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Evaluation of Nutrition Education in School Curriculum of Nepal: A Descriptive Content AnalysisAashmaDahal1✉Emailaashma.dahal@mbahs.edu.np
Dr.
NeetiBhat1,2Emailneeti.bhat@mbahs.edu.npBibechanaSapkota1Emailbibechana.sapkota@mbahs.edu.np
1Department of Public Health and Community MedicineMadan Bhandari Academy of Health SciencesHetaudaNepal
2Department of PhysiologyMadan Bhandari Academy of Health SciencesHetaudaNepal
Authors: Aashma Dahal 1*, Neeti Bhat 2, Bibechana Sapkota3
1. Aashma Dahal(Corresponding Author)
Affiliation: Department of Public Health and Community Medicine
Madan Bhandari Academy of Health Sciences
Hetauda, Nepal
Email: aashma.dahal@mbahs.edu.np
2. Dr. Neeti Bhat
Affiliation: Affiliation: Department of Physiology
Madan Bhandari Academy of Health Sciences
Hetauda, Nepal
Email: neeti.bhat@mbahs.edu.np
3. Bibechana Sapkota
Affiliation: Department of Public Health and Community Medicine
Madan Bhandari Academy of Health Sciences
Email: bibechana.sapkota@mbahs.edu.np
ABSTRACT
Background
One of the cornerstone nutrition program in Nepal is School Health and Nutrition Program. But, the program struggles to meet to address the agenda of nutrition as the school curriculum itself lacks relevant topics and accuracy of information regarding knowledge in nutrition, hence lacking a global standard.
Aim
This curriculum analysis study aims to assess the inclusion of nutrition education in school curricula of Nepal in grades of 6–8, identify gaps, and propose strategies for integrating nutrition education effectively into the curriculum for better nutrition outcomes in children.
Methods
The curriculum analysis started with a narrative review to identify the prevailing nutrition-related disorders in Nepal. Then, Basic Education Curriculum of Nepal, updated in 2077 for grades 6–8, was reviewed to study its learning outcomes of nutrition-related courses. Then, nutrition-related contents of all subjects in these grades were outlined and mapped. The evaluation of curricular contents based on themes like -current problems in public health nutrition, the accuracy of the nutrition information, the pedagogical approach and assessment techniques, and the strengths and weaknesses of the contents of grades 6–8. At last, the contents on nutrition education were compared with a few international curriculums to evaluate their alignment with global curriculum standards.
Results
It was found that, although, there is an escalating prevalence of obesity, anemia, and micronutrient deficiencies among school-going children in Nepal, the national curriculum has significant shortcomings in relevance to the content and accuracy of the information on these topics.
Conclusion
Therefore, an updated curriculum addressing current needs should be put in place, which also offers opportunities for in-depth learning to children by adoption of effective strategies for curriculum development and delivery.
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INTRODUCTION
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There is an intricate interplay between health and education. By leveraging this interdependence of health and education, we could bring more impact health promotion behaviors through mutual reinforcement. 1One such successful innovative program in Nepal is “school mid-day meals, where students are given nutritious lunch in schools, which aims to improve their education and health outcomes. 2 Despite this, it is imperative to acknowledge that these interventions have not fully achieved their goals as there has been a narrow focus on mitigating immediate hunger through basic sustenance and neglecting the educational component. 3The approach from "nutrition into education" could benefit from a parallel approach of "education into nutrition" for more sustainable and impactful changes. Researchers have shown that at least 50 hours of nutrition education per year is required to support behavior change. 4Nutrition education in schools can lead to informed nutritional behaviors, through which we can achieve reduction of childhood obesity and improved academic performances. 5A study by WHO evaluating the success of school health and nutrition programs has included Nepal in its list of countries that have effectively adopted measures reflecting success in behavior change. 6 Still, nutrition education in the school curriculum suffers from a notable research gap. Therefore, in this study, we have reviewed prevalent nutrition-related disorders in Nepal, assessed nutrition education in school curricula (grades 6–8), and proposed evidence-based strategies for implementing nutrition education from grades 6–10 in Nepal.METHODOLOGY
This descriptive content analysis study determines if the school curriculum reflects real needs. We followed the PRECEED part of the PRECEED –PROCEED planning model, developed by Lawrence W. Green for generating research questions which eventually contributed to the curriculum analysis 7and Taba's model of curriculum development8 for identifying priorities required in curriculum development. The curriculum contents were analyzed through a narrative literature review. Nepal Demographic Health Survey 2016,9 NDHS 2022,10 and National Nepal Micronutrient Status Survey 2016 11 and Global Nutrition Report 2022 12 were reviewed to identify nutrition-related disorders in Nepal. For analysis of the school curriculum, the Basic Education Curriculum, 2069, and their official textbooks published by Curriculum Development Centre Sanothimi, Ministry of Education, from grade six to grade eight were reviewed.13 The primary focus of this evaluation was to analyze the extent of nutrition-related content. The curriculum was systematically analyzed to assess the integration of nutrition-related topics in the subjects. The textbooks were especially mapped by carefully reviewing them to identify in which subjects the contents related to nutrition are included.14
The contents were evaluated based on the following research questions based on Taba’s model of curriculum development and PRECEED-PROCEED Planning model.
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1.
Are the curriculum’s learning goals challenging, clear, and appropriate; is its content aligned with its learning goals?
2.
Is it accurate and appropriate for the intended audience?
3.
Is the instructional design engaging and motivating for the intended student population?
4.
Is the system of assessment appropriate and designed to guide teachers’ instructional decision-making?
5.
Does its learning goals reflect the vision promoted in national standards in health?
6.
Does it address important individual and societal nutritional needs?
These steps were crucial for evaluating the adequacy of nutrition education content in the curriculum. We assessed the content's accuracy and relevance presented in the curriculum by fact-checking, application to real life, and application beyond the classrooms. 15It ensured to provide students with accurate information and practical scenarios. We analyzed the textbooks of grades 6–8 for studying pedagogical activities to deliver nutrition topics with a focus on identifying approaches that enhance students' understanding and application of nutrition concepts through interactive and engaging methods. Furthermore, the textbook assessments were evaluated for promoting critical thinking capacity and deeper learning opportunities.16 Based on the above analysis, the strengths and weaknesses of the contents of each grade were listed. The identified gaps were documented. This step identified areas where nutrition education could be improved to improve effectiveness in content. In the next step, we evaluated the nutrition related curriculum taught in other countries using case study methodology. Search boolean codes in combination with the terms “school”, “curriculum” and “education” were employed. The evaluation included the curriculum available in English. A thorough analysis of the curriculums was conducted to identify common themes and was compared to our national curriculum with a focus on assessment of contents and pedagogical methods. Comparing our local curriculum with international curriculums was pivotal for improvement and understand the level of alignment with global practices. Finally, suitable strategies were identified to address the gaps in nutrition education in school children from grades six to eight in Nepal. The strategies were grounded on evidence-based practices followed internationally. The methodology has been summarized in Fig. 1.
Fig: The study design methodology
RESULTS
Prevalence of nutritional disorders in Nepal:
Nepal is facing a double burden of malnutrition. The rise of non-communicable diseases is alarming and we are struggling to combat existing infectious diseases in the country. 17Moreover, an estimated 2–3 percent of GDP is costed due to vitamin and mineral deficiencies in Nepal. Nearly 60 percent of children are selenium deficient and 44 percent are deficient in vitamin B6. These deficiencies are associated with long term chronic diseases’ risks and developmental consequences. 18 In 2017, 69% of children aged 6–23 months were anemic in Nepal. On the other hand, childhood obesity has been emerging as another threat in the past few years. 19Nepal Demographic Health Survey Report 2022 reports that stunting and wasting(25%, 8%) and have slightly reduced from the situation of 2016 (36%, 10%respectively) 10 but, we are still behind our targets given by the Sustainable Development Goals. 20
Nutrition education in Nepalese school curriculums:
In grades six, seven and eight, the food and nutrition contents in subjects like Science and Health and Population subjects13, 14 were analyzed and the findings have been presented in Table 1, Table 2 and Table 3 respectively.
Strength | Weakness |
|---|---|
● Dedicated Nutrition Chapter: A dedicated nutrition chapter is included in the curriculum, emphasizing the importance of nutrition in education. ● Clear Categorization of Foods: Students can understand the contents as simple categorizations of food have been made. ● Cultural Relevance: Culturally relevant foods and Nepali names enhance the relevance of the curriculum within the local context. ● Basic Framework Introduction: A basic framework for dietary requirements, energy-giving, body-building, and body-protecting foods will provide the foundation for nutrition knowledge. ● Fundamental Exercise: The exercises in the textbook provide students with a fundamental understanding of nutrition concepts. ● Physical exercise is incorporated with nutrition-related information. Steps for doing exercise are also taught. | ● Lack of Depth: Although the content introduces nutrition, a deeper understanding fails to develop, potentially leaving students unprepared. ● Missing Portion Guidelines: For understanding a balanced diet, there is a lack of information on portions and nutrients such as fat. ● No Balanced Food Plate: Lack of a simple and easy “food plate” model ● Absence of Real-Life Examples: A lack of real-life examples and practical applications makes it difficult for students to apply their knowledge in everyday situations. ● Limited Visual Aids: Visual aids lack naming and descriptions, which could make it difficult for students to use them effectively. ● Overemphasis on Recall: Textbook exercises tend to focus on simple recall rather than fostering critical thinking and deeper understanding. ● Assessment Gaps: Students aren't assessed on how their nutrition knowledge can be applied in everyday life, which creates a gap for real-life application. ● Lack of Reflective Exercises: Less emphasis is placed on students reflecting on what they have learned, which inhibits critical thinking. ● Limited Question Diversity: Question types are limited to comprehensively assess students' skills and knowledge. ● Missing Practical Skills Lessons: The curriculum does not address practical skills such as gardening, breastfeeding, cooking, and addressing obesity and undernutrition, which are vital to real-life situations. |
Strengths | Weakness |
|---|---|
● Graded Content: Grade 7 content is more challenging than Grade 6 content, which encourages students to learn more. ● Deeper Understanding: The curriculum introduces the food pyramid and categorizes foods according to dietary needs. ● Visual Learning: Students are more likely to comprehend complex concepts when they use diagrams and images. ● Nutrient Detail: Nutrients' sources and functions are discussed in detail. ● Awareness of Junk Foods: Learning about junk foods allows students to realize the importance of a healthy diet. ● Hands-On Activities: Practical activities are for eg. collecting information about junk foods available in the market, bringing foods from home, and discussing their nutritional value. | ● Superficial Learning: Despite its graded difficulty level, this content promotes superficial learning, particularly about nutrients and sources. ● Complex Food Pyramid: Complex food pyramids may overwhelm students. Further, the food temple released by the Dietary Guidelines of Nepal is not incorporated. ● Lack of Standardization: There are no specific guidelines for evaluating nutritional values in activities, which leaves room for misinterpretations. ● Rote Learning: Practices such as matching exercises and short answers may encourage rote learning, reducing opportunities for deeper understanding. ● Exclusion of Important Topics: Topics like ghee and cereals are body-building foods that are not covered in the curriculum, which limits students' knowledge. |
Strengths | Weakness |
|---|---|
● Dedicated Nutrition Chapter: There is a separate chapter dedicated to nutrition education that highlights its importance. ● Coverage of Nutrition Disorders: ● Nutrition-related disorders like marasmus, rickets, anemia, night blindness, and scurvy are well covered. ● Symptoms and Preventive Measures: The signs and symptoms of these disorders offer practical preventive measures, enhancing students' understanding. ● Balanced Diet: A balanced diet, and locally produced food are encouraged. ● Practical skills like the preservation of nutrients are given. | ● Inaccurate Information: Inaccurate information is given ● Confusing Texts: and confusing irrelevant sentences, such as enhancing awareness of marasmus in the context of night blindness. ● Lack of Clarity: It should follow a logical and comprehensible structure for students in presenting complex ideas on nutrition-related disorders. ● Superficial Approach: While discussing complex topics like malnutrition, the curriculum has a superficial approach, which may hinder students' understanding. ● Inadequate Visuals: Limited images and visuals to aid learning as visuals are essential for comprehensive learning at the school level. ● Missing Cognitive and Emotional Aspects: Integration of the cognitive and emotional components, is lacking. These aspects are important for wholesome learning. ● Practical Activities are not emphasized. The absence of practical activities in the content limits students' ability to apply their knowledge and skills. ● Inadequate information regarding Processed Foods: The curriculum doesn't sufficiently address processed foods, including their definition, examples, and their impact on health. |
We included two case studies: Alberta Health Services, Canada, and Community Voices for Health, American University, USA to compare with the Nepalese curriculum.21,23,24,26 These comparisons are presented in Table 4.
Content | Nepal | Alberta Health Services, Canada | Community Voices for Health, American University, USA |
|---|---|---|---|
Type of curriculum | Traditional curriculum | Traditional curriculum | Integrated curriculum |
Categories of food | Cereals, beans & pulses, fruits & vegetables, water, milk, fish & meat | Grains, vegetables & fruits, milk and alternatives, meat & alternatives | Carbohydrates, proteins, fat & oil, minerals, Vitamins, and Water |
Remark: Cereal is often a confusing term for children as many believe it to be corn flakes and chocos | Remark: Grains are clearer for students to grasp | Since the curriculum is integrated, the categories are based on science. | |
Concept of a balanced diet | Only type | Appropriate amount (quantity) and type (quality) of food. | Appropriate amount (quantity) and type (quality) of food. |
Remark: Lists of foods provided | Remarks: The curriculum includes detailed information about portion sizes and specific examples of foods within each category. Here's an example of how such information might be structured for the "Grains" category: 1 slice of whole wheat bread or ½ cup of cooked white pasta | Remark: Typical serving sizes provided. | |
Knowledge about diversified foods | ⭐⭐ | ⭐⭐⭐⭐ | ⭐⭐⭐ |
Remark: Names listed out | Remark: Plenty of lists along with serving sizes provided | Remark: Typical foods and their serving sizes are provided. | |
Over consumption nutrients | Doesn’t include | Acknowledges effects of overconsumption of nutrients. | Acknowledges effects of overconsumption of nutrients. |
Alternatives | Doesn’t include | Included | Doesn’t include |
Healthier food options such as whole grains and fibers | Doesn’t include the incorporation of whole grains into diet | Clearly explains about whole grains and fibers | Clearly explains about whole grains and fibers |
Healthy behaviour | Doesn’t include. | Included | Doesn’t include |
Standardization | Lacking | Present | Present |
Relevant activities to real-life | Lacking | Present | Present |
Reflective activities | Lacking | Present | Present |
Deep learning and critical thinking activities | Lacking | Present | Present |
Visual representation of a balanced diet | Food pyramid. | Food plate. | Food plate |
Remark: Recall-based activities | Remark: Critical thinking activities | Remark: Critical thinking activities | |
Learning opportunities related to life skills | Lacking | Present | Lacking |
Remark: self-perception, self-esteem, and role of healthy behaviors. | |||
Nutrition label | Lacking | Lacking | Present |
Strategies for improving nutrition education in Nepal:
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Integrated curriculum: Incorporate nutrition education into other subjects, such as science, health, physical education, and math (e.g., calculation of nutritional values) as part of an integrated curriculum. This approach emphasizes nutrition in all aspects of one's life.
2.
Project-based learning: Encouraging healthy behavior and developing a deeper understanding of nutrition concepts through project-based learning (PBL) in schools.14
For eg.: Farm-to-school.
3.
Affective and Behavioral aspect: Design learning objectives incorporating affective components (motivations, values, etc), and personalized behavioral components ( self-assessments, behavioral-change strategies, etc.).21
4.
Providing adequate learning opportunities: One unit lesson each year limits students' abilities to develop informed nutritional decisions. To achieve better learning results, a competency-based approach is recommended without time constraints.
5.
Parent and community involvement: Parental modeling and an enabling environment in the community are essential to the development of nutrition behaviors.22
6.
Coordinating with school meal programs: Cafeterias can serve as learning labs, in which students are exposed to balanced meals. 16
7.
Reflective activities: Students are encouraged to become aware of their food choices through this activity.23
8.
Activities that are more relevant and effective based on the real world: For eg. My plate, reading nutrition labels, meal planning, portion analysis, and planning, recognizing junk foods
9.
Toolkit for teachers to teach nutrition education
10.
Giving priority to culturally and locally relevant foods
11.
Include content related to body image, self-esteem building, and the adverse effects of poor behavior
12.
Present food as more than just a source of fuel and nutrients. Teach how food provides pleasure and connects us with ourselves, our families, our cultures, our nature, and our communities.24
13.
Ensure that learning resources for students are accurate by involving multiple stakeholders, such as nutritionists and health professionals
14.
Introduce problems associated with over nutrition.
DISCUSSION
We found significant shortcomings in Nepal's school curriculum compared to global nutrition education practices. The curriculum is inadequate when evaluated in terms of prevalent nutrition disorders in Nepal(relevance to national context) any innovative pedagogical and assessment techniques, and the accuracy of information. However, a unit is assigned to it in every grade from 6 to 8. Unfortunately, the curriculum development center of the country has not made health and population a mandatory course for students in grades 9 and 10 in Nepal. This limits the learning opportunity of students at the secondary level regarding nutrition and health.
Educating children and adolescents about healthy behaviors at an early age is a proven method for influencing their lifestyle choices as adults. Translating nutrition knowledge into terms that are needed, understood, culturally acceptable, socially acceptable, and adopted is a major challenge. However, regrettably, preparing an individual to live a healthy life through informed nutritional choices has not received the same importance as other technical fields such as science and mathematics. This practice keeps the concept of primordial level of prevention in health neglected.
The food and nutrition system is dynamic as newer findings in nutritional education continue to evolve, thus, it is crucial to identify the nutritional priorities with new information and country-specific contexts in mind to provide relevant nutrition education. The best approach to tackling nutrition-related problems is to adopt a transformative strategy, building sustainable change through education, rather than taking a piecemeal approach.
Educators need to acknowledge that a significant number of children in classrooms worldwide are either currently suffering from nutritional deficiency disorders or are at risk. Educators must therefore demonstrate that education can contribute to the solution of nutritional issues. The goal of curriculum design is to organize the fundamental elements of education in a logical, coherent, and consistent manner. A meaningful educational outcome is created by providing students with careful planning of learning opportunities, learning experiences, instructional methods, and content. 25
For imparting nutrition education to bring sustainable behavior changes, we suggest a framework proposed by Contento et al.26 This has also been suggested by FAO and has been elaborated in Fig. 2.
Fig. 2
Fig. 2: The framework for identifying and formulating nutrition education
According to the proposed framework, problems should be identified by analyzing the current situation. After evaluating existing practices and perspectives, reviewing educational priorities within the country, and developing key competencies for children, the process involves establishing key competencies for the children. Moreover, it requires an understanding of the learning that enhances motivation or facilitates change and the environmental conditions that allow for an effective implementation.
The authors have presented a conceptual framework for developing the curriculum using the Health Belief Model. 27In this figure, we see connections between the "why" and the "how". The "why" pertains to the reasons behind individuals' beliefs and perceptions about nutrition, representing the motivational phase of the behavior change process. Cultural context has a significant impact on the motivational phase since it influences perceptions and beliefs. Hence, when designing the motivational phase for students, cultural considerations need to be taken into account. Similarly, "how" refers to the action phase of behavior change, which includes strategies and interventions intended to foster behavioral change in students. In this regard, the goal of nutrition education can be defined as enhancing awareness and motivation and facilitating individuals in taking proactive actions regarding nutrition.
IMPLICATIONS for RESEARCH
An enhanced curriculum needs to be relevant as well as accurate while also offering opportunities for in-depth learning. This content analysis suggests strategies for an upgraded curriculum, such as integrating nutrition education across multiple subjects, adoption of project-based learning approaches, incorporating behavioral change aspects, contextualized learning, replacing my plate with nutrition pyramid, reflective activities, engaging parents and communities in the process, utilizing visual aids for instructional purposes, and collaborating with nutritionists to develop educational resources. It is crucial to update the curriculum to empower students capable of making informed nutritional choices. This revised curriculum should prioritize promoting behavior change towards healthier nutrition practices, aiming for a significant decrease in nutrition-related disorders. Following are the implications:
To increase stakeholder engagement in curriculum development.
Exploration of evidence-based teaching strategies that foster critical thinking and real-life application of nutritional concepts.
Incorporation of local and contextual culinary knowledge
Strengthened emphasis on junk food awareness
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Acknowledgement
We would like to thank our colleagues of Madan Bhandari Academy of Health Sciences for their help in this research project.
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Funding:
The authors have not received any kind of funding for this work.
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Data Availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request
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Author Contribution
AD: Conceptualization, visualization, and wrote the main manuscript text.N.B: Conceptualization and wrote the main manuscript text, prepared figures.B.S: Reviewed and edited the manuscript.
Conflict of Interest:
The authors would like to declare no conflict of Interest.
Consent for publication:
Not applicable.
Ethical Approval:
NA
This work has been previously published online in a conference proceedings document. (IFPRI-Delivering for Nutrition in South Asia-2023). This paper in its draft form was presented as a poster in the conference.
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