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DEVELOPMENT OF A NUTRITIONAL EDUCATIONAL TOOL AND ITS
APPLICATION FOR PRIMARY SCHOOL CHILDREN ON FIVE-COLORED
VEGETABLE CONSUMPTION
Alongkote Singhato1,*, Sunard Taechangam2, Chanida Pachotikarn2, Gene Charoonruk2,#
1
Master of Science in Food and Nutrition for Development (Nutrition and Dietetics),
Thailand
2
Institute of Nutrition, Mahidol University, Thailand
*e-mail: [email protected], #e-mail: [email protected]
Abstract
Providing appropriate nutrition information to children can help improve their
knowledge and nutritional habits. Regularly consuming five-colored vegetables is beneficial
to health due to various amounts of nutrients and natural color pigments found in vegetables.
Previous studies have shown that media animation used as an educational tool to educate
children is more effective in attracting children’s attention than other contemporary
educational tools. No previous studies have been conducted using media animation to help
improve knowledge in children on consuming five-colored vegetables in Thailand. This was
a quasi-experimental study aimed to educate primary school children on consuming fivecolored vegetables through development of three media animation modules as follows:
benefits of vegetables and basic food exchange list of vegetables; vegetables comparable
portion/serving sizes; benefits and advantages of consuming five-colored vegetables; and
suggested cooking methods and their applications for consumption in daily life.
The effectiveness of the media animation was assessed in 36 primary school children
in grades 3 and 4 from three primary schools in Singburi province. Self-administered
questionnaires were developed for children as follows: attitude questionnaire (15 questions to
elicit positive or negative attitudes); knowledge questionnaire (20 questions per module); and
satisfaction questionnaire to assess level of satisfaction on media animation (video, audio,
etc.) using a five-scale smileyometer (i.e., awful, not very good, good, really good, and
brilliant). Children’s responses to the questionnaires were obtained pre- and post
intervention. In general, most children significantly improved their knowledge and attitude
on consuming five-colored vegetables (p<0.05) after viewing the developed media animation.
In addition, overall satisfaction level for the developed media animation was 4.34 (from a
total score of 5). In conclusion, the developed media animation is acceptable and an
attractive learning tool to help primary school children learn about the benefits of consuming
five-colored vegetables.
Keywords: five-colored vegetables, media animation, cartoon animation
Introduction
According to the Thai Bureau of Nutrition, 40% of Thai teenagers eat three meals per
day. However, the report also showed that just only 35% of them who do eat three meals a
day consumed vegetables everyday (1). Food consumption behavior is affected by foods that
are readily available, offered and served in the family, and eaten by peers at school (2). The
decision or the choice to eat certain foods is a life-long learning process. People choose to
accept certain food is inherent on how they were first introduced to the food and whether the
experience was pleasurable (3). Fast foods, foods high in calories, and foods low in fiber are
especially appealing to teenagers because of their palatability. Hence, the influence of
friends at school can inadvertently affect their food consumption behavior. However, the
effects of long term high caloric food consumption such as fried foods and beverages with
added sugar can also lead to unhealthy lifestyle that can bring about chronic diseases such as
cardiovascular disease, high cholesterol, hypertension, dyslipidemias, type 2 diabetes, and
obesity (4).
Obesity is fast becoming a public health problem affecting both developed and
developing countries. In Thailand, an increase in prevalence of obesity has been reported in
children in Bangkok and in the central region of the country, more so than in any other
provinces (5). Singburi, a province located in the central region of the country has the
highest prevalence of chronic diseases per population ratio than any other provinces in the
central region of the country (6, 7).
Vegetables are an excellent source of dietary fiber, vitamin, and mineral, and they
assist in weight management and lowering risk of many chronic diseases (8-10). According
to the Dietary Guideline for Americans, eating vegetables is highly recommended for they are
major sources of nutrients including vitamins, potassium, folate, and magnesium and they are
also associated with lowered risk for developing chronic diseases (i.e., cardiovascular
diseases and stroke) when two-cups of vegetables and fruits per day is consumed on a regular
basis (11). Vegetables provide a low calorie food source that is ideal for people who are
interested in losing excess body weight. Consuming large amount of vegetables over a
period of time can help reduce hypertension, according to the Dietary Approaches to Stop
Hypertension or “DASH” diet (12). The approach involves increasing consumption of fruits
and vegetables, fat-free milk products, whole grains, nuts, white meats, and no added sugar
beverages, while advocating the reduction of additional salt in the diet. In North America,
Europe, Australia, and New Zealand, the “5 A Day” program encourages the consumption of
at least 5 portions a day of fruits and vegetables (13). In Thailand, the Thai Nutrition Flag,
recommends consumption of 4-6 rice-serving spoons of vegetables a day for the general
population (14).
Many countries have now started to shift their campaigns in promoting vegetable
consumption to promoting the importance and awareness of a rainbow of vegetables (or fivecolored vegetables). Five-colored vegetables is the variety of colors that can be generally
found in vegetables---green, red, yellow/orange, blue/ purple, and white (15, 16). Experts
suggest regularly consuming five-colored vegetables daily over one or two colored
vegetables (i.e., green, red, etc.).
Five-colored vegetables contain nutrients and
phytochemicals which are beneficial to human health (16, 17). Green-colored leafy
vegetables, commonly consumed in regular diets of most people, are a source of calcium--benefiting bones and teeth formation. Cruciferous vegetables such as broccoli are rich in
vitamin A (promoting normal visual function by acting on visual pigments and photoreceptor
cells). Other green-colored vegetables such as cabbages and green bell peppers are excellent
sources of vitamin C---promoting collagen synthesis, a protein abundant in connective tissues
and cartilages. Vitamin C (ascorbic acid), a strong anti-oxidant that helps prevent oxidative
damage and enhances infection resistance by promoting immunologic activities among cells
(16, 17). Green-colored vegetables are also excellent sources of phytochemicals, dietary
fibers, and potassium which has been extensively studied and affirmed to be beneficial to the
cardiovascular system in lowering both systolic and diastolic blood pressures in people with
normal and high blood pressure (16-18). Red-colored vegetables such as red bell peppers and
tomatoes are excellent sources of vitamin A and potassium. Tomatoes and tomato products
are excellent sources of lycopene, a natural pigment with lipid soluble compound, which can
be found in cell membranes and other lipid components in human body as well. Lycopene
has an effectively strong anti-oxidative property and has been reported in lowering cancer
risk (i.e., prostate cancer) by inhibiting carcinogenesis. Lycopene has also been reported to
lower risk of atherosclerosis development by reducing critical biochemical substances such as
low-density lipidoxidation (19). Yellow and orange-colored vegetables such as carrots and
yellow bell peppers are excellent sources of carotenoids and vitamin C and their roles as
strong antioxidants in minimizing cell damage against free radicals greatly benefit cell
proliferation and degradation, growth, and protection. Yellow and orange-colored vegetables
are rich in beta-carotene---a pro-vitamin A that can be converted to vitamin A in the human
body. Beta-carotene is a strong anti-oxidant that can protect cell damage from free radicals.
A study conducted by Van Poppel et al. reported that consumption of vegetables containing
large amounts of beta-carotene can help lower risk of some cancers (i.e., pulmonary and
certain gastro-intestinal carcinomas) by inhibiting carcinogenic cell formation (20). Yellow
and orange-colored vegetables such as orange bell peppers are good sources of vitamin C,
potassium, and folic acid. Blue and purple-colored vegetables (i.e., egg plants, purple
cabbages, etc.) are rich in anthocyanins, a flavonoid pigment compound that acts as an antioxidant by capturing dangerous oxidative compound that lead to lipid peroxidation of cell
membranes and cell damage. A study conducted by Oancea et al. demonstrated that
anthocyanins were involved in maintaining memory function by reducing oxidative stress in
the brain and maintaining normally visual function by improving night vision, lowering risk
of cancer by inhibiting tumor formation, and stimulating pancreatic cell activities in diabetic
patients (21). White-colored vegetables such as garlic and onions contain quercetin, a natural
flavonoid compound that may help minimize risk of cancer development by inhibiting
malignant cell formations and the conversion of saturated fatty acids to free radicals (22-24).
Long-term garlic consumption helps in lowering risk of cardiovascular disease progression
by decreasing serum cholesterol and serum triglyceride levels (25). The report showed that
long-term garlic consumption can reduce hypertension incidence and platelet aggregation
(blockage of blood flow) in a normal healthy population.
The concept of adding a variety of colored vegetables and incorporating it regularly
into the daily diet help people become more aware of the benefits in consuming a rainbow of
vegetables in comparison to just consuming one or two colored vegetables. Encouraging
children to consume a rainbow of vegetables regularly can be challenging for teachers in
schools and for parents at home. Children have a normal tendency to resist eating any type of
vegetables that do not appeal to them or they are not familiar to consuming. Educating
children on eating a rainbow of vegetables can help them lower some level of displeasure,
anxiety, and negativity towards those vegetables and help them move positively on a path of
accepting or appreciating other kinds of vegetables.
Studies have shown effects of nutritional knowledge on food behavior (26). Teaching
children to know and have a positive attitude towards five-colored vegetables, their benefits
and consumption thereof, is a task educators and health professionals should consider to
promote and encourage in any vegetable consumption campaign. Many methods have been
developed and used to educate children on any particular subject matter---from learning how
to wash their hands to learning how to build a toy replica of an airplane (i.e. puppetry,
animated print comics, interactive computer games, cartoon animation, etc.) (27-30).
Experts, however, have suggested that educating school age children via media (i.e., cartoon
animation) can make them better understand the content or message in a more attractive and
entertaining learning environment as well as helping them to retain the message for a longer
period of time than any other types of media (31, 32). As there are numerous studies using
cartoon animation to educate primary school children on various health topics, many of them
have reported mixed results (33). In Thailand, no cartoon animation has ever been developed
to educate primary school children on consuming five-colored vegetables. Hence, this study
developed media animations as an educational tool to educate primary school children to
improve their knowledge and attitude of five-colored vegetables.
Methodology
Participants
A random sample of three primary schools (public) in Singburi province was selected.
A total of 36 children in primary schools were randomly sampled. Signed inform consents
were obtained from parents or legal guardians prior to participation. The study protocol of
this study design was reviewed and approved by the Committee on Center of Ethical
Reinforcement for Human Research, Faculty of Graduate Studies, Mahidol University. Study
inclusion criteria included primary school children in grades 3 and 4, age 8-10 years old (both
male and female), and willingness to participate in the study. Exclusion criteria included
children with medical history of vegetable allergies, siblings, exhibiting behavioral problems
(i.e., attention deficit hyperactive disorder [ADHD]) and inability to participate throughout
the study period.
Development of educational media animation
Three cartoon animation modules were developed with Adobe Photoshop CS5 and
Adobe After Effects CS6 software programs (Adobe Systems Inc. San Jose, CA) to create
graphic animations. The animations were closely supervised by a team of professional
graphic animators. Production of sound and its effects, cover music, and dubbed
voice/narration were added into the animations by means of computer graphic packages
available freely and purchased on the internet. The message/content of each module covered
the following topics: 1. Module I: benefits of vegetables and Basic Food Exchange list of
vegetables; vegetables comparable portion/serving sizes; 2. Module II: benefits and
advantages of consuming five-colored vegetables; 3. Module III: suggested vegetable
cooking methods and their applications for consumption in daily life. A robotic cartoon
character, Mr. Robot, was created and designed to explain to the viewers the purpose of each
specific module in question as well as providing benefits of each colored vegetable. As soon
as Mr. Robot appears on the computer monitor, the narration starts and viewers attention
were fixed on the animated character and its messages. Mr. Robot was designed to appeal to
the younger audience. The nutritional content in the three modules were validated by a team
of experts and professionals in the field of nutrition and dietetics at the Institute of Nutrition,
Mahidol University (INMU). The cartoon animations were created and validated to appeal to
children by a team of experts and professionals in the field of computer animations and
graphics working in the industry.
Development of questionnaires
1. Satisfaction questionnaire of developed cartoon animation
This study used the smileyometer scale to determine the satisfaction level of the
developed cartoon animations (34). The smileyometer scale is a self-administered
satisfaction questionnaire designed to evaluate pleasure with graphic quality (visual), audio
quality, content-based satisfaction, length of animation, and overall satisfaction to illicit level
of agreement or disagreement based on a five-level scale (i.e., awful, not very good, good,
really good, and brilliant) was developed to evaluate the overall design of the educational tool
as well as to rate its visual graphics/animation appeal and the audio quality.
Figure 1. The smileyometer
2. Attitude questionnaire on consuming five-colored vegetables
A thirty closed-ended self-administered multiple choice questionnaire with five
available choices was developed to ascertain children’s attitude on consuming five-colored
vegetables. Questions were divided into positive attitude and negative attitude categories
adapted from the Knowledge, Attitude, and Practice (KAP) for use in children (35). An
example question includes “Do you think that regularly consuming five-colored vegetables
can help reduce chronic disease risks in the future?” and "Do you think that consuming
vegetable is unnecessary in children?" Each response was data entered and coded for
analysis.
3. Basic knowledge questionnaires
Three basic knowledge questionnaires were developed specifically for each of the
three modules to test knowledge improvement---pre-test (before watching animated media)
and post-test (after watching animated media) as follows: 1. Module I: benefits of vegetables
and Basic Food Exchange list of vegetables---a thirty self-administered multiple choice
question (four possible choices) was developed to determine knowledge on benefits of
vegetables and Basic Food Exchange list of vegetables both before and after watching the
animated media. An example question includes “What compound is found in vegetables that
aids the digestive tract system?” and "Which choice is the one serving of raw vegetable?" 2.
Module II: five-colored vegetables questionnaires---a thirty self-administered multiple choice
question (four possible choices) was developed to determine knowledge and understanding of
consuming five-colored vegetables both before and after watching the cartoon animations.
Example questions include “Which natural pigment found in orange/yellow-colored
vegetables helps in vision?” and "Which type of vegetable is rich in potassium?" 3. Module
III: suggested vegetable cooking methods and their applications for consumption in daily
life---a thirty multiple choice self-administered questionnaire was developed to determine
level of knowledge and understanding in both before and after watching the cartoon
animation on the appropriate methods for cooking vegetables and their application in their
daily meals. Example questions include "Which cooking method for vegetables is suitable
for people who want to manage their weight?" and "Which vegetable menu can cause chronic
diseases if regularly consumed over a long period of time?" All three questionnaires in each
of the modules used the same criteria to classify level of knowledge (<50% low, 50-75%
moderate, and >75% high).
Intervention
Three local primary schools in Singburi province were randomly selected from a total
of 25 primary schools for this study. Thirty-six primary school children were randomly
selected to participate by a random draw from grades 3 and 4. Parents or legal guardians of
randomly selected children in grades 3 to 4 received a letter describing in detail the purpose
of the study (i.e., study objectives, informed consent, etc.). Study intervention process took
three days to complete.
1. Baseline data collection and viewing cartoon animation module I (day 1)
At baseline, randomly selected primary school children were invited to their
respective schools in the evening to be briefed on the purpose of the study. Once parents and
children understood the aim of the study and have agreed to participate in the study by
signing and submitting the informed consent forms, the steps for data collection for day 1
were as follows: 1. baseline data collection and anthropometric assessments (weight and
height information obtained from school record); self-administered basic knowledge
questionnaire on general benefits of vegetables conducted before viewing cartoon animation
(module 1); 2. children were led to a room as a group to view a five-minute educational
media animation (module 1) on general benefits of vegetable and Basic of Food Exchange list
in vegetables; 3. After viewing the cartoon animation, children were asked to complete
another set of a self-administered questionnaire testing their basic knowledge of five-colored
vegetables (to compare their basic knowledge score between pre- and post-intervention).
Furthermore, children were asked to complete a self-administered developed cartoon
animation's satisfaction questionnaire for media animation (module 1).
2. Viewing cartoon animation module II (day 2)
Children were re-invited on the consecutive day to participate in the continuation of
the study as follows: 1. self-administered basic knowledge questionnaire on consuming five
colored-vegetables before watching cartoon animation (module 2); 2. children then viewed a
ten-minute educational media animation (module 2) on consuming five-colored vegetables; 3.
children completed another set of a self-administered questionnaire testing their knowledge
on consuming five-colored vegetables (to compare their knowledge score between pre- and
post-intervention) and asked to complete a self-administered cartoon animation's satisfaction
questionnaire (module 2).
3. Viewing cartoon animation module III (day 3)
On the third consecutive day, children were re-invited to participate in this study as
follows: 1. children completed the self-administered basic knowledge questionnaire on
suggested vegetable cooking methods and their applications for consumption in daily life
before viewing the cartoon animation (module 3); 2. subsequently, children viewed a fiveminute educational media animation (module 3) on suggested methods for cooking
vegetables and their applications for consumption in daily life; 3. children were then asked to
complete another set of a self-administered questionnaire testing their knowledge on
suggested vegetable cooking methods and their applications for consumption in daily life (to
compare their knowledge score between pre- and post-intervention); 4. children were asked
to complete a self-administered cartoon animation's satisfaction questionnaire and
respondent's attitude questionnaire on the developed cartoon animation. Children were
further asked to write their suggestions on the cartoon animation modules.
Statistical analysis
Mean and standard deviation of age, height for weight percentile, knowledge score,
respondent's attitude questionnaire, and satisfaction score on developed cartoon animation
were reported. Paired-sample t test was used to compare the mean scores of the knowledge
and attitude test between pre- and post-interventions. Statistical analyses was performed by
using the Statistical Package for Social Science (SPSS Inc, Chicago, Il), version 18.0.
Statistical significance is established at p<0.05 with a confidence interval of 95%.
Results
At baseline, most children (83%) were in the normal weight for height percentile
(Table 1). Also, most of them consumed vegetables (53%) and breakfast (75%) every day.
Paired-sample t test revealed that children significantly improved their knowledge after
watching module I (p<0.05), module II (P<0.05), module III (P<0.05), and average score of
all three module (P<0.05) with 12 children (33%) were high knowledge level (>75% of total
score) and 24 children (67%) were moderate knowledge score (50-74.99% of total score), and
average percentage score improvement compared by pre- and post-test was 63% (data not
shown). Furthermore, their positive attitude score increased significantly (P<0.05) and
negative attitude score decreased significantly (P<0.05) on consuming five-colored
vegetables when finished with all three media animation educational modules (Table 2.).
Table 1. Baseline data of children with weight, height, percentile, and food intake behaviors.
Variables
Gender
Male, n (%)
Age
Mean (SD)
Weight
Mean (SD)
Height
Mean (SD)
Percentile
<5th, n (%)
5th-84th, n (%)
85th-94th, n (%)
>95th, n (%)
Vegetables consumption
Every day, n (%)
3-4 times/week, n (%)
1-2 times/week, n (%)
never, n (%)
Breakfast consumption
Every day, n (%)
3-4 times/week, n (%)
1-2 times/week, n (%)
never, n (%)
Grade 3
Grade 4
Overall
9 (50)
9 (50)
18 (50)
8.44 (.51)
9.33 (.48)
8.88 (.66)
30.72 (5.75)
36.05 (5.2)
33.38 (6.04)
131.33 (3.64)
140.05 (4.99)
136.08 (6.04)
1 (3)
15 (42)
0
2 (6)
1 (3)
15 (42)
0
2 (6)
2 (6)
30 (83)
0
4 (11)
10 (28)
1 (3)
3 (8)
4 (11)
9 (25)
4 (11)
3 (8)
2 (6)
19 (53)
5 (14)
6 (17)
6 (16)
15 (42)
2 (6)
1 (3)
0
12 (33)
5 (14)
0
1 (3)
27 (75)
7 (19)
1 (3)
1 (3)
Table 2. Knowledge and attitude improvement on consuming five-colored vegetables compared between
before and after watching three animation educational media modules.
Intervention
Module I, mean (SD)
Module II, mean (SD)
Module III, mean (SD)
Average score of all three modules, mean (SD)
Positive attitude score, mean (SD)
Negative attitude score, mean (SD)
*Extremely significant difference
**Significantly difference
Pre-test
10.86 (1.24)
7.67 (1.43)
8.97 (1.25)
9.16 (.68)
66.44 (2.95)
23.47 (4.24)
Post-test
15.89 (1.26)
13.64 (2.12)
13.97 (1.52)
14.49 (.84)
67.75 (2.66)
22.28 (3.43)
P value
<0.001*
<0.001*
<0.001*
<0.001*
0.002**
0.027**
When compared by gender, paired-sample t test revealed that there were no
significant difference on knowledge and negative attitudes between male and female in all
three animation educational media modules, except for positive attitude score that were
significantly different between male and female both before (P=0.01) and after (P=0.03)
intervention (Table 3.).
Table 3. Knowledge and attitude improvement on consuming five-colored vegetables compared by gender
between before and after watching three animation educational media modules.
Intervention
Module I, mean (SD)
Module II, mean (SD)
Module III, mean (SD)
Average score of all three modules
after intervention, mean (SD)
Positive attitude score, mean (SD)
Negative attitude score, mean (SD)
Pre-test
Male
10.78
(1.43)
7.56
(1.33)
8.78
(.94)
9.04
(1.82)
65.17
(2.87)
24.56
(4.14)
Female
10.94
(1.05)
7.78
(1.55)
9.17
(1.5)
9.3
(1.89)
67.72
(2.49)
22.39
(4.17)
P
value
0.73
0.64
0.36
0.32
0.01*
0.10
Post-test
Male
15.56
(1.54)
13.61
(2.11)
14.06
(1.3)
14.41
(1.85)
66.72
(2.84)
23.22
(3.33)
Female
16.22
(.8)
13.67
(2.19)
13.89
(1.74)
14.59
(2.02)
68.78
(2.07)
21.33
(3.36)
P
value
0.09
0.94
0.69
0.56
0.03*
0.07
* Significantly difference
Satisfaction and acceptance of the cartoon animation in all three modules were
evaluated by the smileyometer. Table 4. revealed that all children were satisfied and they
accepted the three cartoon animation modules
Table 4. Satisfaction scores of all three animation educational media module evaluated by children used of
smileyometer.
Satisfaction
Videos satisfaction
(maximum=5) , mean (SD)
Audios satisfaction
(maximum=5), mean (SD)
Medias length satisfaction
(maximum=5), mean (SD)
Medias contents satisfaction
(maximum=5), mean (SD)
Medias overall satisfaction
(maximum=5), mean (SD)
Module I
Module II
Module III
Overall
3.68 (0.51)
4.45 (0.32)
4.39 (0.28)
4.08 (0.79)
3.08 (0.8)
3.9 (0.43)
4.2 (0.3)
3.64 (0.88)
4.44 (0.8)
4.08 (0.64)
4.69 (0.46)
4.33 (0.84)
4.13 (0.45)
4.46 (0.33)
4.58 (0.23)
4.28 (0.75)
4.36 (0.63)
4.47 (0.50)
4.41 (0.5)
4.34 (0.74)
Discussion and Conclusion
The aim of this study was to evaluate the developed cartoon animation modules on
consuming five-colored vegetable to assess the effectiveness and acceptance among young
children.
Overall results indicated most children’s knowledge and attitudes were
significantly improved after intervention. Also, they were satisfied and they accepted all
three modules of media animation. Unfortunately, due to limitation of funding and research
duration, a longer period of study as well as a follow-up of whether knowledge, attitude, food
behavior after the intervention period is still retained among this group of people further on is
suggested. The samples of this study were limited to rural children in Singburi, therefore the
results cannot be generalized to all Thai children. The study found that educating primary
school children via animation educational media to improve their nutrition knowledge such as
consuming vegetable was an effective strategy. However, promoting children to eat more
dietary fiber is needed. The schools should encourage them to have their dietary fiber at the
meals by providing high fiber diet or snack, which were accepted by children (36). In
addition, a study conducted by Lazzeri et al. reveled that skipping breakfast can affect the
amount of vegetables and fruits intake, therefore encouraging Thai children to have their
breakfast daily is needed (37).
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