Balanced diet related knowledge, attitude and practices (KAP) among adolescent school girls in Noakhali district, Bangladesh: a cross sectional study

Introduction

The word “Adolescence” comes from a Latin word “Adolescere” which means to mature, to grow, to emerge, or achieve an identity [1]. According to the World Health Organization (WHO), adolescents are those aged from 10 to 19 years [2]. Adolescence is a unique period of a girl’s life as physical, cognitive, and psychological development occurs in this period [3]. Adolescence is a transition period from childhood to adulthood and characterized by rapid physical, biological, and hormonal changes resulting in psychosocial, behavioral, and sexual maturity in an individual. It is known as the second growth spurt of life, and both boys and girls undergo different experiences in this phase [4].

Physical and mental changes are experienced during adolescent periods, and that is why a balanced diet is vital during this period and due to a lack of maintaining a balanced diet, adolescent girls suffer different types of micronutrient deficiency, and iron is one of them is an essential mineral for adolescent girls as it has several biological functions in the body, including respiration, deoxyribonucleic acid (DNA) synthesis, cell proliferation, and energy production [5]. Nutrition and physical growth are integrally related; a balanced nutritional diet is a requisite for achieving full growth potential. Failure to consume an adequate diet at this time can result in delayed sexual maturation and can arrest or slow linear growth [6].

More than 1.8 billion adolescents live in the world, among which 89% live in middle-income and low-income countries [7]. In South Asia, the prevalence of under-nutrition among adolescent girls is always in the same conditions as before due to a lack of proper knowledge and little attention in nutrition [8]. In Bangladesh, the rate of low body mass index (BMI) is about 50%, and the rate of anemia (Hb<12 mg/dl) among adolescent girls is about 25–27% [9]. In Bangladesh, it is estimated that about 50% of adolescent girls intake lower energy than they needed, and there are several factors associated with it, such as- education level, socioeconomic status, income level, etc. [10]. Nutrition in adolescents can be satisfied by providing a healthy diet with more fibers [11].

It is estimated that half of the adult body weight and one-fifth of adult height is gained during this period [12]. The adolescent period is significant for girls for better future life, including- pregnancy and lactation. So, nutritional knowledge is required for a healthy lifestyle. Improving nutritional knowledge, attitude, and practices of adolescent girls will lead to more economic growth and healthier individuals [13].

Importance of behavioral studies was revealed by Waisbord [14] which applied to child survival programming. Behavior manifested in three forms, namely knowledge, attitudes, and practices [15]. Nutrition knowledge is essential for individuals to acquire a lifestyle that is healthy and free from disease [16]. Interventional studies which was carried out in Malaysia found that the knowledge, attitude, and practice of undergraduate students on healthy eating improved after intervention [17]. Improving the nutrition attitudes, knowledge, and practices of adolescents and youth is very important as it will lead to a more food-conscious society and healthier individuals [18].

This study was conducted to determine the level of knowledge, attitude, practice on a balanced diet, and its associations with different socioeconomic characteristics of the study population. Determining adolescent schoolgirls’ knowledge, attitude, and practice of a balanced diet will provide concrete evidence, from where it is possible to generate a change mechanism to improve the situation.

Methods

Results

From the socio-demographic characteristics of the respondents’ table (Table 1) indicates that the age of adolescent girls involved in this study was ranging from 13 to 17 years (Mean ± SD:15.11 ± 1.05). Among all the respondents, 44.1% of girls were from government schools and 55.9% of girls from non-government schools. More than one-third of the subject’s parents had a low level of education. Most of the respondents’ fathers were employed; however, mothers were mostly unemployed housewives.

The study found that about 41.2% of subjects were underweight, which indicated the low nutritional status of adolescent girls in our study area. Only 43.3% were normal, 12.0% were overweight, and 3.5% were obese (Table 1). It was also found that 47.4% were non-anemic and 80 subjects were suffered from anemia, among which 44.7% were mildly anemic, 7.2% were moderate anemic, and 0.7% were severely anemic. Analysis of knowledge, attitudes, and practices of a balanced diet by the study participants reveals that 45.6 % of them had good knowledge, 42.7% of them had good attitudes towards a balanced diet; however, the practice of consuming a balanced diet was rather low (only 4.5%).

Table 2 represents the association between socio-demographic characteristics and dietary behaviors, and the analysis found out the relation exists between types of school, parents’ education and occupation, and BMI with knowledge, attitudes towards a balanced diet; nevertheless, with practice, varying degree of relation was observed.

In the present study, it was found that there was a statistically significant relationship between student’s knowledge, attitude, and BMI to type of school (p<0.05). While the relation between type of school and practice was not significant (p=0.262) (Table 2), it was also identified that the relationship between knowledge and attitude to parent’s education was statistically significant (Table 2) in where there was no relation between balanced diet practices and father’s education but had associations with mother’s education.

The present study identified that the knowledge score among Noakhali Govt. Girls High School and Poura Kalyan High School were nearly (OR:1.06; 95% CI:0.620–1.815) and (OR:0.65; 95% CI:0.380–1.118) which was higher than the Bangla Bazar High School. While seeing the father’s occupation, it was found that the balanced diet knowledge score was about (OR:1.322; 95% CI:0.432–4.051) and (OR:2.058; 95% CI:0.748–5.659) which was higher in laborer and high employed fathers respectively than unemployed father. This table also describes that a mother’s education was significantly associated with a knowledge score regarding a balanced diet (p<0.05). Those score on balanced diet was higher in those whose mothers were highly educated (Table 3).

The attitude score on a balanced diet was significantly correlated with the mother’s education and types of school of adolescent girls from Noakhali Govt. Girls High School and Poura Kalyan High School had a higher positive attitude approximately (OR:0.614, 95% CI:0.357–1.056) and (OR:0.38; 95% CI:0.220–0.661) than Bangla Bazar High school. In the case of a mother’s education, those respondents’ mothers who had higher education had a positive attitude. It was also found that a highly educated mother’s adolescent girl had (OR:1.090; 95% CI:0.510–2.331) higher positive attitude than illiterate and primarily educated mother’s children (Table 3).

Discussion

This study was conducted in order to assess the dietary behavior of school-going adolescent girls in the Noakhali region. The nutritional status in terms of BMI of the girls was also seen in this study, and it was found that, the nutritional status of the study area girls not very good, which similar to another study conducted by Nurul et al. [9]. According to the balanced diet knowledge score, almost half the adolescents possessed good knowledge on a balanced diet, which is similar to the result of the study by Saibaba et al. [22] but did not corresponds with Parvin et al. [23].

In terms of the attitude towards a balanced diet, the result indicated that more than half of the adolescents had an indifferent attitude towards a balanced diet. Furthermore, there was a strong relationship between knowledge and attitude of adolescents on a balanced diet. In other studies, it was stated that only a few adolescent girls who had knowledge of a balanced diet had a better attitude and practice on a balanced diet [2], [3], [23]. Regarding the practice of a balanced diet among adolescent girls, it was found that only 4.5% of subjects have a good practice. Therefore, having good knowledge does not always ensure excellent practice. The study findings showed dissimilarity to result by Choi et al. [24].

In this study, it was found that there was a strong association between types of school and knowledge on a balanced diet. Government school-going adolescents had better knowledge compared to non-government schools, but the rate of over-nourished was higher in government schools than non-government schools. These findings contradict the result of Shaaban et al. [25], and according to this study, private schools had better knowledge, attitude, and practice than government schools, but this knowledge was not adequate for adolescents. It was also found that private schools have a slightly better knowledge of a balanced diet than government schools. However, both schools had inadequate knowledge of a balanced diet. Knowledge about the sources of protein, carbohydrates, fat, etc., was higher in private schools than in government schools adolescent [25]. The attitude score was much similar in both types of schools. Nevertheless, practice on a balanced diet did not depend on knowledge of a balanced diet (p>0.05). Private schools are not like non-government schools and that is why the result of this study was not similar to the previous study as the environment of the non-government school is quite different from a government school.

Paternal education and occupational status played a substantial impact on dietary behavior regarding a balanced diet. Maternal education was mostly associated with the knowledge of a balanced diet and BMI of girls. It was found that 43% of adolescents had good knowledge of a balanced diet whose mother was highly educated. On the contrary, obesity among adolescents was higher with the education of mothers, which is related to Choi et al. [24]. Father occupation did not have much effect on the balanced diet behavior among adolescent girls. However, knowledge of a balanced diet was significantly correlated with the father’s occupation (p<0.05). On the other hand, the mother’s education associated mainly with the dietary behavior of adolescent girls except for practice. So, the dietary behavior of adolescent girls is directly associated with the type of school, socioeconomic status, parent’s education, home, and social environment [26]. According to Faruk Ahmed, a highly educated parent’s children have less susceptibility to being underweight, but they are prone to be overweight and obese. Furthermore, The consumption of protein-rich foods such as milk, meat, eggs, and fruits is higher among children with educated mothers [10]. Adolescent girls with proper nutrition knowledge have good dietary behavior. In this study, it is found that more than 50% of girls had a positive attitude who had good knowledge of a balanced diet, and 50% of girls had a good practice on a balanced diet correlated with knowledge on a balanced diet.

Practice on a balanced diet is essential for physical and mental growth in future life. In this study, it was found that those who had moderate practice on a balanced diet, had normal BMI (52.9%). Moreover, the prevalence of overnutrition was higher among poor and moderate practice on a balanced diet than good practice. Nutritional knowledge was significantly associated with dietary habits. Many studies concluded that poor attention on nutrition and knowledge leads to health problems in the future [27], [28]. According to this study, two-third of adolescents believed that food consumption should be lower during adolescence than adults.

Personal hygiene is a crucial factor, which is associated with anemia. There was less chance of being anemic who had good personal hygiene, which was found in this study. It was found that only 19.1% of adolescents had anemia, who had a good score in personal hygiene. However, there is no association between personal hygiene with anemia, which is opposite to the study by Monika et al. [29].

Conclusion

The study underscores balanced diet-related knowledge, attitude, and practice of high school students of three different schools and found even if there is knowledge and a positive attitude, the practice of having a balanced diet is meager. A big chunk of students was underweight, and their parent’s education & occupation had varying degrees of association with their knowledge, attitude and practice (KAP). Hence, proper target-oriented programs and interventions should be adopted at high school level, and the related socioeconomic factors should be addressed in order to achieve better health. Counseling can be done to increase the knowledge, attitude and practice on a balanced diet among adolescent girls. Several types of plan and awareness programs can be organized by government and non-government organizations to enrich the dietary behavior among adolescent girls.