Introduction
“I think education is both using and improving knowledge and that changes the whole picture. If you want to change attitudes, start with a change in behavior”
William Glasser
Nutrition is considered as the science of food and its relationship or association to health that is concerned primarily with the role played by nutrients in body growth, development and maintenance. The subject of nutrition is very extensive, the community aspects of which deals with in five sections: dietary constituents, nutritional requirements, assessment of nutritional status, nutritional problems in public health and nutritional programs in India. The association of nutrition with immunity, infection, fertility, maternal and child health and family health have engaged scientific attention. Of greater significance during recent years is that the science of nutrition has moved out of the laboratory and linked itself to epidemiology. This association has given birth to newer concepts in nutrition such as epidemiological assessment of nutritional status of communities, nutritional and dietary surveys, nutritional surveillance, nutritional and growth monitoring, nutritional rehabilitation, nutritional indicators and nutritional interventions – all parts of what broadly constitutes as nutritional epidemiology. Good nutrition means “maintaining a nutritional status that enables us to grow well and enjoy good health”. (1)
Nutritional status means the current body status of a person or a population group, related to their state of nourishment (the consumption and utilization of nutrients). It is an in-depth evaluation of both objective and subjective data related to an individual’s food and nutrients intake, lifestyle, and medical or clinical history. (3,4) It is an important index resulting out of complex interaction between the food we eat, our overall state of health, and the environment in which we live- in short, food, health, and caring, the three “pillars of well being”. (5)
The nutritional status of under five children is one of the important indicators of household wellbeing and one of the determinants of child survival. Poor nutrition leads to ill health and ill health causes further deterioration of nutritional status. (6) The nutritional status of children does not only directly reflect the socioeconomic status of the family and social well being of the community, but also the efficiency of the health care system along with the influence and the effect of the surrounding environment. (2) There are two methods to determine and assess the nutritional health status of children out of which the most commonly used are Direct type – anthropometry and clinical methods. . Clinical method utilizes a number of physical signs, (specific & non-specific), that are known to be associated with undernutrition and deficiency of vitamins & micro-nutrients. While Anthropometry method utilizes indicators such as weight, height, MUAC – Mid Upper Arm Circumference and calf, waist-hip ratio, head and chest circumference ratio, triceps skin fold thickness, weight for age, height for age and weight for height etc. to determine the presence of undernutrition. (2,3)
Assessment of Nutritional status of children when resulted to be low or poor as per recommended criteria by IAP/WHO indicates undernutrition. The terms ‘malnutrition’ and ‘undernutrition’ are often used loosely and often interchangeably. Malnutrition refers to all deviations and departures from adequate and optimal nutritional status including energy or calories as well as specific nutrient deficiency types of undernutrition and over-nutrition (obesity). It is an impairment of health resulting from deficiency of calories and/or more essential nutrients, and over nutrition, which is an excess of one or more nutrients and usually of calories. It weakens the immune system and causes significant growth and cognitive delay. (23) The term ‘undernutrition’ is used to refer to generally poor nutritional status, but also implies underfeeding.
Malnutrition arises from deficiencies or imbalance of specific nutrients or from diets based on inappropriate or inadequate combinations or proportions of foods such as goitre, scurvy, anaemia and xerophthalmia are forms of malnutrition caused by inadequate iodine, vitamin C, iron and vitamin A, respectively. Malnutrition can also result from excess nutrient losses or utilization. Undernutrition is caused primarily by an inadequate intake of dietary energy, regardless of whether any other specific nutrient is a limiting factor or as a result of any diseases such as diarrhea or dysentery, acute respiratory infections, malaria and measles etc.
Healthy eating behaviors in childhood are very important as its lack may lead to inadequate intake of food nutrients and/or calories which is one of the important and immediate causes of undernutrition. It thus helps prevent acute child nutrition problems, any nutrient deficiencies, malnutrition, and growth retardation, in addition to preventing chronic, long-term health problems such as cardiovascular diseases, type 2 diabetes, cancer, obesity, and osteoporosis. Parents are mostly responsible on this subject as they are effective on their children’s eating behaviors and preferences. Especially, mothers are the role models of their children about eating behaviors. Therefore, it is important to determine mother’s eating habits to support healthy nutrition of both child and mother. Eating behaviors of the mother are affected by some factors such as socioeconomic status, educational status, age, working position, and knowledge level of nutrition of mother. As a result, it is believed that nutritional knowledge level of the mother could be effective on eating behaviors of their children. (36) If mothers have adequate nutritional knowledge then they would be aware and fully understand the importance for them and their children to have adequate nutrition lest they suffer from its consequences. Thus it is essential to bring about adequate, appropriate and necessary changes in the nutritional knowledge and attitude of mothers which could be considered an act of intervention thus leading to improved nutritional status of them and their children and reducing undernutrition.
Intervention is defined as the act of intervening, interfering or interceding with the intent of modifying the outcome. Studies that are designed to determine and evaluate the effect of an intervention which in the field of health care means specific treatment or practice are called intervention studies. They are thus considered to provide the most reliable as well as high level evidence in epidemiological research. They have many types out of which the community intervention study is most commonly used to determine the effect of providing any intervention at the level of the community basis. (8) Most common example is the provision of nutritional interventions to the mothers and the children at the community level to improve their nutritional health status thereby reducing malnutrition.
There are two types of Nutritional interventions – Specific and Sensitive that are provided to the children and their mothers to improve their nutritional health status and thus preventing or reducing the occurrence of undernutrition. Nutrition specific interventions target the immediate determinants of malnutrition while the Nutrition sensitive interventions target the underlying and systemic causes of malnutrition.
Nutrition-specific interventions having drastically reduced the burden of undernutrition in the world will not alone however eliminate it, in combination with nutrition-sensitive interventions, there is enormous potential to enhance the effectiveness of improving the nutritional status of children globally. Out of all the nutritional interventions that have been provided, only some of them had proven evidence of effectiveness for reducing maternal and child undernutrition while the rest of them had either insufficient evidence or ranging from little to no evidence regarding their effect for reducing undernutrition along with those interventions that were not reviewed at all.
Some examples of nutritional interventions are: provision of supplementary feeding, fortification of foods such as iodized salt, immunizations, early initiation of breast feeding of infants within 1 hour and exclusively up to 6 months and providing nutritional health education (30,31). To combat malnutrition, it has been recommended by many researchers that nutrition intervention should be accessible, sustainable, culturally sensitive and integrated with local resources (32,33,34). One such intervention being training of some community members to provide education regarding nutrition to care-givers in their villages to make them aware regarding various factors responsible for occurring of undernutrition and measures for preventing it and thus improving or restoring childhood nutrition health. (35) Provision of nutritional education to mothers of under 5 years of age while has little to no effect on nutritional health status of children directly unlike supplementary nutrition that has proven adequate effect, is considered to render significant impact on nutritional knowledge, attitude and practice of mothers that affect the nutritional status of their children thus indirectly improving it and thereby preventing occurrence of undernutrition.
Nutrition health education is defined as “any combination of educational strategies, accompanied by environmental supports, designed to facilitate voluntary adoption of food choices and other food and nutrition- related behaviors conducive to health and well-being; nutrition education is delivered through multiple venues and involves activities at the individual, community, and policy levels.” (2) It addresses and targets the food preferences and sensory-affective factors; person related factors such as perceptions, beliefs, attitudes, meanings, and social norms; and environmental factors. (9)
Nutrition education has three essential phases or components. 1) A motivational phase, where the goal is to increase and spread awareness and enhance motivation of the intended audience, the focus being on why to make changes. 2) An action phase, where the goal is to facilitate the ability to take action, the focus being on how to make changes. 3). An environmental component where nutrition educators work with policymakers and others to promote environmental supports for action, its focus being on increasing awareness and enhancing the motivation of the intended audience. Which can be achieved when the intended audience realizes the benefits or the positive outcomes that can be gained by taking particular course of action and thus values these outcomes or results. Each component needs to be based on appropriate theory and research.
There is a procedural model for developing and designing theory based nutrition education programs which is made easier by following a specific procedure. One such is provided by Contento based on a logic model in which nutrition educators plan the inputs, outputs and outcomes that are the three components of nutrition education as described above. (10)
Nutrition education is not just learning about foods and nutrients, but learning what to do and how to act to improve nutrition. develop policies and programs to increase public awareness of the importance of eating well, foster food environments that enable healthy food choices and build the capacities of individuals and institutions to adopt food and nutrition practices that promote good health.
It involves promoting lifelong healthy eating behaviors and habits, involving the families and the community, establishing school “learning” gardens: linking lessons with practice, developing national guidelines for better diets and nutrition, creating environments that support good nutrition and healthful food choices. Nutrition education gives people the knowledge and skills to feed themselves and their families well adequately, get the right foods at the right prices, prepare healthy foods and meals which they enjoy, recognize poor food choices and resist them and teach their children and others about healthy eating. (21)
As Nutritional health education aims at bringing about change and thereby improving the knowledge, attitude or behavior, practice and perception of the person to which it is provided regarding a particular topic or concept, it often involves and utilizes the concept of Behaviour Change Communication.
Behavior change communication (BCC) is an interactive changing process of any intervention with individuals, families, communities and/or societies to develop communication strategies to promote positive behaviors which are appropriate to their settings. This in turn provides a supportive environment which will enable people to initiate, sustain and maintain positive and desirable behavior outcomes. (52) It is the strategic use of communication to promote positive health outcomes, based on proven theories and models of behavior change. BCC employs a systematic process beginning with formative research and behavior analysis, followed by communication planning, implementation, and monitoring and evaluation.
Providing people with information and teaching them how they should behave does not lead to desirable and adequate change in their response/behavior. However, when there is a provision of supportive environment with information and communication (teaching) then desirable change is achieved in the behavior of the audience or target group. Thus, BCC is proved to be an instructional intervention which has a close interface with education and communication. It is a strategic and group oriented form of communication to obtain a desired change in behavior of target group. (53)
It has been suggested that nutrition education programmes might be more effective if they were supported by a sound theory specifically addressing change in nutrition behavior. A model for behavior change that has the potential to be employed for nutrition education programmes is Hubley’s (1993) behavioral change model, the components of which deal with beliefs, attitudes, subjective norms and enabling factors (BASNEF). (38)
The subjective norms are beliefs about the types of behavior other influential individuals would wish the targeted subject to display. Enabling factors, including income, housing, water supply and food production, must also be available so that the intention leads to a change in behavior. According to this model, individual beliefs about the consequences of certain behaviors and the value placed upon each consequence lead to personal attitudes or judgements. These attitudes, combined with the subjective norms of the community and intersectoral enabling factors, contribute to behavioral intention. According to the BASNEF model, the starting point is the individual person’s behavior. Nonetheless, an understanding of the influences on behavior can lead to intervention that extends beyond the individuals. (38)
Rationale of the study
“Investing in early childhood nutrition is a surefire strategy. The returns are incredibly high.” Anne M. Mulcahy
Undernutrition is a worldwide public health problem that jeopardizes children’s survival, health, physical and psychological growth, development and wellbeing thereby slowing national progress towards development goals. Undernutrition is often an invisible problem. There is a critical window of opportunity to prevent undernutrition by taking care of the nutrition of children in the first two years of life, girls during adolescence, and mothers during pregnancy and lactation – when proven nutrition interventions offer children the best chance to survive and reach optimal growth and development. (27)
One of the greatest problems for India is undernutrition among children. Children are considered to be the most important natural resource and biggest human investment for development in every community. However even after so many years of independence, it has made a little progress in improving the health condition of children in comparison to the developed countries. Since 1947, India has made substantial progress in human development. Still the manifestations of malnutrition are at unacceptable levels and it is still struggling with this problem. India is home to 40 percent of the world’s malnourished children. Every year, 2 million children die in India, accounting for one in five child deaths in the world. More than half of these deaths could be prevented if children were well nourished. Nutrition is a core pillar of human development and concrete, large-scale programming not only can reduce the burden of undernutrition and deprivation in countries but also can advance the progress of nations. (22,24,25)
More broadly, malnutrition in India is in a state of silent emergency and thereby demands greater priority than ever before. The nutritional status of population is therefore critical to the development and well-being of the nation (22)
Government of India has initiated various programs that address the problem of undernutrition and its related factors. The two major large-scale national programs aimed at providing supplementary nutrition to children are Mid Day Meal (MDM) Program and ICDS Program. MDM Program benefits the over-5 years old. (25) Integrated Child Development Services (ICDS) is the largest national programme for promotion of mother and child health that is under the administration of Department of Women and Child (WCD). Despite vast infrastructure in ICDS programme, the nutritional status of women and children remain almost the same as that of previous years, reasons include poor education on nutrition to improve feeding practices at home, inadequate training of Anganwadi workers, poor supervision. (28) . ICDS Program has limited reach and coverage. Educating and motivating mothers to provide supplementary nutrition to their children may be the most practical strategy to maintain effective supplementation, but there is limited data about its feasibility and sustainability. The Goal-1 of MDG is to halve the prevalence of underweight children under five years of age in the period 1990-2015. (25)
Thus a nutritional intervention is required to be provided to the children either
Very few studies determining the effectiveness of Nutritional Health Education in improving the Nutritional Health Knowledge and Attitude of Mothers of children of 1 to 5 years age group have been conducted in town of Waghodia in Waghodia Taluka of Vadodara District.
Therefore, the major objective of the present study was to determine the effectiveness of Nutritional Health Education as an interventional measure in improving Nutritional Health Knowledge and Attitude of Mothers of children of 1 to 5 years age group in town of Waghodia. It was an effort in designing and implementing a nutrition health education intervention aimed at both increasing knowledge about and promoting positive attitudes and behavior change towards child nutrition and feeding, domestic sanitation and hygiene .