Interpretation (in light of other evidence)
The findings of this study are consistent with prior studies that
suggest that nutrition education in schools can improve knowledge and
awareness about anaemia; increase demand and improve compliance with IFA
supplements; and change adolescent dietary
behaviour.29-33 The pedagogical approach employed in
the education sessions differed from conventional approaches in schools
and was designed to be interactive and participatory, which we believe
crucially contributed towards greater acceptance of the intervention and
a positive impact on knowledge and attitude.34 Similar
studies conducted in school settings in India using varied approaches,
such as single or multiple interactive education sessions delivered by
doctors, trained experts using flipcharts, videos and other interactive
methods have been found to improve knowledge and/or change behaviours
related to anaemia and its prevention. 29-32Evaluation of the Weekly Iron and Folic Acid Supplementation (WIFS)
programme in India and other low-and-middle-income countries found that
one of the key factors influencing increased uptake of IFA supplements
was implementation of a coordinated and timely information education and
communication strategy that dispelled misconceptions and rumours, and
capitalised on the positive effects. 25, 35-39Moreover, as indicated by Joe et al (2022), increased awareness and
subsequent demand-generation by target groups will help address other
institutional barriers related to the supply and distribution of IFA
supplements.16
The present study also reported knowledge about anaemia to be low among
boys before the start of the intervention, in concordance with several
other studies.40-42 Although recent data indicate no
major gender disparities in the coverage of IFA supplementation in
schools, being aware of anaemia itself acts as a motivation for
consumption of IFA tablets.17, 18 Equal emphasis must
therefore be given to educating both boys and girls about anaemia and
its prevention.
The inclusion of nutrition education in formal education programmes
targeted to children in primary schools is one of the most commonly
recommended strategies because of its potential in developing positive
health, eating, and lifestyle habits that may persist into
adulthood.43, 44 Murimi et al (2018) highlighted
several features of successful school-based nutrition education
interventions: engagement of parents, identification of specific
behaviours to be modified, ensuring fidelity by training educators,
adequate dosage, and age-appropriateness of
interventions.45 Several of these features warranted
more attention in the present study, including training, appropriateness
of content, dosage and engagement of parents. For example, the role of
teachers was essential to intervention success, but they expressed
difficulties related to time constraints and training. To resolve time
limitations as well to ensure continuation and viability, they suggested
the content be included in the national curriculum. Gaining an
understanding of anaemia motivated teachers, to help ensure fidelity and
realise project objectives, but this could be further improved by
providing adequate training, endorsement and implementing a
teacher-friendly intervention.25, 46-48
Despite co-development of the content of the education sessions, some
teachers were hesitant to focus on topics related to menstruation and
pregnancy, particularly in the presence of boys. In patriarchal
societies like India where gender norms are strict, menstruation and
pregnancy are considered as ’women’s’ topics and exclusion of boys from
related discussions can further increase gender
disparities.49, 50 Hence, research needs to be
conducted to understand how best to include these topics in sessions
involving both boys and girls.
One of the benefits of school-based health and nutrition education
programmes is that children act to spread the information, bringing it
to their homes to achieve transmission of the information to the whole
family.51, 52 Our findings reveal the same with
students discussing and sharing topics learnt with friends and families.
However, to achieve better impact, studies recommend involvement of
families and communities in the nutritional education programmes from
the beginning. 52-55