brown, Moore, Hooper, Gao, Zayegh and Ijaz15)A systematic literature review indicated that childhood obesity and subsequent health problems could be improved through nutrition education.(Reference Leis, de Lamas, de Castro, Picáns, Gil-Campos and Couce16) Nutrition education courses can improve participants’ nutritional knowledge and help improve badly balanced eating habits.(Reference Li17) Those with better nutritional knowledge tended to demonstrate healthy dietary behaviours, such as increased consumption of vegetables and fruits, and decreased consumption of sugar.(Reference Dickson-Spillmann and Siegrist18) In the childhood obesity prevention guideline compiled by the Taiwan Pediatric Association, it was strongly recommended that nutrition education be incorporated into the core curriculum of schools.(Reference Lee, Tiao, Yeung, Lin and Chen19) Presently, nutrition-related topics are included in health education curriculum for schoolchildren in Taiwan. However, in practice, health education teachers in elementary schools do not necessarily have expertise in health education, and they often face challenges when guiding students in obtaining health-related knowledge and skills.(Reference Lin20) Consequently, elementary school children may not be able to acquire knowledge on healthy eating in schools, which may affect the development of healthy dietary behaviour.
To promote nutrition education on campus and improve the dietary habits of schoolchildren, the WHO has put forward specific teaching recommendations based on empirical research. Selected recommendations were adopted to develop intervention materials of this study: (1) Designing professional nutrition courses; (2) Parental participation; (3) Experiential learning such as cooking and food preparation activities; (4) Using media for teaching; (5) Establishing a learning community to provide resources and feedback.(21) These teaching strategies should be implemented and evaluated by empirical research. Scholars have proposed the concept of parental influences on shaping the children’s preferences and eating behaviours.(Reference Savage, Fisher and Birch22) In addition to nutrition educators working in schools, parents may also play a similar and active role in teaching their children about nutrition.(Reference Gillespie and Achterberg23–Reference Schafer and Keith25) Increasing nutrition interventions attempted to incorporate family involvement and take-home activities to encourage good nutrition practices at home(Reference Charlton, Comerford, Deavin and Walton26,Reference Murimi, Moyeda-Carabaza, Nguyen, Saha, Amin and Njike27) ; however, a systematic review of nutrition interventions with parental involvement showed the inconclusive effectiveness.(Reference Verjans-Janssen, van de Kolk, Van Kann, Kremers and Gerards28) The possible explanations for the inconclusive results might be that ensuring parental involvement in school-based interventions was challenging, and the information on parental attendance was often lacking.(Reference Langford, Bonell, Jones and Campbell29) Further approaches to encourage parental engagement need to be explored and tested. The present study referred to the above recommendations, considered common dietary problems of Taiwanese schoolchildren, and designed a nutrition education course module that combined simulation teaching videos and parental involvement. Simulation is considered an effective educational technique in nursing education. Either virtual patients or scenarios are commonly created for nursing students to practice and acquire skills.(Reference Lavoie and Clarke30–Reference Koukourikos, Tsaloglidou, Kourkouta, Papathanasiou, Iliadis, Fratzana and Panagiotou32) Simulation video is also recommended as a teaching media to enhance student engagement in the learning process.(Reference Coyne, Frommolt, Rands, Kain and Mitchell33) Its possible application in nutritional education should also be examined. The objective of the study was to evaluate the effectiveness of the intervention and to observe whether this curriculum could improve schoolchildren’s knowledge, positive attitudes, and behavioural practices about healthy eating.
Methods
Study participants
This study adopted a quasi-experimental design. The experimental group and the control group were recruited from two elementary schools located in different districts in Taipei City in Taiwan. Study participants were third-grade students aged 9–10. The experimental group consisted of 35 students who received nutrition education module instruction. The control group consisted of 30 students who received health courses that were not related to nutrition education (e.g. physical activity and personal hygiene) during the intervention period. Before the participants were recruited, the school teachers confirmed that neither of the two groups had taken relevant nutrition courses. This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving study participants s were approved by the Tri-Service General Hospital in Taiwan (#1-106-05-065). Written informed consent was obtained from the guardians of all participants and their parents.
Course module planning and preparation
The course module consisted of four lessons of 40 minutes each, which were implemented from September to October 2018. The four lessons conducted weekly for four weeks. Course topics were formulated based on schoolchildren’s nutritional issues as identified in the literature review, prior understanding of learners’ needs, and taking into the consideration the folk festivals occurring during the semester. The four themes were Sugar patrol, Balanced Diet during the Mid-Autumn Festival, Rainbow Fruit and Vegetables, and Smart Dine Out. Table 1 presents details about the topic contents and course flow.
Table 1. Content of the nutrition education course modules for the experimental group
The course began with a five-minute simulation video depicting the daily life and dietary experience of a fictional character ‘Student Nutritionist Mimiko’, such as going to the market with family to buy groceries and hanging out with classmates for a meal in a restaurant. Teachers used these simulation videos to stimulate students’ learning motivation and guide students to connect the scenario in the video with life experiences. After watching the videos, the teaching was then extended to guide students to realize the importance of healthy eating and to discuss how to implement healthy eating behaviours in daily life. Each lesson ended with a specially designed homework assignment, ‘Little Nutritionist Learning Worksheet’, allowing students to assume the role of nutritionists at home and fill out the worksheet with their parents, thereby extending the effectiveness of classroom learning. To encourage parental participation, the instructor prepared a ‘letter to parents’ before the intervention started, explaining course objectives and establishing an online communication group to provide resources and feedback.
Evaluation of intervention effectiveness
Intervention effectiveness was evaluated using a self-administered questionnaire which was compiled according to the study objectives and with reference to the questionnaires used in the Nutrition and Health Survey in Taiwan (NAHSIT) which was a series of surveys conducted by the government. The target population of the surveys included elementary school students, and the specialized questionnaires were planned.(Reference Administration34) A total of 43 questions were used to assess ‘Healthy Eating Knowledge’, including the functions of foods, nutrients and disease, nutritional contents in food, tips for making healthy food choices, the necessity of balanced diet, and the concept of healthy eating. A higher score indicates better knowledge about healthy eating (Cronbach α = 0.72). Fifteen questions were used to assess ‘Healthy Eating Attitudes’, referring to the attitude towards making healthy eating choices. A five-point scale was used for scoring, with a higher score indicating a more positive attitude towards healthy eating (Cronbach α = 0.68). Finally, 16 questions were used to evaluate ‘Healthy Eating Behaviour’, concerning the recommended daily intake of six food groups, healthy breakfast intake, sugar-sweetened beverage consumption, fried food consumption, and low-nutrient-density food consumption. A higher score in this question set indicated a better implementation of healthy eating behaviours (Cronbach α = 0.63).
Data collection and statistical analysis
Both the experimental group and the control group took a questionnaire survey before and after the nutrition education course. The collected data were analysed using SPSS 23 (SPSS, IBM, Armonk, NY). Generalized Estimating Equations (GEE) were used to assess the effectiveness of curriculum intervention on healthy eating knowledge, attitude, and behaviour. The GEE method can be used to analyse repeated measures with non-normal response variables, and it can take into account the correlation of within-subject data.
Results
The pre- and post-test questionnaires
All the participants of two groups completed the intervention and the pre- and post-test questionnaires. There were no statistically significant differences between the experimental and control groups in terms of gender distribution, self-perceived body size satisfaction, and BMI (Table 2). The two-sample t-test showed that there was also no significant difference in the pre-test scores of healthy eating knowledge, attitude, and behaviour between the two groups (Table 3). The results of the GEE analysis showed that the intervention had no significant effect on the mean overall score for healthy eating knowledge (β = 2.452, P = 0.147). However, there was a significant improvement in ‘tips for making healthy choices’ and ‘the necessity of balanced diet’ after intervention (β = 0.81, P = 0.06; β = 1.257, P = 0.007) (Table 4). The intervention also had a significant effect on the attitude towards healthy eating (β = 4.705, P = 0.048) (Table 5), but not on healthy eating behaviour (Table 6).
Table 2. Study participant characteristics, BMI, and pre-test scores
Table 3. Mean scores of healthy eating knowledge, attitude and behaviour before and after the intervention
a Comparison of pre-test scores between the two groups using the two-sample t-test.
Table 4. GEE analysis results of the effectiveness of nutrition education intervention on healthy eating knowledge
Note: Y = β0 + β1 (pre- and post-test) + β2 (group) + β3 (pre- and post-test × group); Pre- and post-test: post-test = 1, pre-test = 0, Group: experimental group = 1, control group = 0.
Table 5. GEE analysis of the effectiveness of nutrition education intervention on healthy eating attitude
Note: Y = β0 + β1 (pre- and post-test) + β2 (group) + β3 (pre- and post-test × group); pre- and post-test: post-test = 1, pre-test = 0, group: experimental group = 1, control group = 0.
Table 6. GEE Analysis of the effectiveness of nutrition education intervention on healthy eating behaviour
Note: Y = β0 + β1 (pre- and post-test) + β2 (group) + β3 (pre- and post-test × group); Pre- and post-test: post-test = 1, pre-test = 0, Group: experimental group = 1, control group = 0.
After-school learning worksheets and online group interactions
Besides questionnaire data, the review of after-school learning worksheets showed that those distributed in the first lesson had the highest completion rate, with 34 copies returned. As the course progressed, only 28 worksheets filled out fully by both parents and students and signed by parents were returned for the fourth lesson. In addition, the online group interactions among parents and intervention instructor were limited. During the intervention process, only four parents frequently and consecutively interacted in the online group to discuss the course content and after-school learning worksheets.
Discussion
The features of this intervention study were to utilize simulation videos as the primary teaching medium in designing the curriculum and to use after-school learning worksheets as assignments to encourage parental involvement. The intervention helped participants make significant improvements in their scores on the knowledge and attitude question sets, which could be attributed to the use of simulation videos in the curriculum which raised participants’ learning motives and concentration. However, there was no significant change in participants’ healthy eating behaviour. Changes in nutrition behaviours might not be observed after a short-term intervention, which emphasizes the need to conduct long-term interventions measuring effects on nutrition behaviour outcomes.(Reference Lin20) Besides, although previous studies suggested that parental involvement and take-home activities should be effective strategies to help children develop healthy eating practices,(21,Reference Charlton, Comerford, Deavin and Walton26) it was observed in the present study that the level of parental involvement was unable to sustained during the entire intervention, which might be associated to the unsatisfied outcomes in changing schoolchildren’s eating behaviour.
Simulation video has been widely used in nursing education because of its advantages in creating real-life situations for students to engage in the learning process.(Reference Ghosh, Spindler, Dyer, Christmas, Cohen and Das35,Reference Said, Saied, Gaafar and El-Houfey36) This study extended its application to nutrition education for elementary students, and found its effectiveness in improving participants’ knowledge and attitude regarding healthy eating. In order to motivate participants’ learning interests and guide them to reflect real-life experiences, the short simulation videos showed the daily life of a fictional character who is at the same age as the study participants. Participants watched the simulation video and learned how the fictional character completed various dietary-related missions. After watching the video, participants were asked to imitate the fictional character’s missions and complete homework assignments. The use of simulation videos allows for the demonstrations of situations that learners are yet to experience and provides them with a contextualized opportunity for learning.(Reference Coyne, Rands, Frommolt, Kain, Plugge and Mitchell37)
Based on observing students’ reactions in class and analysing the learning worksheets, it was found that some students and parents had difficulties in grasping numerical concepts such as the daily ‘recommended upper limit of added sugar’ and ‘calories contained in snacks’. Teaching nutritional knowledge often involves computational skills. For future intervention material design, it is suggested that numerical concepts be translated into specific food types and servings to facilitate comprehension. For example, if a schoolchild eats one slice of red bean bread for breakfast, sugar-free beverages shall be recommended when choosing pared drinks. Additionally, instructors might illustrate the abstract concept by analogy with concrete cases, for example, by using the traffic light system to help students identify foods with high energy density and learn to be cautious about intaking these foods.
Several limitations of this study and suggestions for future research are addressed. This intervention was implemented for small sample size. In terms of implementation process, an issue should be mentioned was about the imperfect completion of ‘Little Nutritionist’ after-school learning worksheets designed to increase parental involvement. The worksheets were designed to be completed by children and parents jointly, but the handwriting on some returned worksheets appeared to be completed by children alone. Future intervention should consider improving the after-school worksheet design or planning other parents-child activities to encourage parental engagement. Moreover, the intervention period coincided with the Mid-Autumn Festival in Taiwan, and the topic of choosing healthy festival foods was purposely integrated into the curriculum to conform participants’ real-life experience. However, during actual implementation, it was found that schoolchildren’s dietary preferences in cultural festivals tend to be shaped by sociocultural environment, rather than being easily altered through a short-term intervention. Furthermore, peer influences on schoolchildren’s eating behaviours were not included in this intervention. Peer effects on children’s eating behaviour were observed to link with the consumption of energy-dense and low-nutrition value foods,(Reference Ragelienė and Grønhøj38,Reference Zhou, Bian and Huang39) which should be taken into account in future nutrition interventions for schoolchildren.
Abbreviations
GEE: Generalized Estimating Equations
Acknowledgements
None.
Financial support
This research was funded by the Tri-Service General Hospital in Taiwan.
Conflict of interest
None.
Authorship
SR and YC designed the study, and SR implemented the intervention. Both SR and YC contributed to data analysis and manuscript writing. Both authors read and approved the final manuscript.
Open access
