Mal J Nutr 26(2): 189-201, 2020
          School-based nutrition education to improve children 
          and their mothers’ knowledge on food and nutrition in 
          rural areas of the Philippines
                               *
          Idelia G. Glorioso , Milflor S. Gonzales & Andrea Marie P. Malit
          Food and Nutrition Research Institute, Department of Science and Technology
                                                   ABSTRACT
               Introduction: Nutrition education among school children and their mothers is an 
               opportunity to promote lifelong healthy eating behaviours to improve their nutrition 
               and well-being. The present study determined the effectiveness of nutrition 
               education modules in improving children and their mothers’ knowledge on food 
               and nutrition. Likewise, changes in attitude and behaviour among children were 
               also determined.  Methods: Five nutrition education modules were developed with 
               key messages on healthy plate, fruits and vegetables, protein sources, nutrient-
               dense sources of energy, and water and healthy beverages. Grades 2 and 3 students 
               received 60 hours of nutrition education with a duration of 25 minutes per session. 
               Students were divided into two groups: (1) nutrition education alone (n=83) and 
               (2) nutrition education with feeding (n=83). Simultaneously, a total of nine one-
               hour nutrition education sessions were conducted among mothers, following the 
               same five modules taught to the students. Mothers were also grouped according 
               to their child’s group.  Results: Student participants in both groups exhibited 
               improvements in mean scores on knowledge, attitude, and behaviour (KAB) from 
               baseline to end line. Based on results of mothers’ classes, mean post-test scores 
               of participants were significantly higher than mean pre-test scores in both groups. 
               Group 1 had a higher increase in score from 67.2±32.8 at pre-test to 71.8±33.7 in 
               post-test.  Conclusion: The developed nutrition education modules were effective 
               in teaching children proper nutrition. Incorporation of these modules into the K to 
               12 curriculum will emphasise importance of proper nutrition in early childhood. 
               Moreover, mothers’ classes can be an effective way to bridge the gap between school 
               and community nutrition interventions. 
               Keywords: School-based nutrition education, nutrition knowledge scores, 
               mothers’ nutrition classes
          INTRODUCTION                                     Survey of the Department of Science 
          Stunting and underweight among and Technology-Food and Nutrition 
          Filipino school children of 6-10 years           Research Institute (DOST-FNRI) (FNRI-
          old are still public health problems of          DOST, 2015). Overweight and obesity 
          high severity with prevalences of 31.1%          are also growing problems for this age 
          and 31.2%, respectively, as reported in          group with a prevalence of 8.6%.
          the 2015 Updating National Nutrition                 Nutrition plays a vital role in ensuring 
          __________________________
          *Corresponding author: Idelia G. Glorioso
          Supervising Science Research Specialist, Food and Nutrition Research Institute
          Department of Science and Technology, DOST Compound, Bicutan, Taguig City
          Tel: (63) 8837-20-71 local 2287; Fax: (63) 8837-29-34; E-mail: maideliag@yahoo.com
          doi: https://doi.org/10.31246/mjn-2020-0004
             190                       Glorioso IG, Gonzales MS & Malit AMP
             full potential physiological and cognitive    al., 2012). Another systematic review 
             growths among children. Eating habits,        which  identified  effective  behavioural 
             which also develops early in life, can        models and behavioural change 
             also affect health and nutritional status     strategies showed a similar outcome and 
             of children. Thus, teaching nutrition  suggested that interventions should also 
             at an early age can be an opportunity         be focused on developing children’s and 
             to promote lifelong healthy eating  parents’ perceived competence at making 
             habits and other behaviours to improve        dietary and physical changes (Nixon, 
             nutrition and well-being of school  2012). Evidence suggests that school-
             children.                                     based nutrition education is effective 
                Schools are the most effective and         in improving nutrition knowledge and 
             efficient  venue  to  reach  out  to  young   attitudes of school children. Nutrition 
             children, school staffs, families and  education in the classroom is intended 
             community members via nutrition  to convey nutrition information and 
             education. In addition, children and  change unhealthy attitudes to motivate 
             adolescents spend the most time in  students in establishing healthy eating 
             schools (Aldinger & Jones, 1998; Perez-       practices and to teach positive skills. 
             Rodrigo  et al., 2001). Several studies           In the Philippines, schools recently 
             examined the effects of school-based  transitioned to a new curriculum with a 
             nutrition and health education in  13-year basic education called the K to 
             improving nutrition and health-related        12 Programme. The K to 12 Programme 
             knowledge, attitude and behaviour (KAB)       covers Kindergarten and 12 years of 
             of children related to healthy eating,  basic education (six years of primary 
             diet, physical activity, and increased  education, four years of Junior High 
             consumption of fruits and vegetables  School, and two years of Senior High 
             (Wall  et al., 2012; Watts, 2012; Evans       School [SHS]). In this curriculum, 
             et al.,  2016). Other studies looked into     nutrition is taught in the first quarter 
             the duration, length and frequency  of each school year among Grades 1-4 
             of nutrition education interventions  students as part of their Health subject. 
             in relation to increasing fruits and  For Grade 1, nutrition topics focus 
             vegetables consumption, increasing on healthful and less healthful foods, 
             physical activity, promoting healthy  consequences of eating less and good 
             eating and reducing overweight and  eating habits. Nutrition topics for Grade 
             obesity among school children (Morgan         2 include healthy foods and the body, 
             et al., 2010; Prelip et al., 2012; Rosario    and guides in eating a balanced diet 
             et al., 2012; Moss et al., 2013). Based on    such as the food pyramid and healthy 
             a systematic review across 7218 studies       plate. For Grade 3, good nutrition and 
             about the effectiveness of school-based       health, and Nutritional Guidelines for 
             interventions among children and  Filipinos (NGF) are topics included in 
             adolescents aged 6–18 years old, most         the curriculum guide. Reading food 
             school-based interventions (82.0%) labels and food safety principles are 
             have the potential to improve dietary  topics discussed in Grade 4 (Department 
             and physical activity behaviours and to       of Education, 2016). Given that the 
             prevent unhealthy body weights in low-        curriculum is particularly new, learning 
             and middle-income countries. To reach         materials can still be enhanced so that 
             full potential, process evaluations that      students acquire in-depth knowledge, 
             document programme implementation  skills, and attitudes, particularly on 
             should be conducted (Verstraeten et           nutrition. Developing a good nutrition 
                   School-based nutrition education to improve children and mothers’ knowledge     191
          education module is important to create         MATERIALS AND METHODS
          an effective nutrition education (Anwar         Development of nutrition education 
          et al., 2018).                                  modules
              Most of the local nutrition Workshop
          interventions by the government are  A workshop was conducted among 
          focused only on children as programme           teams of DOST-FNRI nutritionist-
          participants. However, in reality, mothers      dietitians and teachers from Daang Hari 
          and caregivers play an important role in        Elementary School, Bicutan, Taguig City, 
          achieving proper nutrition for children.        Philippines to develop comprehensive 
          Extending nutrition interventions to  nutrition education modules that are 
          mothers will have a positive impact on          in line with the K to 12 curriculum. 
          health and nutrition. Improved nutrition        Five nutrition education modules were 
          knowledge of mothers can be applied  developed based on the pre-determined 
          in their households, thus preventing  key messages of the researchers. 
          malnutrition among children (Sukandar 
          et al., 2015).                                  Pre-testing of nutrition education modules
              In August 2017, the DOST-FNRI  These nutrition education modules 
          undertook a comprehensive one-year  were pre-tested to determine their 
          school-based programme on food attractiveness, comprehensibility, 
          and nutrition, which includes feeding  acceptability, and self-involvement of the 
          underweight school children and modules for Grades 2 and 3 students, 
          nutrition education among targeted  and to assess if the materials given to the 
          school children and their mothers. The          teachers were sufficient for the conduct 
          programme, Forging Public-Industry-             of nutrition education classes. Pre-
          Society alliance: A Program United for          testing activities were done in elementary 
          Healthier Kids (PISO for Healthy Kids),         schools of both urban and rural areas. 
          consisted of four components, namely,           These elementary schools had similar 
          Project 1 – Translation of Pinggang Pinoy       characteristics with the study schools, 
          for Children into Adequate Meals, Project       but were not study participants. 
          2 – Translation of Pinggang Pinoy for               The study employed random 
          Children into Adequate Meals - Recipe           pre-testing. Pre-tested lessons were 
          Development, Project 3 – Nutrition  representative  of  five  modules.  Out  of 
          Education, and Project 4 – Evaluation           the 29 lessons in each module, nine 
          Research.                                       lessons were randomly selected for 
              Project 3 of the programme - Nutrition      pre-testing. These pre-testing lessons 
          Education aimed to develop nutrition  were also representative of the different 
          education modules for use by Grades 2           learning activities included in the 
          and 3 teachers of four selected public          modules like word search, true or false, 
          elementary schools, and to conduct  and matching type. Nutrition education 
          nutrition education campaigns among  lessons that were to be pre-tested 
          Grades 2 and 3 students of selected  were given to the teachers in advance 
          public schools and their mothers or  for familiarisation. Collaterals for the 
          caregivers. Therefore, the present study        lessons  like  worksheets,  posters,  flash 
          determined the effectiveness of these  cards, big books, and puzzles were 
          developed nutrition education modules           also given in advance to the teachers. 
          in improving children and their mothers’        Teachers demonstrated the lessons in 
          knowledge on food and nutrition.  the modules and conducted individual 
          Likewise, changes in behaviours among           or group activities for the evaluation of 
          children were also determined. 
            192                      Glorioso IG, Gonzales MS & Malit AMP
            the lessons. After the demonstration,  nutrition concepts in every module to 
            the researchers conducted key ensure that the teachers understood the 
            informant interviews using a validated      content of the modules. After discussions 
            questionnaire developed by the on the technical content of the modules, 
            researchers following the metrics of  a teaching demonstration of the nine 
            attractiveness, comprehensibility, sessions in each module was done. 
            acceptability and self-involvement.         The teacher-participants were grouped 
                                                        and asked to demonstrate the nine 
            Study design and participants               topics in each module. The facilitators 
            The study used a quasi-experimental  and nutritionists gave comments and 
            design. The study participants were from    suggestions for further improvement 
            the PISO for Healthy Kids programme  in discussing the nutrition concepts. 
            who received nutrition education. A  A follow-up meeting was conducted 
            total of 1,788 Grades 2 and 3 students      among Grades 2 and 3 teachers after 
            from four schools in Laguna, Philippines    completing each module. This was done 
            were included in the nutrition education    to get feedback from the teachers on the 
            sessions from August 2017 to March  use of these modules.
            2018. Among these students, 166 were            Copies of the nutrition education 
            considered eligible study participants  modules were given to the teachers, 
            based on criteria for age (7-9 years old)   which served as their guide in teaching 
            and nutritional status (underweight).  students. The teachers followed the 
            The criteria for age were based on the      modules provided by the project and 
            age grouping of the Philippine Dietary      used the collaterals for each module. 
            Reference Intakes (PDRI). The eligible  The teachers taught the modules 
            participants were the ones assessed  in their individual creative ways by 
            based on changes in their KAB. Students     adding more photos and drawings, and 
            were distributed into two groups: (1)  supplementing the modules with audio-
            nutrition education alone (n=83) and (2)    visual presentations and videos.
            nutrition education with feeding (n=83).        The students were exposed to 
            Simultaneously, nutrition education  nutrition education topics through 
            sessions were conducted among mothers       a 25-minute session totalling to 144 
            of these selected students, following  sessions (about 60 hours). There was 
            the  same  five  modules  taught  to  the   a dedicated time slot for the 25-minute 
            students. The groupings of the mothers      nutrition education session, and was 
            were based on their child’s grouping.       conducted during school days (Monday 
                                                        to Friday). The nutrition sessions were 
            The intervention                            not incorporated in the Health and 
            Implementation of nutrition education       Science subject because in the existing 
            component                                   curriculum, nutrition concepts are only 
            A training entitled “Teaching Nutrition     discussed  in  the  first  quarter  of  each 
            for Healthier Kids” was conducted to  school year. The four schools conducted 
            capacitate the teachers for the ensuing     different number of hours of nutrition 
            conduct of nutrition education in  education sessions, ranging from 57.50 
            selected schools in Bay and Calauan,  hours to 60.42 because of varying school 
            Laguna, Philippines. A total of 51 Grades   activities and class suspensions due to 
            2 and 3 teachers from Calauan and Bay       typhoons and holidays (Table 1). Two 
            Central Elementary Schools attended  nutritionist-researchers were assigned 
            the training on July 24-25, 2017. A  to ensure that the nutrition education 
            nutritionist emphasised important 
                                                        sessions were conducted during school