Integrated school based nutrition programme improved the knowledge of mother and schoolchildren

Abstract This study evaluates the effects of nutrition education on improving knowledge, attitude, and practice (KAP) of mothers and the improvement of the nutritional status of their children. A cluster randomized controlled design using multistage sampling was employed. The integrated school‐based nutrition programme included gardening, nutrition education for parents, and supplementary feeding for children (GarNESup). KAP of mothers was assessed using pretested questionnaires administered by teachers. The randomly selected schools were randomly allocated into two groups: Both schools provided lunch to targeted children with one‐dish indigenous vegetable recipe, but School 1 received iron‐fortified rice whereas School 2 was provided ordinary rice. Eighty wasted and/or anaemic children in each school were fed for 120 days. Nutrition education for children's parents was done every school card claim day and during parent–teacher meetings using 10 developed modules. Weight, height, and haemoglobin level of children and KAP of mothers were measured at baseline and endpoint using standard techniques. KAP of mothers who had completed more than six modules had significantly increased from baseline to endpoint: Negative consequence of worm infestation (33.3% to 60.6%, P = 0.035), importance of serving breakfast for children (42.4% to 78.8%, P = 0.004), cooking vegetables (63.6% to 93.9%, P = 0.002), and purchasing fortified foods was recorded (51.5% to 93.9%, P = 0.000). Children in School 1 had significantly higher weight gain (1.33 ± 0.72) and haemoglobin level (0.49 ± 0.99) than children in School 2 (0.84 ± 0.59; 0.12 ± 0.70). Nutrition education resulted to significant increase of mother's KAP and the implementation of the integrated school‐based nutrition model significantly improved children's nutritional status.

the scaling-up of the rice fortification programme in the Philippines, significant increases in the percentages on parent's knowledge about iron were observed from baseline to endpoint: knowing what is iron (30.2% to 97.5%, P ≤ 0.001), identifying good food sources of iron (28.3% to 95.0%, P ≤ 0.001), and what iron-fortified rice (IFR) is and can do (5.6% to 81.9%, P ≤ 0.001). A significant increase in the practice of buying IFR was also observed from baseline to endpoint (2.4% to 51.4%, P = 0.041).
Internationally, a programme by Cornell University, Ithaca, New York, on International Nutrition uses nutrition education among children or parents as one of their tools in mitigating malnutrition and hunger (Cornell University, 2014). Improved nutrition education has been one of the key factors to prevent 12,000 deaths a year worldwide according to the UN Millennium Campaign (United Nations, 2012).
This study evaluates the effects of nutrition education on improving KAP of mothers and the improvement of the nutritional status of children as a result of the implementation of the school-based nutrition programme. The results of this study could serve as a model for administering nutrition education for mothers in the schools as an integral component for scaling up the school-based nutrition programme that effectively links school garden produce to school feeding (GarNeSup).

| Study design and study sites
A cluster randomized controlled design using multistage sampling was employed in this study. It was conducted in the province of Cavite with a total population of 2,856,765 and an area of 1,297.6 km 2 .
DepEd Cavite province had 27 school districts with 280 public elementary schools. All schools were clustered per district. In each district, schools were classified as with and without school gardens.
About 72 (40%) have school gardens, but only 27 schools or one per district were practicing biointensive gardening (BIG). Schools were then stratified based on population either <700 or >700 schoolchildren. The study sites were two schools randomly selected from the 15 schools with >700 schoolchildren.

| Sample size
The sample size was calculated based on mean weight of 18.0 and 1.7 kg SD as reference value. Assuming a minimum increase of 1.2 kg SD, 90% power test at 5% level of significance, the sample would be 42 children for each group (Angeles-Agdeppa, 2006). However, because the study has other variables to measure (e.g., haemoglobin) where variability could be high, and to allow higher attrition rate, the sample size per group was increased to 80 children in each school.
The inclusion criteria set for this study were schoolchildren aged 6 to 8 years old, underweight with weight-for-age z-score less than 2 SD

Key messages
• Improved KAP of mothers as a result of nutrition education sessions.
• Linking school garden with supplementary feeding through nutrition education of parents is an effective nutrition sensitive and nutrition specific interventions to improve nutritional status of schoolchildren.
• Improved nutritional status of children as a result of the integrated school-based nutrition programme comprising of gardening, nutrition education, and supplementary feeding.
(WAZ < −2 SD) and/or anaemic as indicated by haemoglobin level < 12 g/dl (WHO, 2001), with parental consent, and not a participant of other feeding programmes. A total of 908 schoolchildren (School 1, N = 420; School 2, N = 488,) were screened for underweight and anaemia. Eighty (80) children in each school were selected on an enrolment basis and served as participants of this study.

| Supplementary feeding
A 3-week cycle menu was developed by the Department of Science and Food purchasing and meal preparation were done by a teacher assigned as feeding coordinator assisted by volunteer parents.
Children in each school were fed lunch daily for 120 days during school day in a designated feeding room under the supervision of trained research assistants.
Baseline and endpoint measurements were conducted for weight, height, and haemoglobin level. Weight of children was measured using a Detecto weighing scale (Webb City, Mo. U.S.A.) whereas height was measured using a microtoise (Depose, France) posted flat against the wall.
All children were in light clothing and barefooted during measurements.
Measurements were taken twice by trained research assistants to validate the accuracy then take the average. All equipment was calibrated every measurement day. Underweight was defined as weight-for-age z-score less than 2 SD (WAZ < −2 SD), stunting was height-for-age z-score less than 2 SD (HAZ < −2 SD), and wasting was weight-for-height z-score less than 2 SD (WHZ < −2 SD; WHO, 2007).
Nonfasting whole blood (about 5 ml) was collected via venipuncture by experienced registered medical technologists from the DOST-FNRI. All samples were collected in the morning at the schools and were processed immediately within 4 hr after blood extraction using a portable spectrophotometer by cyanmethemoglobin method. In this study, haemoglobin cut-off point for anaemia at sea level was used; hence, a haemoglobin concentration of >70 to <120 g/L was considered anaemic (WHO, 2001).

| Nutrition education
Mothers of the schoolchildren in School 1 and School 2 were the participants of nutrition education. The research team developed 10 modules on health and hygiene, nutrition, and gardening for use during nutrition education sessions. Trained teachers administered the lectures during parent-teacher meetings usually done when there was a need to solicit parent's participation in school activities. Another avenue for educating parents was during card day when parents go to school to personally receive their child's school performance card. In the Philippines, mothers do this responsibility. Moreover, mothers were also tasked to do meal planning, preparation, and cooking. In an effort to observe gender sensitivity in this study, the letter of invite to attend the nutrition education classes was addressed to both parents. However, only 145 mothers have responded. Mothers were encouraged to visit the school garden and read various types of information, education, and communication materials such as flyers, theme posters, and billboards posted in the school premises. These were developed by the project team specifically for the study. Baseline and endpoint KAP were assessed using pretested questionnaires, which consisted of 15 items each for knowledge, attitude, and practice. Every item was a closed-ended statement asking the respondent to answer "Tama" if they thought the statement was correct, "Mali" if they thought the statement was wrong, and "Hindi Alam" if uncertain of the answer. Also, every nutrition education session, the teachers administered a pre-post-test contained in each module. This study arbitrarily considered completing six modules as high attendance in nutrition education. Those who have attended 1 to 5 modules were considered as low attendance in nutrition education.

| Gardening
The International Institute for Rural Reconstruction led the technical assistance in the implementation of schools garden using the BIG approach. Schools were given garden implements so that gardens will be maintained. Teachers assigned as garden coordinators were trained and oriented about the project. The BIG approach features key principles and practices that promote garden health and resilience: School gardens must use organic fertilizers (kakawate-based), must have at least 200-m 2 garden bed and deep dug at least 1 ft, good water source, proper drainage system, and use mulch to protect soil. Daily produce from the gardens, usually leafy greens, were used in the supplementary feeding following the developed vegetable recipes.
Different types of vegetables from the gardens that were used in the supplementary feeding were weighed and recorded. Total weight was the sum of the daily harvest and was costed based on current price of the vegetables in the locality at a given period.

| Limitations
The process and manner how teachers delivered the lectures to children was not observed; hence, quality of teaching and actual time allotted were not directly observed and recorded by the research team.

| Socio-economic demographics and other information
Most of the participants belonged to a single/nuclear family (61.9%) with a mean household size of 6. The mean monthly family income Most of the father (60.0%) and mother (60.6%) had high school education, and the major occupation was either skilled related work (32.5%) or unskilled related work (30.5%).
The age of children was similar between schools with a mean of 6.71 ± 0.78 years. Distribution of children by grade was not significantly different between schools (P = 0.207). Most of the children who participated in the study were Grade 1 (41.9%).
The proportion of children who were dewormed in School 1 and School 2 was 76.2% and 83.8%, respectively. The proportion distribution of children who were dewormed was not significantly different between schools (P = 0.236).
Of the total 160 children qualified to participate in the study, a complete data set from baseline to endpoint was only obtained from 146 children. Reasons for dropouts were transferred residence (School 1 = 8.8%; School 2 = 7.5%) or sickness/illness (School 2 = 1.2%).

| Nutritional status
At baseline, the mean weight and height values were similar in both schools. Mean weight and height of children had significant increase in School 1 and School 2 from baseline to endpoint; however, the mean increase in weight in School 1 was significantly higher (1.33 ± 0.72, P = 0.0134) than in School 2 (0.84 ± 0.59) (Table 1).
Moreover, significant decreases were observed in the prevalence of underweight children in School 2 (56.2% to 34.2%, P = 0.002) and prevalence of stunting in School 1 (43.8% to 26%, P = 0.004) from baseline to endpoint (Table 2). At baseline, mean haemoglobin level of children was similar in both schools. Significant increase in the mean Hb levels in School 1 (0.49 ± 0.99, P = 0.000) at the end of supplementary feeding.

| Nutrition education
Of the 160 mothers of children invited for the nutrition education Improved practices from baseline to endpoint were observed: It was easy for the mothers to convince their children to eat vegetables (36.4% to 69.7%, P = 0.003); they do not need to force their children to eat vegetables (9.1% to 30.3%, P = 0.039). Also, a significant improvement in the practice of purchasing fortified foods was recorded (51.5% to 93.9%, P = 0.000). On meal preparation, they practice washing the vegetables before use (27.3% to 87.9%; P = 0.000).
Among those who had low attendance in nutrition education, no significant improvement was observed in their KAP (Table 3). Table 4 shows a significant increase in the mean scores of prepost-test of parents concerning lessons on constraints and challenges in understanding nutrition (3.0 to 3.5, P = 0.000), sustaining nutrition in home settings (0.5 to 4.4, P = 0.000), proper nutrition guidelines and nutrition practices (4.4 to 6.0, P = 0.002), complimentary feeding (1.6 to 5.6, P = 0.000), encouraging children to eat vegetables (3.9 to 5.7, P = 0.000), vegetable preparation and cooking (2.6 to 6.0, P = 0.000), food fortification (3.3 to 6.1, P = 0.000), guide for vegetable garden (2.6 to 6.1, P = 0.000), and personal hygiene and health (4.4 to 5.9, P = 0.000).
The knowledge and practices of the mothers showed significant relationship to the weight of the children (P < 0.05) (    role models of their children about eating behaviours (Nurcan, Kisac, & Karakuş, 2014). It is assumed that nutritional knowledge level of the    nutritional interventions to children, the mother's nutrition knowledge applied in daily life at home greatly affects the condition of the family nutrition (Dadang & Faisal, 2015) should be a cause of concern. It is in this context that the project developed nutrition modules for use during learning sessions.
Taking into account the benefits of gardening and supplementary feeding as a components of the GarNeSup project showed significant increments in mean weight and height in both schools which translated to significantly reduced prevalence of underweight in School 2 whereas significant decline in stunting prevalence (43.8% to 26%, The results of the present study is in congruent with the findings of a systematic review that showed that providing supplementary food to young children in low-and middle-income countries had small but statistically significant positive effects on weight and height (0.12kg gain for weight and 0.32-cm increase in height over 6 months in the most rigorous trials). Positive effects were also seen for other physical outcomes such as height-for-age scores, weight-for-height scores, and haemoglobin levels (Kristjansson et al., 2007). However, weight gain in this present study revealed higher increments in both School 1 and  (Global Panel, 2015).
Poor maternal education (formal and informal) has been identified as a major constraint to good childcare practices in Ghana (Johnson et al., 1994). A well-resourced, targeted, and coordinated nutrition education can improve maternal nutritional knowledge, health careseeking behaviours, and practices significantly. Effective utilization of knowledge and skills gained from health and nutrition education is, therefore, expected to improve the health and nutritional status of children through improved knowledge and care practices (United Nations, 1992). The nutrition education conducted in this study revealed an improvement in knowledge of mothers; however, some were not translated to positive attitude and practice. In almost all the nutrition modules, the posttests results of the mothers showed a significant result. Moreover, a significant positive relationship between the scores on nutritional knowledge and practices of mothers and the weight status of the child is noted in this study (P = 0.007; P = 0.046), respectively. The result is similar in previous published studies wherein some studies have reported that maternal nutritional knowledge is positively associated with the nutritional status of children (Appoh & Krekling, 2005;Dadang & Faisal, 2015;Saaka, 2014); others have also shown that adequate knowledge per se is not always translated into appropriate actions (Fathea et al., 2014;Waihenya, Kogi-Makau, & Muita, 1996). Understanding the factors that determine the translation of adequate child health and nutritional knowledge into appropriate actions might help design more effective interventions against malnutrition. It remains unclear whether giving mothers adequate knowledge on proper childcare practices has an independent impact on child growth (Saaka, 2014).

| CONCLUSION
Nutrition education resulted to significant increase of mother's KAP and the implementation of the integrated school-based nutrition model significantly improved children's nutritional status. Using IFR in the feeding programme adds up to the beneficial effect in reducing the prevalence of anaemia. Programme implementers should not neglect the importance of nutrition education of parents as an integral activity of any interventions aiming at improving child's nutritional and health status because parents, specifically mothers, are responsible in creating environments for children that may foster healthy eating behaviours.