NUTRITION KNOWLEDGE, ATTITUDES AND PRACTICES OF CHILDREN

ABSTRACT

Nutrition Education is the process by which people gain knowledge, attitudes and skills necessary for developing appropriate dietary habits. Schools, families and communities are the main social contexts in which lifestyles are developed. They are excellent settings for promoting nutrition knowledge, attitudes and practices (KAP). In Kenya, there is scarcity of information on nutrition knowledge of primary school children. In addition, there is paucity of data on how nutrition knowledge influences their nutrition practices. The purpose of this study was to establish primary school pupil‟s nutrition knowledge, nutrition- related attitudes and practices in Kajiado District, Kenya. In addition, the study aimed at establishing the relationship between nutrition practice and nutrition knowledge and nutrition-related attitudes children. The study adopted a cross sectional analytical study design. A total of 280 randomly selected pupils from two schools; one urban and another rural were selected to participate in the study. To verify the self-reported practices, a 15% randomly selected sub-sample of the pupils were visited in their homes to observe nutrition-related practices. Focus group discussions were held with class 1-4 pupils, teachers and parents separately. The findings of the focus group discussion were used to explain the findings of the survey by providing in-depth information on nutritional knowledge, attitudes and practices. Data was analyzed using the Statistical Package for Social Scientists (SPSS) version 16. Correlations were used to establish the relationship between nutrition knowledge and practices such as washing hands as the data was continuous in nature. T-test was used to establish significant differences in knowledge and attitude mean scores. Chi-square was used to establish relationships between knowledge and attitude since the data was categorical. The overall nutrition knowledge was fair; the mean score was 13.8 out of a total of 20 questions. The nutrition knowledge of the children in Isinya Primary School was significantly higher (14.2 ± 2.69) than those of children from Nkoile Primary School (12.7 ±2.33) p= <0.001.The pupils had an overall attitude mean score of 62.4±11.73. Nkoile Primary School had significantly higher mean attitude score compared to Isinya Primary School (69.7±10.46) and (60.3±11.25) respectively. There was no significant relationship between dietary diversity and the attitudes towards nutrition r= 0.025, p=0.069. Therefore, the hypothesis that there is no significant relationship between the pupils‟ diet diversity and their nutrition-related attitudes is not rejected. In contrast, there was a negative correlation between nutrition knowledge and dietary diversity score r= -0.133, p= 0.027. Logistic regression analysis revealed that pupils who had a positive attitude and those whose performance was above average were more likely to undertake appropriate nutrition practices. Pupils who had positive attitude towards nutrition were 3 times more likely to wash hands before handling food (ODDS RATIO [OR] =3.25; 95% Confidence Interval [CI] =1.19-8.84; P=0.02). This implies that Schools should inculcate positive attitudes towards nutrition among the pupils in order to encourage nutrition-related practices. Moreover, they should provide clean latrines, hand washing facilities with adequate amounts of soap and water in appropriate places to encourage hand washing. The findings of this study were not conclusive given that most variables were not positively associated with appropriate nutrition practices. As such, there is need to replicate a similar study on school children in other ASAL districts in Kenya in order to strengthen these research findings. The findings may be useful to organizations such as the Ministry of Education (MOE), Flemish Association for Development Cooperation and Technical Assistance (VVOB), International Centre for Research on Agro-Forestry (ICRAF), and other development partners dealing with education and health of school going children. The findings will also contribute to the existing body of knowledge in nutrition and health education.

CHAPTER ONE:

INTRODUCTION

1.1 Background information

Good nutrition, health and education are key factors on the global agenda. None of these three factors alone, however, will suffice to achieve social and economic development; only in combination will they enable progress towards a world without poverty and hunger (Food Agricultural Organization [FAO], 2005a). Nutrition education is a significant factor in improving nutrition knowledge, attitudes and practices (KAP) of school children, family and the community at large (Contento, 2007). It is important to note however, that though nutrition education is an important entry point to teaching nutrition it is not the only source of nutrition knowledge. There are other entry points such as school environment, school meals, health and nutrition clubs and school gardens among others (Mbithe, 2008). In addition, the family and community play an important role in the acquisition of nutrition knowledge and nutrition-related practices. The school on the other hand is one of the main social contexts in which lifestyles are developed (FAO, 2005b). It offers an enabling environment to foster the indigenous nutrition Knowledge Attitudes and Practices the pupils have learnt from their homes and community (Eboh and Boye, 2006).

The nutrition knowledge acquired throughout school life is a factor of interaction between the school curriculum, school environment, the family and community (FAO, 2005b). To be effective in improving nutrition knowledge, nutrition education must address at least four fundamental areas: the classroom curriculum, the school environment, the family and community (FAO, 2003). The formal curriculum should be designed to provide adequate learning opportunities for learners to develop knowledge, attitudes and skills for adopting healthy eating behaviors (Valleau et al., 2004). Although the core objective of the schools is to provide education; it can also provide food through school meals in order to improve children's diet and health, provide healthy influences such as availing clean drinking water, availing dust bins and compost pit, encouraging physical activity, hygienic latrines, soap and hand washbasins and leaky tins (FAO, 2003). All these contribute to nutrition knowledge, attitudes and practices.

In line with this, the Ministry of Education in Kenya in collaboration with Flemish Association for Development Cooperation and Technical Assistance (VVOB) and International Centre for Research on Agro-Forestry (ICRAF) established “The Healthy Learning Programme” in 2008. This programme supports capacity strengthening activities focused on improving the nutrition knowledge for school children at national, district, school and community levels. It facilitates the introduction of education school projects like school gardens, school meals, hygiene and sanitation, water management and other initiatives. This is done with the aim of supporting sustainable learning and food and nutrition security in primary schools and their surrounding communities, while simultaneously linking current school feeding programmes and school meals to local solutions. Based on this background, the study was intended to establish the status of pupils‟ nutrition knowledge, attitudes and practices in two primary schools namely Isinya and Nkoile which were participating in the Healthy Learning Programme in Kajiado District.

1.2 Statement of the problem

Malnutrition is widespread among school children in many developing countries. Nutrition education contributes to acquisition of nutrition knowledge, attitudes and practices which may lead to improved nutrition status (World Health Organization [WHO]/FAO, 1998). Despite this, nutrition education which has a potential to address malnutrition has not been given much emphasis in the school curriculum in Kenya. In the formal school setting, the teaching of nutrition-related subjects like Home science and Agriculture is declining. Home science covering nutrition education and agriculture covering food production and preservation among other topics have been removed from the syllabus. Only a few topics, with a reduction in content, are included in the science syllabus (Kenya Institute of Education [KIE], 2002). These include: Introduction to foods and nutrition, functions of nutrients, nutritional requirements for different groups of people, food hygiene, nutrient-deficiency diseases, food poisoning, food preservation and storage (KIE, 2002). Furthermore, there is no evidence that the science teachers were inducted on how to teach these nutrition topics (Mbithe, 2008).

In the school curriculum nutrition is not considered a core subject like Mathematics, Kiswahili and English and therefore it is allocated less time in the school timetable (KIE, 2002). A comparison of the FAO Guidelines for Nutrition Education in Primary Schools for Developing Countries and the Kenya Science Syllabus shows crucial deficits in the curriculum. The content coverage is narrow and not evenly distributed throughout the eight classes. Also, key topics such as Food and Emotional Development, Eating habits and Social Influences, Food and Production (which contains some agricultural content) and Consumer Aspects of Foods have been excluded from the Kenyan syllabus (FAO, 2005b). The deficits in the syllabus on coverage of nutrition education implies that nutrition knowledge and good hygiene and dietary practices could be lacking or need improvement among school children in Kenya (Mbithe, 2008).The limited nutrition education offered in primary schools focuses on increasing pupils‟ knowledge of good nutrition and passing examination, with less emphasis on motivation, attitude change and establishing good nutrition and health practices (FAO, 2005b). In addition, the role of the school environment, family and community has not been fully exploited to address gaps in nutrition knowledge, attitudes and practices of school children.

There is scarcity of information on primary school pupil‟s nutrition knowledge, attitudes and practices in Kenya. Similarly, there is scarcity of information on the relationship between nutrition practice and nutrition knowledge and nutrition related attitudes and nutrition-related attitudes in Kenyan primary schools. Appropriate nutrition knowledge, positive attitudes towards nutrition and appropriate nutrition practices are particularly important in Arid and Semi Arid Lands (ASAL) areas like Kajiado experiencing chronic food insecurity where malnutrition rates are consistently high and often exceeding the emergency threshold. Poor nutrition and health, inadequate water, poor sanitation and cultural issues in the district may not favour practices such as food production, food choices, consumption and appropriate hygienic practices like washing hands after visiting the toilet or before eating due to lack of adequate water. The Healthy Learning Programme is attempting to respond to this need by providing an enabling environment for the improvement of nutritional status of primary school pupils in Kajiado (VVOB/MOE, 2008a).

1.3 Purpose of the study

The purpose of this study was to establish the status of nutrition knowledge, attitudes and practices of primary school pupils in Isinya and Nkoile Primary Schools in Kajiado district. This study also established the relationship between nutrition-related practices and nutrition knowledge and nutrition-related attitudes.

1.4 Study objectives

The objectives of the study were:

1. To determine the socio-demographic and socio-economic characteristics of the pupils‟ household.
2. To determine the level of nutritional knowledge among pupils in Isinya and Nkoile Primary Schools in Kajiado.
3. To establish the sources of nutrition information for pupils.
4. To determine the attitudes of pupils towards nutrition.
5. To assess the nutrition practices of the pupils‟.
6. To establish the relationship between nutrition-related practices, nutrition knowledge and nutrition-related attitudes of the pupils.

1.5 Hypotheses

The study tested the following hypotheses;

H_01: There is no significant relationship between the pupils‟ nutrition-related practices and nutrition knowledge.

H_02: There is no significant relationship between the pupils‟ nutrition practices and their nutrition-related attitudes.

1.6 Significance of the study

The findings may be useful to the study schools, Ministry of Public Health and Sanitation, Ministry of Education, Flemish Association for Development Cooperation and Technical Assistance (VVOB), International Centre for Research on Agro-Forestry (ICRAF), World Food Programme (WFP) and other development partners dealing with education and health of school going children in order to design interventions to improve nutrition-related practice.

The findings may be used to review or re-design policies and implementation strategies related to nutrition and health of school children. The findings will also contribute to the on-going research efforts on the role of nutrition education in improving nutritional status of school children. It is also expected that the findings will be disseminated through publication in peer reviewed journals and references.

1.7 Delimitations of the study

The study was carried out among school children in Kajiado District, which is part of the Arid and Semi-Arid Lands (ASAL) in Kenya. Results can only be generalized to school children in similar situations.

1.8 Limitations of the study

Children are not the key decision makers on nutrition practices in school and at home hence most of their nutritional practices were not dependent on their choices. In addition, information on practices depended on self-reporting and not observation. Since the schools were in the Arid and Semi-Arid areas where population is sparse, some pupils' homes were very far from school and therefore it was not possible to visit all study pupils in their homes and thus only a sub-sample was visited to observe the nutrition-related practices. The socio-demographic and socio-economic characteristics determined and discussed in this report were limited to household composition, education, occupation levels, and ownership of household items and sources of; food, lighting and drinking water. Information on income levels and household expenditure could not be obtained since pupils did not have this information.

1.9 Conceptual framework of the study

This study adapted a conceptual framework from Mbithe (2008) on Factors affecting the success of nutrition education interventions in Primary Schools. It focused on nutritional knowledge illustrating the link between the school curriculum, school environment, community and nutrition knowledge of school children. It takes into consideration that the school cannot work in isolation stating that what is learnt in school is practised in schools, homes and the community. The community on the other hand influences the level of nutrition knowledge and supports school nutrition-related activities. School curriculum

Topics, learning and teaching

Pupils‟ Nutrition Knowledge, attitudes

and nutrition-related practices

Figure 1.1: Factors affecting nutrition knowledge attitudes and practices among primary school children.

Source: Adapted and modified from Mbithe, 2008

The family as a basic unit in a society is a key source of nutrition knowledge and also provides a conducive environment to practice what is learnt in schools. What is taught in school is influenced by the school curriculum. Though the school curriculum plays a key role in improving pupils‟ knowledge it is obviously not an adequate source of knowledge, collaboration, of all the stakeholders is of importance if pupils are to achieve adequate nutrition knowledge. The school environment on the other hand, is an excellent setting for learning and practicing what is taught in school and at home.

1.10 Operational definition of terms

Attitude towards nutrition: This represents an individual's degree of like or dislike or perceptions on nutrition knowledge, practice and Healthy Learning and School Feeding Programmes.

Curriculum: Refers to everything that runs or occurs under the auspices of a learning institution to address key learning areas. These areas are the ideas that focus on learning, learners, content and teaching and learning materials rather than on subjects as ends in themselves.

Nutrition Practices: Are those that are and can be influenced by nutrition knowledge and nutrition-related attitudes. In this study nutrition practices includes: dietary diversity score, food preservation, washing of hands before and after eating, washing of hands after visiting the toilet and washing fruits and vegetables before eating them.

Nutrition Knowledge: Refers to pupils‟, teachers‟ and parents‟ knowledge in the following areas covered in the syllabus: food nutrients; balanced diet; deficiency diseases; food preservation; storage hygiene and nutritional requirements for different groups.

Nutrition Education: Is the process by which people gain the knowledge, attitude and skills necessary for developing good dietary habits and other nutrition related practices conducive to health and well-being (Contento, 1995; FAO, 2005a).