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NSM-NCD2013 Symposium 2a - Healthy Kids Programme - Development and evaluation of Nutrition Education Package for Primary School Children
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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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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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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 mins5 mins5 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)
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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 3Topic 2
Topic 4 Topic 6Topic 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 SessionKAP Survey
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Photos: Intervention Session Year 1 (2011)
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Engagement sessions 2011
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Photos: Intervention Session Year 2 (2012)
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Engagement sessions 2012
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Photos: Intervention Session Year 1 & 2 (2011 - 2012)
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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 SessionKAP 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
No. Intervention (n=151)
Frequency
n (%)
Control (n=121)
Frequency
n (%)
Beginning of the year 2011
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)
End of the year 2012
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.
Note: KAP at 2011 was collected in Feb 2011.; KAP at 2012 was collected in Sept-Nov 2012.
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Table 3.3: Top 3 most frequent drinks in year 2011 and 2012
No. Intervention (n=151)
Frequency
n (%)
Control (n=121)
Frequency
n (%)
Beginning of the year 2011
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)
End of the year 2012
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.
Note: KAP at 2011 was collected in Feb 2011.; KAP at 2012 was collected in Sept-Nov 2012.
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Table 3.4: Top 3 most consumed breakfast in year 2011 and 2012
No. Intervention (n=151)
Frequency
n (%)
Control (n=121)
Frequency
n (%)
Beginning of the year 2011
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)
End of the year 2012
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.
Note: KAP at 2011 was collected in Feb 2011.; KAP at 2012 was collected in Sept-Nov 2012.
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Table 3.5: Top 3 most favourite leisure time activities in year 2011 and 2012
No. Intervention (n=151)
Frequency
n (%)
Control (n=121)
Frequency
n (%)
Beginning of the year 2011
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)
End of the year 2012
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
Note: KAP at 2011 was collected in Feb 2011.; KAP at 2012 was collected in Sept-Nov 2012.
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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 ModulesTM
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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