CHAPTER 5: DISCUSSION
5.2 Baseline nutrition knowledge (pre-test)
This study found that the overall baseline nutrition knowledge mean score was 31.1% (7.16 out of 23). Internationally, the results of baseline nutrition knowledge have been very different as seen by Seher (2008) in the USA who reported an average total score of 85%
following a nutrition knowledge test amongst 31 Grade 4 learners. Similarly, in the UK, Lakshman et al (2010) also found high pre-test scores where Grade 5 and 6 learners received 78.6% among their intervention and 75.8% for the control. However the study by Lakshman et al (2010) included 2519 learners which is a very large sample size and makes the results more reliable. Although the baseline results for this study are low for the 9-12 year old age group they are not uncommon in South Africa as Oosthuizen et al (2011a) also found that the multiple choice questions in their study were poorly answered by learners, aged 9-13 years, in an informal settlement in Gauteng.
The sample size and age range for Oosthuizen et al (2011a) study was very similar to this study (experimental n = 82 and control n = 91) thus making the two comparable. However the dropout rate in the Oosthuizen et al (2011a) study was quite high with 27 learners from the experimental group unable to complete the short term post-test and 70 learners in the control group. This was even higher for the long term measurement.
This study and Oosthuizen et al (2011a) show a very low level of nutrition knowledge amongst learners, especially when compared to developed countries such as the USA and UK. These low levels can be attributed to a number of factors, mainly a lack of time and under-staffing. Park et al (2006) surveyed 3141 educators across Korea about the current status of nutrition education, problematic areas, education time and methods and the proper nutrition educator ratio. It was found that 95.5% of educators felt that NE is urgently needed and suggested that one nutrition educator be placed in each school to help with this area of education (Park et al 2006). Other factors may include poor teaching at school level or an educators interpreting and teaching the curriculum based on their personal beliefs and attitudes (Carless 2004). Carless (2004) found that three main issues arose in teaching when looking at a classroom setting. These included the use of the educators’ mother tongue,
discipline problems and use of the prescribed language. If educators revert back to their mother tongue when teaching it reduces the use of the prescribed language (Carless 2004).
This may have occurred in the schools involved in this study which would worsen their understanding of English and the use of it in the game and questionnaire. Discipline problems are also present in the Sweetwaters classrooms due to the big classes and “teacher-fronted”
activities, as mentioned by Carless (2004). Carless found that in an attempt to improve the prescribed language, learners were often less effective in successfully completing a task because they were not proficient in the language of the task. Similarly, the educators in this study may sacrifice quality of work to try and teach English. Insufficient or incorrect information being passed down from families has been noted in the community. Poor nutrition which has resulted in poor cognitive development may also cause reduced ability to retain knowledge (Kimani-Murage et al 2010). As has been shown, low nutrition knowledge leads to poor food choices and eating habits which results in a large problem with both over- and under-nutrition.
5.2.1 Learners’ knowledge of FBDG
At baseline the learners appeared to have some knowledge on the FBDG that were not directly related to food, such as eating a variety of foods, exercise and drinking water (2.56 out of 4, 64%). This was unlike the findings of Oldewage-Theron and Egal (2009) where only 3.1% of children gave the correct answer for the amount of water that should be consumed daily, however Oosthuizen et al (2011a) found that learners in their study had a better knowledge of water consumption (52.7%). There were high scores in the first four questions of this study. This indicated that the learners had a good basic knowledge of common nutrition concepts in that 65.4% knew that exercise was important and 70.7% could choose the correct options for good examples of exercise. Oosthuizen et al (2011a) and Oldewage-Theron & Egal (2009) found that although an understanding of the importance of exercise at baseline was not low, it was not among the top scoring questions and only 37.8%
and 47.8% of their sample respectively chose the correct answer. Oosthuizen et al (2011a) showed a low pre-test score of only 19.2% for variety in the diet which was different to this study where the concept of eating a variety of foods as well as water consumption were quite well answered with 64.7% and 55.3% of learners choosing correctly for these two questions.
5.2.2 Learners’ knowledge of food groups
The food groups section was not answered as well as the FBDG section (average score was 40%), but better than Oldewage-Theron & Egal (2009) who found that even less of the children in their study were aware of the food groups (13.4%). However in this study, only 4.1% could identify a fortification logo, and 4.5% could explain what they could do in order to increase their fruit and vegetable intake if they needed to. Other studies have generally focused on the number of servings that should be consumed in each of the food groups rather than how to increase or decrease certain food groups from the diet as this study did.
Questions asked by Oldewage-Theron & Egal (2009) and Oosthuizen et al (2011a) about fruit and vegetables were generally fairly well answered at baseline with a correct score of between 42% and 50% (Oldewage-Theron & Egal 2009) and 74.1% (Oosthuizen et al 2011a). Nevertheless, it was found that more specific questions regarding the main function of fruits and vegetables or the sources of certain vitamins were poorly answered in both studies. A similar finding was made in this study where only 15.4% were able to correctly answer the questions asking what we get from fruits and vegetables.
Other questions that were poorly answered were those about foods high in fat (5.3%) and sugary foods (5.6%). For those questions where the learner could choose “all of the above”
there seemed to be a problem. Learners were given a few different options that were all correct and they needed to choose all of them in combination thus although many of them chose answers that were not incorrect, they were not the answer that was required. This may have contributed to the low scores for the above mentioned questions. Other studies found that learners had a slightly better knowledge of which foods should be eaten occasionally or avoided altogether (Oldewage-Theron & Egal 2009; Seher 2008). These low pre-test results further reinforce the necessity for implementing strategies such as a game or ESM because it shows clearly that the information that is taught is not being retained effectively.
Even at baseline 61.3% of the learners knew which foods made up the starchy food group, possibly because this is the staple food group in this area, as is with most rural areas in KZN.
This is contradictory to what Oldewage-Theron & Egal (2009) found where only 23.7%
could classify foods into this group, as well as Seher (2008) in the USA who found that learners could correctly identify foods in the grain less often than those in the fruit, vegetable and dairy groups.
5.2.3 Learners’ knowledge of nutrient content
The number of correct answers continued to decline with the average total for nutrient content being 25.2% (1.26 out of 5) and the rest of the questions in that section scored between 10% and 24%. The learners were aware of the basic concepts of nutrition but knew little about the nutrient content and the results of intake. This can be seen by the way the individual questions were answered.
Interestingly, the question in this study asking about foods that contained vitamin A was answered better than the rest of the section on nutrient content (54.5%) which was very poorly answered (for example, 10.5% correctly answered on how to reduce saturated fat intake). This was poorly correlated with the small percentage of learners (20.7%) who could answer what the function of vitamin A was. A similar result (33.3%) was found by Oosthuizen et al (2011a) when participants were asked the same question.
5.2.4 Learners’ knowledge of nutrient benefits and deficiencies
The total percentage of correct answers in this section was just less than 19%. A possible reason for these questions being poorly answered may be that this section is more detailed and requires a better understanding of nutrition. The learners in this study seemed to have very little knowledge on what the benefits and deficiencies of macro- and micronutrients found in certain foods are. This is consistent with Oosthuizen et al (2011a) who asked a question about oranges helping to heal sores and only 13.5% answered correctly.