Comparative Study: Nutritional Status of School Children
as Perceived by Health Belief Model
*Ebtisam M. Abd El-Aal ** Basma R. Abd El-Sadik *** Noha A. Mohamed
*Lecturer of Community Health Nursing; ** Lecturer of Pediatric Nursing, Benha University; *** Lecturer of Community Health Nursing, Beni-Suef University
Abstract
Nutrition in school children is vital; and good eating habits support healthy growth and development. The Health Belief Model (HBM) is a theory used to determine the likelihood that a person will engage in disease prevention and health-promoting activities. Aim of the study to examine nutritional status as perceived by Health Belief Model among primary school children. Research design: A quasi experimental design was used. Setting: The study was conducted at three primary schools at Benha City and three schools at Beni-Suef City. Sample: Multistage random sample was applied for selection of students from the previous governorates and included 273students; 143 from Benha and 130 from Beni-Suef schools, Tools: Three tools were used I): An interviewing questionnaire sheet including three parts 1) Socio demographic data of school children 2) knowledge about nutrition as perceived by Health Belief Model. 3) Practices through asking questions about nutrition. II): Observational checklist for Medical health status of school age children. III) An anthropometric measurement as weight, height, body mass index. Results There were statistically significant differences related to nutritional problems between both groups of children in Benha and Beni-Suef schools. The mean score of children regarding Health Belief Model in Benha is slightly better than Beni-Suef. There are statistically significant differences between students in Beni-Suef and Benha city regarding all Health Belief Model items before and after the educational program (p<0.001).
Conclusion: Around half of school age children at primary schools in Benha and Beni-Suef had average knowledge regarding Health Belief Model, and male students had higher percentage for good knowledge regarding Health Belief Model than females. Recommendations: Continuous health educational programs should be applied at primary school children regarding nutrition as health belief.
Key words: Schools children, Nutrition, Health Belief Model.
Introduction
Schools have been identified as key settings to shape children's health behaviors and impact their lives. School wellness programs are sought to increase children's knowledge of healthy nutritional practices, improve psychosocial variables associated with eating fruit and vegetables, and develop preferences for these foods (Tuuri et al., 2009). School meals recognized as a key element in promoting good nutrition and health for school children, had positive impact on growth and cognitive performance of children, contribute to good health outcomes and to essential efforts to improve education access and completion, particularly for the poor (Gougeona et al.., 2011)
Adequate nutrition is essential for maintaining health, decreasing existing health problems, maintaining functional independence, and improving nutritional status are seriously important to prolong good health status and well-being (Joung et al., 2011). Access to sufficient, safe, and appropriate food is a basic human right, and that, in the case of children, proper nutrition is a fundamental requirement for adequate child development (Shor, 2011).
Poor nutrition or situations of food insecurity could lead to negative developmental outcomes for children and affect their behavioral and academic functioning. Situations of poor nutrition and/or food insecurity of children may arise from different risk factors, such as parental neglect of the children's nutritional needs, poverty, or parental lack of knowledge about how to meet the nutritional needs of children (Shor, 2011). Early childhood malnutrition is irreversible and intergenerational, with adverse consequences on adult health as it is implicated in poor mental and cognitive development ( Tuuri et al., 2009).
The Health Belief Model (HBM) is one such theory, which is widely used to determine the likelihood that a person will engage in disease prevention and health-promoting activities. The HBM is based on five factors of health related attitudes: Perceived susceptibility to a health threat, perceived severity of the health threat, perceived benefits of protective health behaviors, perceived self-efficacy regarding these protective behaviors, and perceived barriers to performing these behaviors (Akey et al., 2013). The HBM was developed in the 1950s to explain health behaviors associated with the failure of people to participate in programs that would reduce disease risk. The HBM implies that health behaviors are determined by health beliefs and readiness to take action (Abood et al., 2003).
Nursing plays a key role in nutrition education because nutrition is a part of child outcomes. The healing of the body can take place only when the nutrients that provide the building blocks for repair are present. The nurse as a nutrition educator is a vital role in the overall healthcare system. School nursing has the opportunity to provide nutrition education that can help to preserve the health of all students within the school (Henning, 2009).
Significance of the study
Malnutrition disorders affect more than 30% of school children, aged 6–12 years in Egypt. Poor dietary quality among children is rapidly becoming a bigger concern because Egypt is characterized by a young age structure, with approximately 43% of the population less than 18 years of age (Galal et al., 2005). Malnutrition in Egypt is not related to a shortage of food, but rather to a lack of access to proper foods, leading to a deficiency in essential micronutrients. Indicators from the 2009 data showed that 30 % of Upper Egyptians suffered from caloric deprivation, and 49 % had poor dietary diversity. Almost a third of Upper Egyptians suffer from iron, zinc, or vitamin A deficiency. Iron deficiency leads to loss of attention and low productivity, which impinges on education and work. The true extent of the burden of ill health and malnutrition is still not fully known (Achterberg Miller, 2004).
Aim of the study
This study aimed to examine nutritional status as perceived by Health Belief Model among primary school children, through:
1- Assessing the primary school children knowledge regarding nutrition as perceived by Health Belief Model.
2- Assessing health status of primary school children.
3- Designing and implementing a nutritional education program for the primary school children according to Health Belief Model.
4- Evaluating the effect of the health educational program according to Health Belief Model.
Research hypothesis
School children who will receive an educational program based on health belief model will have better knowledge regarding nutrition in both groups.
Subjects and Methods
Research design
A quasi Experimental design was used in this study
Setting
The study was conducted at six primary schools; three primary schools at Benha City (Houda Shaarawy, Anas Ebn-Malek & Zaid Ebn-Haresa schools) and three schools at Beni-Suef City (Abu-Bakr El-Sedeek, Omar Ebn-Elkhatab, and Metwally El-Shaarawy Schools.)
Sample
A multistage random sample was used to select the research population from previously mentioned schools, as follows: three schools were chosen randomly from the two settings, total number of classes was 18 classes in Benha City and 12 classes in Beni-Suef City in 5th and 6th grade, 50% of the classes were chosen randomly. All students in selected classes were included in the study. The sample includes 143 students from Benha schools, and 130 students from Beni-Suef schools, under the following criteria, fifth and six grades, free from any medical problems.
Tools of the study
Three tools were used I): An interviewing questionnaire was used to collect data and included three parts:
1) Socio demographic data of school children, which include age, sex, year grade, mother education, mother occupation and family income.
2) School children knowledge about nutrition by using Health Belief Model (guided by Akey et al., 2013) which includes: perceived susceptibility to a health threat (4 questions) as students at school age, bad personal hygiene, insufficient income, children with health problems. , perceived severity of the health threat (5 questions) as high risk for diseases, fatigue, inactivity, poor school achievement, psychological problems, perceived benefits of protective health behaviors (4 questions) as prevention of diseases, improved school achievement, sharing school activity, healthy psychological status perceived self-efficacy regarding these protective behaviors (3 questions) as I have good health, I taking healthy diet, I have enough knowledge about nutrition prevention of malnutrition (10 questions) as taking breakfast daily, taking vegetables and fruits, avoid taking tea after meals, drinking milk daily, taking proteins daily, avoid drinking cola frequently, taking three meals daily, avoid taking chocolate and sweets, taking fast foods, taking snacks. And perceived barriers to performing these behaviors (3 questions) as inadequate knowledge about healthy foods, insufficient income, and faulty nutritional habits.
Scoring system: A correct answer was scored 2, incorrect answer was scored 1, and don't know was scored 0. The total scores was calculated as less than 50% was considered poor, while 50-75% was considered average, and more than 75% was considered good.
3): Children practices through asking questions about nutrition a- child practices for eating healthy diet as number of meals/week from meat, fish, milk cereals, fruits and vegetables. B- Dietary practices at school as taking snakes and adequacy of snakes.
Scoring system: a- one for one times/week, two for two times/week ……….and seven for seven times/week. The total score were seven and mean and standard deviation was calculated. b- Dietary practices for school snacks were scored as 2 for taking snacks regularly, while 1 for sometimes, and 0 for no snacks.
II): Second tool: Observational checklist for Medical health status of school age children guided by (Dudek, 1997) a- child medical health status as general appearance of child, teething health, hair condition, face, gums, skin, tongue, nails, lips and limp. b- Feeling of symptoms of poor nutrition as feeling fatigue during rest can’t play with group, loss of appetite, and feeling fatigue with exertion (self reported questions).
Scoring system: a- Healthy health status was scored 1 and unhealthy was scored 0.
III): Third tool: An anthropometric measurement as weight, height, body mass index.
Content validity:
The tool validity test was done through five expertises from Faculty members of Community Health Nursing Department and Pediatric Nursing Department.
Reliability:
Internal consistency reliability of the questionnaire was 0.78 (Cronbach's alpha), so the questionnaire is reliable to identify the children nutritional health status as perceived by Health Belief Model.
Ethical considerations:
· Oral consent was taken from each child, the teachers, and the administrative personnel. Children were informed that the data collected will be used for the research only, confidentiality manner is assured.
IV: Evaluating Phase
To evaluate the effect of nutritional program through using pre/post test of children as perceived by Health Belief Model.
Procedure:
· Preparation of data collection tools was carried out over a period of three months from beginning of October 2012 to end of December 2012.
· Official letters were issued from the Deans of the Faculties of Nursing (Benha and Beni-suef) to the Educational Regions where the studied schools belonged to, and then letters of the approval to carryout the study were sent to the directors of schools chosen for the study to facilitate collection of data.
· The time plans of the program lasted from October 2012 to March 2013.
· The researcher visited the schools during working times from 9.00 a. m. to 1.00 p.m. twice/week in Benha City and another researcher in Beni-Suef City (Sundays Thursdays).
· The questionnaire sheet takes from 30-45 minutes to be completed, and the program was implemented in 30-45 minutes for a theory session and 30-45 minutes for a practical session according to participants’ needs that was assessed in the pre test questionnaire. The program covered 12 weeks.
Health Belief Model Construction:
It includes four phases:
I: Preparatory Phase: A review of recent, current, national and international literature in various aspects related to Health Belief Model among school age children regarding nutritional status.
II: Assessment phase: The pre test questionnaire was implemented to identify the health condition, nutritional status, children knowledge about Health Belief Model, and school nutrition provided to children.
III: Planning and implementing phase
The nutritional program as perceived by health belief model was designed; the general objective is examining nutritional status as perceived by Health Belief Model among primary school children. The content of the model included the children knowledge related to perceived susceptibility to a health threat, perceived severity of the health threat, perceived benefits of protective health behaviors, perceived self-efficacy regarding these protective behaviors, prevention of malnutrition, and perceived barriers to performing these behaviors.
The Health Belief Model includes 5 sessions for implementing the program.
Sessions for theory through lecture and PowerPoint presentation:
· Knowledge related to perceived susceptibility to a health threat, which includes age, income, and personal hygiene and its effect on their health.
· Perceived severity of the health threat, as high risk for diseases, fatigue, inactivity, poor school achievement, psychological problems.
· Perceived benefits of protective health behaviors, as prevention of diseases, improved school achievement, sharing school activity, healthy psychological status perceived self-efficacy regarding these protective behaviors.
· Perceived barriers to performing these behaviors as inadequate knowledge about healthy foods, insufficient income, and faulty nutritional habits.
· Prevention of malnutrition as taking breakfast daily, taking vegetables and fruits, avoid taking tea after meals, drinking milk daily, taking proteins daily, avoid drinking cola frequently, taking three meals daily, avoid taking chocolate and sweets, taking fast foods, taking snacks.
Pilot study: 27 students (10%) were included in pilot study and excluded from the main study sample, to identify the clarity of the tools’ items, and the estimated time needed for applicability of the tools.
Statistical analysis: The collected data was analyzed and tabulated using the number and percentage distribution; mean and standard deviation using Statistical Package for Social Science (SPSS) version 16. Data were presented using proper statistical tests that were used to determine whether there were significant relations.
Results
Table (1): shows that, 60.1% of studied children in Benha schools were males versus 67.7 % in Beni Suef schools and the rest were females. More than half (55.9%) of studied children were in sixth grade in Benha versus 53.1% of them in Beni-Suef schools with the mean age 11.76±0.59,