Padmashree college of nursing gurukrupa layout, nagarbhavi, bengaluru

FIRST YEAR M.Sc. NURSING

CHILD HEALTH NURSING

YEAR 2011-2013

PADMASHREE COLLEGE OF NURSING

GURUKRUPA LAYOUT, NAGARBHAVI,

BENGALURU - 560072

The growth rate is slightly slowed down but dietary habit is formed and fixed during the school age, which is thus greatly affected by stimuli through school life and peer groups. Nutrition of school age children has not only direct and short-term influence on physical and mental growth during that period but also indirect and long-term influence on the continuing growth and health of the adolescence and the health during the lifetime. The importance of nutrition in school age children has been emphasized because malnutrition during this period can decrease not only physical and mental development but also the learning ability of children.²

A population-based cohort study was conducted on, “Are dietary patterns in childhood associated with IQ at 8 years of age?” in UK. The sample comprised of 3966 children. Dietary patterns were identified using principal-components analysis and scores computed at each age. IQ was assessed using the Wechsler Intelligence Scale for Children at 8.5 years. There is evidence that a poor diet associated with high fat, sugar and processed food content in early childhood may be associated with small reductions in IQ in later childhood, while a healthy diet, associated with high intakes of nutrient rich foods described at about the time of IQ assessment may be associated with small increases in IQ.³

As the frequency of eating with the family is decreased and the number of children eating alone or preparing meal by themselves, is increased due to socioeconomic changes. It has been reported that the quality of the meal is lower when children eat alone than when eating with the family, the rate of skipping meals is increased in children eating alone and the establishment of proper dietary habit is interfered by eating alone.²

Firstly, childhood obesity is one of the most serious public health challenges of the 21st century. According to WHO, globally, in 2010 the number of overweight children under the age of five, is estimated to be over 42 million. Close to 35 million of these are living in developing countries. The problem is global and is steadily affecting many low- and middle-income countries, particularly in urban settings. The prevalence has increased at an alarming rate.⁶

Some nutrients such as calcium, vitamin A, thiamine, and riboflavin are deficient because of unbalanced diet, eating out and overflowing processed foods, to result in the state of nutritional imbalance with over-nutrition and nutrition deficiency at the same time.⁷

Secondly, malnutrition which refers to an impairment of health either from a deficiency or excess or imbalance of nutrients is public health significance among children all over the world. Malnutrition is more common in India than in Sub-Saharan Africa. One in every three malnourished children in the world lives in India. Malnutrition limits development and the capacity to learn. It also costs lives: about 50 per cent of all childhood deaths are attributed to malnutrition.

In India, around 46 per cent of all children below the age of three are too small for their age, 47 per cent are underweight and at least 16 per cent are wasted. Many of these children are severely malnourished.⁸

The other problem caused due to intake of unhealthy diet is foodborne diseases. Each day millions of people become ill and thousands die from a preventable foodborne disease. Proper food preparation can prevent many foodborne diseases. Food can transmit disease from person to person as well as serve as a growth medium for bacteria that can cause food poisoning. In industrialized countries, the percentage of the population suffering from foodborne diseases each year has been reported to be up to 30%. In the United States of America (USA), for example, around 76 million cases of foodborne diseases, resulting in 325,000 hospitalizations and 5,000 deaths, are estimated to occur each year.⁹
Games are an innovative and challenging educational method.. They have also been used as a teaching strategy in medical education, predominantly to review and reinforce lecture material for undergraduate medical students. One such game is snake and ladder game. It is used as a fun way of learning about a topic and can be used for topics on health, hygiene, gender, money, etc. This game has been used in health programs in many developing countries and adapted to the needs of each program. In a school environment, playing board games has many benefits for children of all ages, from helping to develop their visual alertness to increasing their attention span and assisting with memory strategies and reasoning.

An experimental study was conducted to evaluate the knowledge gained from game-based learning versus traditional case-based learning in a continuing medical education (CME) event on stroke prevention and management. Thirty two family physicians and 3 senior residents watched a 30 minute video about stroke prevention and management and were then randomly assigned into two groups (n = 17 case-based group; n = 18 game-based group). The game-based groups played “Snakes and Ladders.” All participants took a 40-point multiple choice knowledge exams. Results showed that the game based group strongly agreed that the event was enjoyable [game-based = 94%; case based = 53%], that their attention was high throughout the event [game-based = 88%; case-based = 41%], and that they would register for a similar event in the future [game-based = 82%; case-based = 41%].Hence activity based learning might help the children learn better about the healthy dietary practices.¹⁰

Children are the gift to this world and it is the society’s responsibility to nurture and care for them. School-age years are crucial for establishing positive self-esteem and self-concept and it is during this time the child learns how to master skills and relate to others.¹¹

Healthy eating means eating a variety of foods that gives the nutrients needed to maintain health, feel good, and have energy. These nutrients include protein, carbohydrates, fat, water, vitamins, and minerals.¹²

A healthy diet provides the fuel that allows the body to function properly. When children are eating an unhealthy diet during their growing years, there can be devastating consequences. Eating an unbalanced diet will affect the body in various ways. Ill health is often a symptom of an individual's poor diet and is demonstrated through conditions such as obesity, fatigue, diabetes and anorexia.¹³

Adequate food and nutrition are essential for proper growth and physical development to ensure optimal work capacity, normal reproductive performance, adequate immune reactions and resistance to infections. Inadequate diet may produce severe forms of malnutrition in children, Vitamin A deficiency and Iodine deficiency disorders.¹⁴

In India nearly one in four children under age of five is underweight. The problem of hidden hunger-that is deficiencies of essential vitamins and minerals, such as iron, Vitamin A and iodine - is also severe. Nutrition is therefore a serious challenge that has not received the attention it truly deserves.¹⁵

The cross-sectional study was conducted on prevalence of malnutrition in government School children in the field area of Azad nagar in Bengaluru between January and June 2010. The study showed that the prevalence of malnutrition in Government schools was 68%. The prevalence of malnutrition in males and females was 57.94% and 42.06% respectively.¹⁶

The other unhealthy dietary pattern prevalent in school children is the intake of foods purchased in vending machines which leads to poor diet quality and that may be associated with being overweight, obese or at risk for chronic health problems such as diabetes and coronary artery disease.¹⁷

Junk foods are often eaten in instead of regular food, an essential Indian diet that consists of wholesome chapatis and vegetables or snacks like upmas and idlis. Not surprisingly eating junk food leads to a sense of starvation both physically and mentally, as the feeling of satiation and contentment that comes after a wholesome meal is absent.¹⁸

Nutrition education is clearly required for the establishment of desirable dietary lifestyles in school age children and the purpose of nutrition education is not to convey simple nutrition knowledge but to actually apply nutrition knowledge to everyday life to maintain more reasonable dietary lifestyle. Elementary school children are sensitive by nature and thus this period is effective for educating basic knowledge including nutrition knowledge on general dietary lifestyle, food selection, dietary habits, and table manners with organized educational contents. Dietary habits are more difficult to change as the age of children increases and thus it is important to provide nutrition education to eat various foods with balance and with moderate amounts by correcting one-sided dietary habits in the school age children.¹⁹

A school programme recognises that child’s best opportunity to learn is through play. Play helps the child to understand their world, to become socialised, to solve problems in an environment and also develop critical thinking skills. Games encourage interaction among learners, increase learners’ levels of motivation, and enhance the opportunity to learn from others. Unlike many other educational formats, game-based learning can bring fun and enjoyment to the learning experience and might encourage greater participation in group learning activities, with the potential to engage learners’ emotions, as well as their intellects.²¹

An experimental study was conducted to assess the effectiveness of snake and ladder game on ailments of children in government schools of Bengaluru. The sample comprised of 60 students. The school children were educated with the aid of snake and ladder game regarding common ailments. It was found to be effective in terms of increasing the knowledge scores. The major findings of the study were: the post-test knowledge scores were higher than the pre-test knowledge scores and the differences between the pre-test and post-test scores were statistically significant at 5% level. This indicates that GAME was an effective method of imparting information to the children regarding common ailments.²⁴

In order that the child should internalize safe habits by means of the game, certain squares in the game have been replaced by positive drawings, in which the child carries out healthy activities, receiving prizes for these, and others in which risky activities are performed, which are penalized. The areas dealt with are: habits (nutrition, sleep, study, games, etc.), Accidents at home, road safety (pedestrian, cyclist and automobile traveller), and swimming pools. Since it is what the child knows best and where he learns his deepest attitudes, this game could be a help to parents in this difficult task.²⁵
In the view of many of the studies, the investigator felt that the incidence of diseases among school children is mainly due to unhealthy dietary pattern and hence the investigator found the need for educating the children so that they will discuss with other children as well as the family members and everyone will be benefited. And investigator have opted teaching through the medium of play as the investigator felt the children of this age will be interested in play and game-based learning can bring fun and enjoyment to the learning experience.

6.3 STATEMENT OF THE PROBLEM

A Study To Assess The Effectiveness Of Game- Based Learning On Knowledge Regarding The Healthy Dietary Pattern Among The School Children In Selected Government Schools, Bengaluru.

1. To assess the existing level of knowledge regarding the healthy dietary pattern among the school children.

2. To evaluate the effectiveness of game-based learning on knowledge regarding the healthy dietary pattern among the school children.

3. To explore the association between pretest and posttest knowledge scores with the selected demographic variables of the school children.

5. 
   OPERATIONAL DEFINITIONS
   

1. School children may have some knowledge regarding the healthy dietary pattern.

2. Game-based learning through the snake and ladder game may motivate the school children to learn easily about healthy dietary pattern.

6.6 HYPOTHESIS

H₁- There will be a significant difference between the pretest and post test knowledge scores of school children regarding the healthy dietary pattern.

H_1- There will be a significant association between the knowledge among school children regarding healthy dietary pattern with selected demographic variables.


6.8 REVIEW OF LITERATURE

Review of literature is a systematic identification, location, selection and summary of written material that contains information on research problems. Literature review is based on the extensive survey of books, journals and international nursing indices.²⁶

1. 
   Literature related to prevalence of nutritional disorders in children.
   

A multicentric study was conducted on “Overweight and obesity prevalence and body mass index trends in Indian children,” in eleven affluent urban schools from five geographical zones of India. The sample comprised of 20,243 children in the age group of 2-17 years. WHO anthro plus was used to calculate Z-scores for height, weight and BMI. Height and weight were measured and BMI was calculated. The overall prevalence of overweight and obesity was 18.2% and 23.9%. The prevalence of overweight and obesity was higher in boys than girls.²⁹

A cross sectional study was undertaken on prevalence of under nutrition among Kora-Mudi children aged 2-13 years in Paschim Medinipur District, West Bengal, India. The sample comprised of 119 children aged 2-13 years, 59 boys and 60 girls. Height and weight measurements were made by standard techniques. Children were considered as underweight, stunting and wasting if their weight-for-age, height-for-age and weight-for-height Z-scores <-2.0 SD of the National Centre for Health Statistics reference standards. The overall prevalence of underweight, stunting and wasting was 52.9%, 49.6% and 22.7%, respectively. About 16.0%, 24.4% and 1.7% of children were found to be severely underweight, stunted and wasted.³⁰

2. 
   Literature related to impact of unhealthy diet in school children.
   

A study was conducted on “Cognitive development in children with chronic protein energy malnutrition,” in Corporation school in the city of Bangalore. The sample comprised of 20 malnourished and 20 nourished children. The neuropsychological battery for children sensitive to the effects of brain dysfunction and age related improvement was employed. The battery consisted of tests of motor speed, attention, visuo-spatial ability, executive functions, comprehension and learning and memory. Malnourished children performed poor on tests of attention, working memory, learning and memory and visuo-spatial ability except on the test of motor speed and coordination. Age related improvement was not observed on tests of design fluency, working memory, visual construction, learning and memory in malnourished children.³¹

A Longitudinal study was conducted on association of overweight with academic performance and social and behavioural problems in United States to examine the relationship between child overweight and educational outcomes. The sample comprised of 13,680 children in third grade. Students were individually administered reading and math assessments. Teachers reported how often students exhibited certain social skills and behaviours. A series of 1-way analyses of covariance and multivariate analysis of covariance was used. The results concluded that overweight children had significantly lower math and reading test scores compared with nonoverweight children in third grade.³²

A study was conducted on “Under nutrition & risk of infections in preschool children,” in India. The sample comprised of 56,438 preschool children. The National Family Health Survey-3 (NFHS-3) database provided the information regarding the age, sex, weight, height, infant and young child feeding practices and morbidity due to infections of the children. Relative risk (RR) of morbidity due to infections was computed in infants and children with stunting, underweight, low BMI for age, wasting and stunting with low BMI. Comparison of the RR for infections in undernourished children showed that the relative risk of morbidity due to infections was higher and more consistently seen in children with low BMI and wasting as compared to stunting or underweight. The small group of children who had stunting with wasting had highest relative risk of morbidity due to infection.³³

A cohort study was conducted on effects of fast-food consumption on energy intake and diet quality among children in a National Household Survey in United States. This study included 6212 children and adolescents 4 to 19 years old. On a typical day, 30.3% of the total sample reported consuming fast food. Children who ate fast food, compared with those who did not, consumed more total energy (187 kcal), more energy per gram of food (0.29 kcal/g), more total fat (9 g), more total carbohydrate (24 g), more added sugars (26 g), more sugar-sweetened beverages (228 g), less fibre (−1.1), less milk (−65 g), and fewer fruits and nonstarchy vegetables (−45 g). Consumption of fast food among children in the United States seems to have an adverse effect on dietary quality in ways that plausibly could increase risk for obesity.³⁴

3. 
   Literature related to importance of healthy diet.
   

A study was conducted on effect of breakfast composition on cognitive processes in Elementary school children in United States. The sample consisted of 15 male and 15 female school children of 9 to 11 year-old. Two experiments compared the effects of two common U.S. breakfast foods (oatmeal and ready-to-eat cereal) and no breakfast on children’s cognition. Using a within-participant design, once a week for 3 weeks, children consumed one of two breakfasts or no breakfast and then completed a battery of cognitive tests. The study concluded that breakfast intake enhances cognitive performance, particularly on tasks requiring processing of a complex visual display. The results extend previous findings by showing differential effects of breakfast type. Boys and girls showed enhanced spatial memory and girls showed improved short-term memory after consuming oatmeal.³⁵

An experimental study was conducted on “School-Based Healthy Eating and Physical Activity Intervention Improves Diet, Food Knowledge, and Self-Efficacy for Native Canadian Children” in Canada. The sample comprised of 122 students. The study design was a pre-test/post-test, single sample design. A total of 122 students completed all 4 measurements (anthropometry, 24-h dietary recall, and 2 questionnaires), at baseline and follow-up. Then a culturally adapted 1-y school-based intervention was given to the students. There were significant increases in dietary intention, dietary preference, knowledge, and dietary self-efficacy, and in the curriculum knowledge scale between baseline and follow-up. The study concluded that intervention programme was significantly associated with increased knowledge, dietary self-efficacy, and dietary improvements.⁴¹

7. MATERIAL AND METHOD

7.1 Source of data

The data will be collected from school children studying in selected government schools at Bengaluru.

The research design for this study is pre- experimental one group pre test and post test design.

• 
  Independent variables
  

• 
  Dependent variables:
  

• 
  Demographic variables:
  

The study will be conducted in selected government schools at Bengaluru.

Population included in this study is school children in the age group of 9-11yrs of age.

The sample size in the study will be 60 school children.

Simple random sampling technique will be adopted for this study.

The study includes school children who

1. Are 9-11yrs of age and are studying in selected government schools, Bengaluru.

2. Can read and write in kannada.

The study excludes school children who

1. Are not willing to play snake and ladder game.

2. Are not available at the time of data collection.

Numerical data obtained from the sample will be organised and analysed with the use of both descriptive and inferential statistics. Master sheet will be prepared based on the numerical data obtained from the sample.The data will be represented in the form of tables, graphs and figures.

1. 
   Descriptive statistics
   
   1. 
      Frequency distribution and percentage will be used to study the demographic variable of school children on healthy dietary pattern.
      
   2. 
      Mean, range and standard deviation will be used to describe the level of knowledge of school children regarding the healthy dietary pattern.
      

2. 
   Inferential statistics
   
   1. 
      Paired’ test will be used to compare the pre and post test knowledge of school children regarding the healthy diet.
      
   2. 
      Chi square test will be used to associate knowledge of school children regarding the healthy dietary pattern with selected demographic variables.
      

• 
  Level of significance will be set at 0.05 to interpret the hypothesis and findings.
  

As the investigator has planned for game-based learning there will be increase in knowledge of school children regarding the healthy dietary pattern.

Yes, the study requires intervention in the form of snake and ladder game. No other intervention which cause any harm will be done for the subject. The consent will be obtained from the school children before conducting the study.

Yes, the permission will be obtained from the concerned authority and subject.

• 
  Privacy, confidentiality and anonymity will be guarded.
  
• 
  Scientific objectivity of the study will be maintained with honesty and impartiality.
  
• 
  Ethical clearance report has been enclosed for the verification.
  

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relevant to enhance the knowledge in the

field of child health nursing speciality.

11. Name and designation

11.1 Guide : Mrs. Arockia Mary

Professor

HOD of Child Health Nursing

11.2 Signature and seal :

11.3 Co- Guide (if any) :
11.4 Signature and seal :

11.5 Head of the department : Mrs. Arockia Mary

Professor