Magazine 2015
International Peer-Reviewed Journal
RESEARCH HORIZONS, VOL. 5 JULY 2015
FOOD & NUTRITION
IMPACT OF NUTRITION EDUCATION INTERVENTION ON
STREET CHILDREN IN MUMBAI
Unnati Shah, Perpetua Machado
ABSTRACT
IMPACT OF NUTRITION EDUCATION INTERVENTION ON STREET CHILDREN IN MUMBAI
The street children population is increasing in Mumbai. Most of them are undernourished. Providing nutrition
education as non-formal education would be an easy procedure to increase awareness and thereby improve
their food habits. In the present study a Nutrition Education Programme (Street Nutripathashala)was designed
for Street Children and its impact on nutrition awareness and wise food selection awareness was
studied.Study design was action research and quasi experimental. Three hundred and fourteen street
children (9-18 years) associated with three institutes {government school (184), NGO (68) and shelter-
home (62) were selected using purposive sampling. One hundred and forty four (46%) street children were
placed in control group, remaining 170 (54%) underwent nutrition education interventionfor a period of
three months, weekly for one hour at their respective centres. Data was analyzed using SPSS (16).Results
were highly significant at p< 0.001. Independent z test indicated higher post-test nutrition awareness
score (Ztwo tailed= -28.57) and higher post-test wise food selection awareness score (Ztwo tailed= -29.10) in
the experimental group participants. Paired z test indicated highly significant increase in the mean Nutrition
awareness score by 10.06± 3.93and Wise food selection awareness score by 3.47± 1.47 in the experimental
group participants among both genders for all ages across the three types of street children.Street children
benefitted from nutrition education intervention (Street nutripathashala). This programme can be used for
street children and be adapted for school children to increase nutrition awareness and wise food selection
awareness thereby improving their food habits.
Key Words : ꢀ %Nutrition awareness ꢀ %Nutrition education interventionÏ%Street children Ï% Street
nutripathashalaÏ%Wise food selection awareness
LIST OF ABBREVIATIONS AND SYMBOLS
CG
Control Group
EG
Experimental Group
NAS
Nutrition Awareness Score
Nongovernmental Organisation
Wise Food Selection Awareness Score
United Nations Children’s Fund
Findings Significant (p < 0.001)
NGO
WFAS
UNICEF
**
Introduction :
Children are an asset for any society. It is the responsibility of the society to nurture them through various
phases of their development, to enable them to make meaningful contribution. Yet there are millions of
children throughout the world who live on street, an unfriendly environment.
Highest number of street children is found in Maharashtra (D’lima and Gosalia, 1992). As estimated by
Tata institute of social science and voluntary organization ‘Action Aid India’ total of 37,059 children were
found to be living on the streets of Mumbai (Rajadhyaksha, 2013). As per UNICEF the exact number of
street children is impossible to quantify but it is likely that every city in the world has some street children,
including the biggest and the richest cities of the industralised world (UNICEF, 2014).
In most of the studies street children examined were malnourished, especially between the ages of 12
and 13, dental caries, skin problems, urinary problems, bone fracturestrauma and upper respiratory tract
infection. Skin diseasesand malariaare found to be more common in children who are street based than
in home based children (Nzimakwe and Brookes, 1994; Thomas et.al., 1998; Ayaya and Esamai,
2
001; Solomon et.al., 2002). A situational analysis of street children in Pakistan reported stunted and
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RESEARCH HORIZONS, VOL. 5 JULY 2015
wasting in 32% of population (Shahabet.al.,2004).Street children were more nutritionally vulnerable as
compared to school children(Ayukuet.al.,2004). A study conducted on 314 street children in Mumbai
reported that 56% of boys and 58% of girls met the standard height for age reference, 54% of boys and
5
7% of girls met the weight for age reference standards and 63% of boys and 68% of girls met the
standard reference for BMI respectively. Out of the remaining children only 13% of boys and 9% of girls
were over nourished, rest all were under nourished(Shah and Machado, 2014).
In India however, it was not until very recently that street children were recognised in planning and policy
development as a separate target group – they were usually considered in the category of children in
need of care and protection. New NGOs have been formed and other organisations like the Indian
council of child welfare have expanded their programmes to include these children. A wide range of
services are being provided which included education, vocational training, counselling and guidance,
recreation, health care, public baths and lavatories usage, shelters, supplementary feeding, nutritional
supplementation and income generation.
Twenty eight percent street children were beneficiaries of NGOs / shelters or some other centres working
for them. About 32% of street children sought help when they needed food, clothing or shelter, while 18
%
tried to do so to meet their educational needs and 11% for employment in order to survive on streets.
From this study it was clear that a majority of street children in Mumbai were in contact with social service
agencies and other service providers, indicating the reach of these organisations(D’souza, 2008).
Nutrition education is provided to school children in the western countries however in India this trend is
emerging. Nutrition education is important though not sufficient to empower street children to improve
their diet. Effect of nutrition education intervention on street children has never been documented but
data on school children with regards to nutrition education intervention has shown significance. Nutrition
awareness has improved significantly post intervention in many studies related to school children such
as mean total nutrition knowledge score of primary school children in intervention group increased by
1
.1 as compared to 0.3 in control group after playing a nutrition related card game and 70% children
considered that game enabled them to choose healthier foods(Laxmanet.al.,2010). Average increase in
fruit intake and significant increase in nutrition knowledge scores in primary school children was observed
after nutrition education intervention(Anderson et.al.,2003).Recent works suggests nutrition knowledge
may play a small but pivotal role in the adaptation of healthier food habits in school children. These
studies conducted on children regardless of the their gender, age and the wide span of intervention
duration ranging from 2 sessions to maximum of 9 weeks showed significant improvement in nutrition
awareness and food habits. Most of the studies conducted in the literature showed many researches
being conducted on demographic issues of street children followed by health and nutritional status;
however no study till date has been conducted with the sole aim to improve nutritional awareness among
street children in Mumbai. Thus the present study was conducted to test the following hypothesis:
Null Hypothesis:Nutrition awareness and wise food selection awareness does not increases significantly
among experimental group participants in both the genders for all ages across the three types of street
children post nutrition education intervention.
Methodology :
The study was conducted in Mumbai. Study population included street children. Study design was
action research and quasi experimental. Ethical approval for research on human subjects was obtained
from (NNCHIEC) affiliated to the University of Mumbai.
SAMPLING TECHNIQUE - Purposive sampling technique was used;three Organizations (State board
school, NGO and Shelter house) in Mumbai, known to have close experience with street children were
approached. These organizations offered various services like imparting education, providing shelter
and food to number of underprivileged children like street children living with their family on streets,
orphans, run away kids, children of sex workers and children in extreme difficulty under the physically
suffering single parent.Informed written consent was obtained from all three heads of the three institutions.
Informed oral consent was obtained from participants of the study.
Inclusion Criteria :
1
2)
)
Children residing on streets /temporary structures / in shelters
Street children affiliated with institutes
3
4)
)
Between the age group of 9 to 18 years
Willing to participate voluntarily
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Data Collection - A nutrition awareness questionnaire was designed to obtain data on nutrition awareness
from street child. A quiz was designed to obtain information on wise selection of food. Face validity,
content validity and reliability score for nutrition awareness questionnaire and wise food selection quizwere
established.
Development of Nutrition Education Programme - A Nutrition Education Programme named
“
STREET NUTRIPATHSHALA” was designed to meet the nutritional needs of street children. The
programme had 12 sessions (Table 1) and used different methods of teaching. Post sessions there was
quiz. First three prizes were awarded after every quiz to motivate children. Post last session (revision
class) doubts were solved if any. Concepts were taught with the help of poster, film and play and learn
method.
Table No 1: Nutrition intervention sessions
Session Content
Method
Teaching
Method
Session
Quiz
1
2
3
4
5
6
7
8
9
Nutrition Introduction
Basic five food groups
Food sources of macro nutrients
Functions of macro nutrients
Food sources of micro nutrients (vitamins)
Food sources of micro nutrients (minerals)
Functions of micro nutrients (vitamins)
Functions of micro nutrients (minerals)
Food pyramid and exercise importance
Poster, play Fill in the blanks
Poster, play 5 Thalis fill up
Poster, play Cross word
Poster, play Match the puzzle
Poster, play Search words
Poster, play Jumbled words
Poster, play Singing game
10
Hygiene importance and Food borne diseases Film
Maze game
1
12
1
Wise selection of food & save nutrients tips
Revision class
Oral talk
Oral
Oral questions
Doubts solving
Intervention - One hundred and forty four (46%) street children were placed in control group. Remaining
70 (54%) street children were trained with the above designed Nutrition Education Programme for a
1
period of three months, weekly for one hour at their respective centres. Before and after intervention
data was obtained on Nutrition awareness data and wise food selection awareness. The nutrition awareness
questionnaire and wise food selection quiz options were shuffled to overcome the retest effect.
The control group participants after post data collection were guided with the true answers. One nutrition
education session for the duration of 2 hours after post data collection was conducted to benefit even
the control group participants.
Statistical Analysis (SPSS)
Descriptive statistics – Frequencies, percentages, measures of centre and measures of variability were
computed.
Advance statistics - Independent z test for contrasting two independent groups on a quantitative variable,
paired z test for contrasting two dependent variables to study the intervention impact. pvalue < 0.01 was
considered to be statistically significant.
Results and Discussion :
A total of 314 street children were studied, inclusive of street children affiliated to 1 - government school
(
184), 1- NGO (68) and a shelter home (62) respectively.
Age and Gender of Subjects
The age of street children ranged from 9 to 18 years with a mean age of 12 years and standard deviation
of 2 years. Among 314 street children, 108 (35%) were girls and 206 (65%) boys respectively. In the
present study age and gender represents street children population, as the average age of initiation to
street life is approximately eleven years(UNICEF, 2014).Worldwide, the population of street boys is
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RESEARCH HORIZONS, VOL. 5 JULY 2015
higher than street girls. In Columbia, the street child population is 75% male and 25% female(Felsman,
1981; Aptekar, 1988).
Impact of Street Nutripathshala Intervention
A total of 170 street children were included in the intervention and 165 completed the intervention. The
reason for their drop out was migration to other places. For the present study two tools were specially
constructed. The reliability (Cronbach Alpha) of the scale for nutrition awareness before intervention was
0
.649 and post intervention 0.756. The reliability (Cronbach Alpha) of wise food selection awareness
scale was 0.644 before intervention and 0.818 after intervention.
Before intervention on a Nutrition awareness scale of 11 items, the theoretical range was 0 to 20 and the
actual range was 0 to 14. After intervention actual range was 3 to 20. Theoretical range for Wise food
selection awareness scale of 4 items was 0 to 12 and actual range before intervention was 4 to 10 and
after intervention was 6 to 12.
There was no significant difference in the pre-test nutrition awareness score (p > 0.01) and pre-test wise
food selection awareness score (p > 0.01) between the control and experimental group street children.
However the difference in post-test nutrition awareness score and post-test wise food selection awareness
score was highly significant (p < 0.001). Table 2 describes the descriptive characteristics, independent
z test value and significance level of nutrition awareness score and wise food selection awareness score
among street children.
Post intervention the mean post-test NAS of control group street children was 6.18 ± 2.35 and post-test
WFAS was 7.07 ± 1.09. In contrast the mean post-test NAS of experimental group street children was
1
6.62 ± 3.93 and post-test WFAS was 10.89 ± 1.19. This difference between the control group and
experimental group street children for post-test NAS (Z two tailed = -28.57, p < 0.001) and post-test WFAS
Z two tailed = -29.10, p < 0.001) was highly significant. Thus awareness at baseline between control and
(
experimental group participants was similar, however post-test awareness score were greater in
experimental group participants.
Table No 2: Baseline and post nutrition education intervention characteristics between
control group and experimental group street children
Variable
CG (n=140)
EG (n=165)
Minimum
score
Maximum
score
Mean score
± SD
Z test
value
Sig
(two tailed)
Pre-test NAS
CG
EG
CG
EG
CG
EG
CG
EG
1
0
2
3
5
4
4
6
13
14
19
20
11
10
11
12
6.07 ± 1.97
6.56 ± 2.86
6.18 ± 2.35
16.62 ± 3.93
7.32 ± 1.12
7.41 ± 1.07
7.07 ± 1.09
10.89 ± 1.19
-1.74
-28.57
-0.66
0.083
0.000**
0.510
Pre-test NAS
Post-test NAS
Post-test NAS
Pre-test WFAS
Pre-test WFAS
Post-test WFAS
Post-test WFAS
-29.10
0.000**
The impact of nutrition education intervention was assessed through changes in the nutrition awareness
score and wise food selection awareness score from baseline to post intervention(Table 3). There was an
improvement in both the scores in the experimental group participants. The mean NAS paired difference
was -10.06 with 3.93 standard deviation of difference and the mean WFAS paired difference was -3.47
and 1.47 standard deviation of difference, among experimental group street children. This increment in
post-test NAS (Paired Z one tailed = -32.84, p < 0.001) and post-test WFAS (Paired Z one tailed = -30.36, p
<
0.001) was highly significant. However in the control group street children the WFAS dropped as
compared to baseline and this drop in scores was also highly significant (Paired Z one tailed = 4.68, p <
.001). There was no improvement in the NAS in the control group street children attributing to the fact
that improvement in the experimental group participants was due to intervention.
0
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RESEARCH HORIZONS, VOL. 5 JULY 2015
Table No 3: Impact of nutrition education intervention on street children
Variable
CG(n=140) Mean score
Mean
paired
difference
Standard
deviation of
difference
Z test
value
Sig
(one
tailed)
EG(n=165)
± SD
Pre-test NAS
Post-test NAS
Pre-test NAS
Post-test NAS
Pre-test WFAS
Post-test WFAS
Pre-test WFAS
Post-test WFAS
CG
CG
EG
EG
CG
CG
EG
EG
6.07 ± 1.97
6.18 ± 2.35
6.56 ± 2.86
16.62 ±3.93
7.32 ± 1.12
7.07 ± 1.09
7.41 ± 1.07
10.89 ± 1.19
-0.10
-10.06
0.25
2.73
3.93
0.65
1.47
-0.46
-32.84
4.68
0.322
0.000**
0.000**
0.000**
-3.47
-30.36
Analysis by Gender
NAS and WFAS were also compared by gender in the experimental group (Table4).There was no significant
difference in pre-test NAS, post-test NAS, pre-test WFAS and post-test WFAS between boys and girls in
experimental group.
Table No 4: Baseline and post nutrition education intervention characteristics between
the boys and girls in experimental group
Variable
Boys(n=121)
Girl(n=44)
Minimum
score
Maximum
score
Mean score ±
SD
Z test
value
Sig
(two
tailed)
Pre-test NAS
Pre-test NAS
Post-test NAS
Post-test NAS
Pre-test WFAS
Pre-test WFAS
Post-test WFAS
Post-test WFAS
Boys
Girls
Boys
Girls
Boys
Girls
Boys
Girls
0
2
3
3
4
6
6
7
14
13
20
20
10
10
12
12
6.40 ± 3.02
7.00 ± 2.34
16.71 ± 3.64
16.36 ± 4.68
7.39 ± 1.07
7.45 ± 1.06
10.89 ± 1.27
10.88 ± 0.99
-1.32
0.45
-0.30
0.03
0.187
0.650
0.759
0.974
Thus it can be concluded that NAS and WFAS post intervention improved equally in both the genders in
the experimental group.
Analysis by Street Children Types in Correlation to Unicef
NAS, WFAS increment were also analysed for each street child type in experimental group
participants(Table 5). In the present study three types of street children were observed.
I. Children on the street comprised of street children who return to their respective families at the end
of the day, however spent most of their day time on streets.(n=43)
II. Children of the street comprised street children who reside as well as sleep in temporary structures
such as (illegal slums, tabelas, pavements and under bridges)(n=51)
III. Third category included Street Children who resided and sleep at shelter home comprising mainly of
children who are orphans, run aways and refugees. The solo reason to enroll themselves with shelter
home has been no contact with their respective care takers either due to death, displacement or
abandonment. (n=71)
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Table No 5: Impact of nutrition education intervention on awareness scores among
three types of street children in the experimental group
NAS
Z value
WFAS
Z value
Street
child
type
f
Mean paired
difference
Std. Deviation
of the difference
-10.11 ± 4.77
-9.33 ± 4.23
Sig
(one
tailed)
Mean paired
difference
± Std. Deviation
of the difference
(
165)
Sig
(one
±
tailed)
I
43
51
71
-13.90
-15.73
-29.36
0.000**
0.000**
0.000**
-2.97 ± 1.55
-3.53 ± 1.41
-3.73 ± 1.40
-12.58
-17.86
-22.40
0.000**
0.000**
0.000**
II
III
-10.54 ± 3.02
As per Table 5 it can be concluded that NAS and WFAS increased significantly in all the types of street
children.
Analysis by Age
NAS, WFAS increment were also examined for children of all ages in experimental group participants.
Table6 discusses the difference in the improvement of scores before and after intervention among
experimental group street children of all age.
Table No 6: Impact of nutrition education intervention on awareness scores among
street children of all ages in the experimental group
NAS
WFAS
Age
f
Mean paired
difference
Std. Deviation
t / z
value
Sig
(one
tailed)
Mean paired
difference
± Std. Deviation
of the difference
t / z
value
(
165)
Sig
(one
±
tailed)
of the difference
9
17
48
26
8
-10.64 ± 5.01
-9.33 ± 4.51
-10.46 ± 4.13
-9.87 ± 2.35
-12.06 ± 3.15
-9.64 ± 3.14
-9.76 ± 3.08
-10.66 ± 3.14
-10.00 ± 3.11
-8.66 ± 3.32
-8.75
-14.31
-12.88
-11.85
-15.31
-12.66
-11.41
-8.31
0.000**
0.000**
0.000**
0.000**
0.000**
0.000**
0.000**
0.000**
0.000**
0.000**
-2.41± 1.22
-3.54 ± 1.45
-3.50 ± 1.39
-4.25 ± 0.88
-4.00 ± 1.26
-3.82 ± 1.87
-3.00 ± 1.73
-4.00 ± 1.78
-3.12 ± 0.64
-3.50 ± 1.04
-8.09
-16.82
-12.81
-13.56
-12.64
-8.39
0.000**
0.000**
0.000**
0.000**
0.000**
0.000**
0.000**
0.000**
0.000**
0.000**
1
1
1
1
1
1
1
1
1
0
1
2
3
4
5
6
7
8
16
17
13
6
-6.24
-5.4
8
-9.07
-13.79
-8.17
6
-6.38
As per the above table improvement in NAS and WFAS was highly significant (p< 0.001) for children of
all ages. The maximum improvement in NAS was observed in 13 year olds whereas in WFAS maximum
improvement was observed in 12 Years old street children.
Thus the above results indicate that there has been an impact of the intervention provided to street
children. Finding of this study are similar with regards to other nutrition education intervention studies
conducted by (Thakur et.al., 1999;Venkaih et.al., 2002; Worsley, 2002; Turconi et.al., 2008 and Tuuri
et.al., 2009).Since no studies on nutrition intervention trials are available especially for Indian street
children broader conclusions could not be drawn in the light of comparisons. This was the first experiment
conducted on street children hence for the present study comparisons were made with the similar
intervention trials conducted on school children.
Summary and Conclusion
The study summarises that the control group and experimental group participants were similar for test
variables at baseline. Post nutrition education intervention there was highly significant difference between
the control and experimental group participants for test variables attributing to the fact that improvement
in the experimental group participants was due to intervention. Mean paired difference and standard
deviation of the difference showed highly significant improvement in the experimental group participants
among both genders for all ages across the three types of street children for NAS (p<0.001) and WFAS
(p<0.001).The nutrition awareness score increased significantly by 10.06 ± 3.93 and wise food selection
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RESEARCH HORIZONS, VOL. 5 JULY 2015
awareness score by 3.47 ± 1.47 respectively in the experimental group street children. Therefore the null
hypothesis was rejected with a probability of type I error less than 0.01%.Thus it can be concluded that
intervention had asignificant impact and helped the street children to increase their nutrition and wise
food selection awareness.
Application of the Study
·
·
·
Street nutripathshala intervention helped to increase nutrition awareness and wise food selection
awareness among street children of the study.
The street nutripathshala content has been provided to the three institutes and can be used in future
as the spiritual aim of the study was to benefit this population.
The intervention programme designed can be adapted for school children in future.
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