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The present study was distinctive in three aspects. For the first time, computer-based nutrition education intervention was applied and evaluated in the Pakistan primary school setting. Secondly, the acceptability of the computer-based nutrition education program in a Pakistan context was explored. Thirdly, the comparison of the present study data with data of Vienna study was carried out.
In the case of the first aspect, the study successfully demonstrated that the children could learn nutrition concepts and healthy eating habits in a lively and interesting environment. As regards the second aspect, the study found that the children and teachers were both positive and receptive to the computer-based nutrition education intervention. However, significant barriers were identified that negatively affect the acceptability of computer-based education, thus eventually, affecting its applicability in the Pakistani primary schools. In case of the third aspect, the comparative analysis helped to interpret further the study results in the broader global context.
Since, in the present study the nutrition knowledge increased in both groups, this implies that use of computer based nutrition education did not confer any additional advantage in the learning of nutrition concepts. Children do not like being passive learners. Rather, they learn through active involvement in the learning process. The intervention presented the nutrition concepts in concrete forms and through motivating and challenging activities, which ensured the children's active involvement. In the light of this result, it can be rightly inferred that irrespective of the delivery mode, creative, motivating and age appropriate nutrition education programmes can facilitate the learning of lifelong nutrition concepts and healthy eating habits. Such learning has more potential to be effectively translated into practice.
As nutrition concepts are abstract and children at the concrete operational stage find them hard to comprehend, establishing innovative and creative methods to teach children about healthy eating habits are crucial. Matheson and Spangler (2001) in a review of 30 nutrition academic curricula suggest that half of the programs incorporated the element of curiosity and challenge to convey the nutrition content. The result of present study supports the finding that use of creative methods increases children's ability to learn and grasp nutrition concepts effectively and easily and are consistent with the research. (DiSogra, L., Reger, B, 2002)
Low nutrition status of Pakistani children is amply documented in literature. However, it is devoid of any mention about the nutrition knowledge of these children. The present study fills this gap by providing data about the existing level of nutrition knowledge of children in Pakistan. It provides evidence that nutrition knowledge of Pakistani children is very low. Furthermore, it demonstrates that this area can be successfully targeted and change can be achieved with relatively few additional resources.
Besides the fact that the present study was unable in establishing any additional learning advantage of computer-based nutrition education, it demonstrated that children were very receptive towards using the computers as a learning device. They regarded learning of nutrition concepts through computers as interesting and entertaining. Generally, in Pakistan, 'learning to operate computers' is considered the main purpose of integrating computers in schools. A valuable outcome of the present study is therefore doing away with the existing notion and replacing it with the idea 'learning through computers' instead.
In this respect, the use of computer as a medium of learning was new to the children. As observed and discussed during the focus group discussions, they faced some difficulties using computers on their own. The success of computer-based education is not dependant upon the quality or quantity of the technology but rather upon the learner's attitude and readiness to use it. The present world is the world of technology and there is need to develop children's competence in computer related technology. Provision of education material through computers may serve a dual purpose - enhancement of learning in the particular subject as well as competence in the use of computer technology.
As discussed in focus group, although student teachers had some basic computer skills, they were not very comfortable using computers as a teaching tool. This indicated their lack of computer efficacy. However, during the intervention, they realized the potential of computers as a teaching tool and showed willingness to use computers in their teaching. Considering, their lack of computer efficiency implies that in order to integrate computers successfully in the Pakistani education system, teachers must recognize the importance of operating computers. Furthermore, they should familiarize themselves with computers as a teaching tool. The successful integration of computer-based education is largely dependant on teacher's attitudes towards computers and their readiness to use them in teaching (Deniz L, 2007).
The study highlighted the problems facing computer-based education, including lack of computer related skills in teachers and children, frequent power breakdowns, lack of support from school administrations and lack of computer equipment and related infrastructure. This brings to light the fact that integration of computers in Pakistani education system requires comprehensive planning regarding physical infrastructure and teacher's training as well as ongoing evaluation and feedback.
There are obviously more chances of today's teachers and students working with computers in classrooms of the future. Therefore, there is need to develop an awareness for incorporating computer-based teaching methods since the beginning. Computer-literate and computer-comfortable teachers are crucial for the effective integration of computers in education. This can be achieved by building up their confidence and improving their computer self-efficacy through providing them exposure to computers during their training. Such exposure will be helpful in developing the willingness to use computers in classrooms.
Given an account of the socio economic status and nutrition Knowledge, the research also adds to the existing body of knowledge. Much of such literature has focused on developed countries. However, the present research was managed to establish in the Pakistani context that children belonging to lower socioeconomic status had significantly lower nutrition knowledge as compared to those who belong to high socioeconomic status. Low socioeconomic status along with low nutrition related knowledge and poor life style habits contributes to the poor nutrition of the individuals.
An additional finding, worthy of raising in the context of the conclusion, is substantial increase in children's nutrition knowledge and retention at post-intervention and follow-up without being cognizant of the repetition of the nutrition knowledge questionnaire. In Pakistan, teachers and students both focus on grade-oriented learning rather than conceptual learning. Therefore, a strong emphasis is placed on examination results. This phenomenon makes children concentrate and learn only those parts of the syllabus that they consider relevant to the exams. However, the present study reveals a different aspect from the prevailing situation, which implies that children can learn and retain knowledge without memorization and learning by rote.
The comparison of the present study results with the Vienna study results revealed two very important aspects. Firstly, in terms of nutrition knowledge at baseline, the study identified that nutrition knowledge of Pakistani children is very low as compared to the children in Vienna study. It signifies the inadequacy of Pakistani school curricula in particular and society in general in providing knowledge related to nutrition and healthy eating to children. In addition, it draws attention to develop efficacious strategies to incorporate nutrition education in the primary school curriculum. It is an established fact that the nutrition concepts learnt early in life are more beneficial in later life. Knowledge is the first step towards the realization of healthy eating habits.
Secondly, in literature, the Pakistani children learning achievement are reported as low as compared to the international standards (Jishnu Das, 2006). Interestingly, the comparison of post-intervention nutrition knowledge results between Lahore study and Vienna study presented a different picture. Children in the present study attained more nutrition knowledge scores as compared to the children of Vienna study. Hence, suggesting that the observed patterns of low achievement of Pakistani children could not be solely attributed to their low intellectual competency. Indubitably, when innovative and interesting strategies are employed to teach children, they can produce equal learning results.
The study results have provided a strong foundation for incorporating nutrition education intervention in primary schools. Computer-based tools were found helpful in disseminating nutrition education. However, they were not the panacea. Other creative mediums were almost equally effective in disseminating nutrition knowledge. Even though, the study was unable to confirm additional advantage of computer-based nutrition education in the learning of nutrition concepts, it would not undermine the potential of computers in the context of the Pakistan school setting.
Since the study successfully demonstrated that children's nutrition knowledge can be increased with the use of both computer-based tools and other innovative and motivating strategies, the following recommendations for incorporation of nutrition education and computer-based education in Pakistan should be considered.
Recommendations for practice
The finding that nutrition knowledge of Pakistani children is low justifies urgent inclusion of nutrition education in order to develop self-efficacy and inculcate skills of healthy food selection and preparation in the primary school curriculum. Considering this, the higher authorities need to acknowledge the importance of nutrition education and must integrate nutrition education in primary schools curricula. The considerably low level nutrition knowledge in student teachers also calls for attention. Nutrition education should be included in the teachers training curriculum. Incorporation of nutrition education in teachers training will prove beneficial in developing awareness in the community through children. Furthermore, it is strongly recommended that teachers training curriculum should be revised. It should incorporate comprehensive training regarding the use of computers as a teaching tool. In developing nutrition programs, more importance should be given to the children of low socioeconomic status.
Recommendations for future research
As the present study was the only study of its kind in the Pakistan context, there is need for further research to substantiate these findings. This is advised in order to ascertain whether similar findings will be found using other computer-based nutrition education programs. Due to the time and resource constraints, the study did not attempt to explore the effects of nutrition knowledge on change in dietary behavior. Future studies are highly recommended in order to explore this aspect.
The future studies to determine the effectiveness of computer-based nutrition education should include varied time spans for the intervention. Further research needs to be conducted, which addresses the effectiveness of computer-based nutrition education among other age groups (adolescent, elderly) and children in different settings (public schools, rural areas). Follow-up after one or two year's duration should be conducted to determine the effect of computer-based education on knowledge gain. Future studies need to explore the nexus between nutrition knowledge, attitudes and dietary behavior specifically in the Pakistani population. There is also need to explore the relationship between parent nutrition knowledge and children nutrition knowledge and dietary habits.