Effect of nutritional education based on the precede-proceed model on improving the growth indicators, knowledge, attitude, and food intake of malnourished children: study protocol for a randomized clinical trial – BioMed Central

Report on a Nutrition Education Intervention to Address Child Malnutrition

Introduction: Addressing Child Malnutrition in the Context of Sustainable Development Goals

Malnutrition remains a significant global public health challenge and a primary barrier to achieving the Sustainable Development Goals (SDGs), particularly SDG 2 (Zero Hunger) and SDG 3 (Good Health and Well-being). The World Health Organization (WHO) defines malnutrition as a dual burden encompassing both nutritional deficiencies (stunting, wasting, underweight) and overnutrition (overweight, obesity). This issue directly contravenes SDG Target 2.2, which aims to end all forms of malnutrition by 2025. Globally, the scale of this crisis is stark; in 2019, an estimated 144 million children under five were stunted, and 47 million were wasted.

The consequences of malnutrition extend beyond hunger, severely impacting SDG 3 by increasing the risk of infection, delaying cognitive development, and raising child mortality rates. In Iran, the prevalence of malnutrition among children is notable, with rates of 19% for underweight, 20% for stunting, and 12.5% for wasting, indicating a critical need for targeted interventions. Factors contributing to this problem are multifaceted and reflect broader development challenges related to SDG 1 (No Poverty) and SDG 10 (Reduced Inequalities), including poor socioeconomic status, low maternal education, and inadequate access to health services and healthy food.

Rationale for a Multi-Level Intervention Framework

Initial observations in south-east Iran revealed a high prevalence of various forms of malnutrition among primary school children, linked to unhealthy dietary behaviors shaped by individual, social, and environmental factors. A detailed diagnostic assessment identified key determinants:

• Individual Factors: Insufficient knowledge, unfavorable attitudes, and low self-efficacy.
• Interpersonal Factors: Limited support from family and peers.
• Environmental Factors: Inadequate resources and restricted access to healthy foods.

A systematic review of existing behavioral models (e.g., Health Belief Model, Theory of Planned Behavior) revealed significant limitations. These models often focus on individual-level factors and fail to address the broader environmental and policy-level barriers essential for sustainable change. This gap highlights the need for an ecological framework that can integrate the multiple determinants of health, aligning with the holistic and interconnected nature of the SDGs.

The PRECEDE-PROCEED model was selected for this study due to its comprehensive, multi-level approach. It mandates a systematic diagnosis of social, epidemiological, behavioral, and environmental factors before intervention design. This structure ensures that interventions are not merely educational but are also supported by enabling environmental factors and reinforcing social support, creating a sustainable pathway to achieving health outcomes related to SDG 2 and SDG 3.

Study Objectives and Hypotheses Aligned with SDG Targets

The study is designed to evaluate an intervention aimed at improving child nutrition, thereby contributing directly to key SDG targets.

Primary and Secondary Objectives

The primary objective is to determine the intervention’s effect on the constructs of the PRECEDE model, including predisposing, reinforcing, and enabling factors that influence nutritional behavior. The secondary objective is to assess the impact on child growth indices (height-for-age, weight-for-age, and BMI-for-age), which are direct indicators for monitoring progress toward SDG Target 2.2.

Study Hypotheses

• Primary Hypothesis: Increased maternal knowledge and self-efficacy, fostered through targeted education (SDG 4, Quality Education), will lead to improved child feeding practices and nutritional outcomes.
• Secondary Hypothesis: A nutrition education intervention based on the PRECEDE-PROCEED model will significantly improve child growth indicators, contributing to better health and well-being (SDG 3).

Trial Design: A Structured Approach to Achieving Health and Education Goals

The study is a parallel-arm, open-label, randomized clinical trial involving 254 malnourished children aged 7 to 12. The intervention group will receive an 8-week nutrition education program, while the control group will receive no intervention. The trial is structured around the nine phases of the PRECEDE-PROCEED model, ensuring a comprehensive and systematic approach.

1. Social Assessment: Examination of the community’s quality of life to ensure the intervention addresses perceived needs, aligning with the people-centered approach of the SDGs.
2. Epidemiological Assessment: A detailed analysis of the prevalence and severity of malnutrition to establish a baseline for measuring progress against SDG Target 2.2.
3. Behavioral and Environmental Assessment: Identification of specific unhealthy eating behaviors and related environmental factors that the intervention must address.
4. Educational and Ecological Assessment: Assessment of predisposing (knowledge, attitude), reinforcing (family, peer support), and enabling (resource availability) factors to design a multi-faceted intervention.
5. Administrative and Policy Assessment: Evaluation of organizational resources and policies to ensure the program is feasible and sustainable. This phase promotes institutional capacity-building and aligns with SDG 17 (Partnerships for the Goals) by coordinating with school administrators, teachers, and parents.
6. Implementation: Delivery of the tailored educational program through lectures, group discussions, and videos, contributing to health literacy and SDG 4 (Quality Education).
7. Process Evaluation: Continuous monitoring of program implementation and quality to ensure fidelity and effectiveness.
8. Outcome Evaluation: Assessment of the program’s short-term effects on behavioral determinants (predisposing, enabling, and reinforcing factors).
9. Impact Evaluation: Final evaluation of the program’s long-term effects on health outcomes, including anthropometric indicators and quality of life, to measure the ultimate contribution to SDG 2 and SDG 3.

1. Which SDGs are addressed or connected to the issues highlighted in the article?

SDG 2: Zero Hunger

• The article’s central theme is malnutrition in children, which is a core component of SDG 2. It explicitly states, “Malnutrition is one of the public health problems and causes of death among children in the world.” This directly connects to the goal of ending hunger and all forms of malnutrition.

SDG 3: Good Health and Well-being

• The article links malnutrition directly to adverse health outcomes. It mentions that “Malnutrition increases risks of infection, growth and cognitive delays, and mortality.” By aiming to improve nutritional status, the study described in the article is working towards ensuring healthy lives and promoting well-being for children.

SDG 4: Quality Education

• The intervention discussed in the article is fundamentally educational. It focuses on “nutrition education” for mothers and school children to improve dietary habits. This aligns with SDG 4’s aim to provide inclusive and equitable quality education, particularly in promoting knowledge and skills for sustainable and healthy lifestyles. The article highlights the importance of “maternal nutrition education” and “school-based programs.”

2. What specific targets under those SDGs can be identified based on the article’s content?

SDG 2: Zero Hunger

• Target 2.2: “By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons.”
  • The article directly addresses this target by focusing on various forms of malnutrition in school-aged children (7-12 years). It provides specific prevalence data for “stunting,” “wasting,” “underweight,” “overweight,” and “obesity,” which are the key concerns of this target.

SDG 3: Good Health and Well-being

• Target 3.2: “By 2030, end preventable deaths of newborns and children under 5 years of age…”
  • Although the study focuses on children aged 7-12, the article establishes malnutrition as a “cause of death among children.” By addressing malnutrition, the intervention contributes to the broader goal of reducing child mortality, as improved nutrition is critical for survival and healthy development from infancy through childhood.

SDG 4: Quality Education

• Target 4.7: “By 2030, ensure that all learners acquire the knowledge and skills needed to promote sustainable development, including, among others, through education for sustainable development and sustainable lifestyles…”
  • The study’s intervention is a “nutrition education” program designed to improve “knowledge, attitude, and self-efficacy” regarding healthy eating. This is a direct application of education for promoting healthy lifestyles, which is a key component of Target 4.7.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

Indicators for SDG Target 2.2

• Indicator 2.2.1: Prevalence of stunting (height for age). The article explicitly mentions “height for age” as a key indicator of child nutrition and provides prevalence data for “stunting (2.8%)” and “severe stunting (0.3%)” among primary school children in south-east Iran. The study’s secondary outcome is to assess “height for age” before and after the intervention.
• Indicator 2.2.2: Prevalence of malnutrition (weight for height), by type (wasting and overweight). The article directly refers to this indicator by citing prevalence rates for “wasting (4.6%),” “severe wasting (0.8%),” “overweight (6.4%),” and “obesity (5.0%).” It also uses “weight for age” to measure “underweight (4.7%)” and “severe underweight (0.9%),” which are also key measures of malnutrition. These anthropometric indices are measured as outcomes in the study.

Implied Indicators for SDG Target 4.7

• Extent to which education for sustainable development, including health and well-being, is mainstreamed. The article implies this indicator through its methodology. The primary objective is to “determine the average scores of the PRECEDE model, including predisposing factors (knowledge, attitude, and self-efficacy).” Measuring changes in these scores serves as a direct indicator of the effectiveness of the nutrition education program in imparting knowledge and skills for a healthy lifestyle.

4. Create a table with three columns titled ‘SDGs, Targets and Indicators’ to present the findings from analyzing the article.

Source: trialsjournal.biomedcentral.com