Nutrition knowledge, attitude and practices among urban primary school children in Nairobi City, Kenya: a KAP study
© Kigaru et al. 2016
Received: 29 July 2015
Accepted: 21 December 2015
Published: 29 December 2015
Kenya is undergoing rapid urbanization resulting in changing lifestyles. Childhood dietary habits are changing and might result in childhood obesity and related health risks. Dietary habits learnt in early life are likely to be carried to adulthood. Nutrition knowledge and positive attitude are known to influence dietary practices. There is paucity of information on nutrition knowledge, attitude and practices of school-children in cities. This study established nutrition knowledge, attitude and practices among urban school children in Nairobi.
A cross-sectional study was conducted among 202 school-children aged 8–11 years, systematically sampled from four randomly selected schools. Structured questionnaire, key informant interviews and focus group discussions were used to collect data. A nutrition knowledge score was determined (correct response: 1, incorrect: 0). Overall knowledge level was the total of correct responses in percentages. Scores of ≤40 %, 41–69 % and ≥70 % were categorized as low, moderate and high knowledge respectively. Dietary practices were determined from frequency of food consumption, habitual patterns and attitude on what they ate. Data were analyzed using SPSS. P-value of p < 0.05 was considered significant.
Pupils had moderate nutrition knowledge (mean score 5.16 ± 1.6, 51.6 %). 65 % did not care what they ate. About 82 % ate food in front of TV unsupervised. Over 70 % had consumed sweetened beverages and 73 % junk foods in previous 7 days. Only 9 % consumed fruits 4–7 times a week. Almost all study children carried money to school and made decision on foods to buy. Chips, candies, sausages and smokies, doughnuts and chocolate were preferred snacks. Nutrition knowledge had no significant relationship with dietary practices, but attitude had.
Children had moderate nutrition knowledge and poor dietary practices, associated with negative dietary attitude. This study recommends activities to raise awareness on the effect of poor dietary practices on obesity and related health risks.
KeywordsNutrition knowledge Dietary practices School children Urban primary schools
Poor dietary practices are major contributors to the development of chronic non-communicable diseases [1, 2]. Kenya is a sub-Saharan country undergoing rapid urbanization resulting in changing lifestyles and dietary habits; the so-called nutrition transition [3, 4]. Most chronic diseases in adulthood originate from dietary practices which are mainly formed during childhood [5–7]. In order to promote healthier eating habits, nutrition knowledge is believed to be important . However, nutrition knowledge alone may not be sufficient to change dietary habits hence in addition there is need to mold a positive attitude toward healthy eating early in childhood [9–11]. With the current change in dietary habits to the western diet and increase in televised food advertisements targeting children, there is even greater need to empower children with the right knowledge and attitudes for making proper food choices . School age children spend more time away from their parents thus, influence from friends and media further affect the formation and stabilization of their dietary practices [13, 14].
There is growing evidence suggesting that young children from developing countries are increasingly making unhealthy food choices especially due to lack of knowledge and wrong perception towards healthy foods [11, 15]. This is mainly because presently the concept of ‘food’ has changed from a means of nourishment to a marker of lifestyle and a source of pleasure as portrayed by media . A large proportion of televised food advertisements are of highly processed foods/convenient foods with, high caloric content, large amounts of fat and sugar, and with little or no micronutrient content . In addition, children in urban centres such as Nairobi, the capital city of Kenya have easy access to numerous fast food outlets, restaurants and supermarkets, and they are left to make decisions on what to eat . Therefore, to be able to overcome the emerging issue of obesity and overweight among children and related health risks, school children have to be empowered to make the right food choices by providing them with nutrition knowledge and changing their attitudes towards healthy eating. A larger study was conducted to assess nutritional status, including body composition, blood pressure, and physical activity levels, along with nutritional knowledge, attitude and dietary practices of school going children in four urban schools in Nairobi Kenya. This article presents the findings on the nutrition knowledge, practices and attitudes.
The study adopted a cross-sectional study design which was conducted among children aged 8–11 years from four randomly selected day public primary schools in Kasarani Sub-county in Nairobi city. The city was purposively selected due to rapid urbanization, transition in dietary practices and lifestyle. Kasarani sub-county was randomly selected. Four primary schools were randomly selected from 17 day public primary schools in the selected sub-county. Proportionate to size sampling was used to sample 202 children. At the school level stratified random sampling was used to select children from each age group 8 years, 9 years, 10 years and 11 years. A representation ratio of boys to girls as 1:1 was anticipated.
A structured questionnaire with a with figure-rating scale for girls (silhouettes) validated and widely used in other studies [18, 19], a head teacher key informant interview (KII) guide and a focus group discussion (FGD) guide were used to collect data. All data collection instruments were pretested in a fifth school that was not part of the main study. The questions were designed based on the research objectives of the larger study. The study pupils filled the questionnaires under the supervision of the researchers who ensured that all the children responded to the study questions. FGDs were conducted to get more information on knowledge, attitude and dietary practices of the children towards healthy eating. Two FGDs per school each comprising of 8 children were researcher facilitated. The research assistant recorded all the deliberations of the discussion. The researcher ensured that the selected venues were comfortable and free from disturbance. Deliberate efforts were made to ensure discussion questions followed each other as they appeared in the guide. To achieve a balanced discussion the facilitator moderated the discussions. The discussions took an average of one hour. Key informant interviews were held with the head teachers of the participating schools to get in depth information on the school environment in terms of promoting healthy dietary practices.
The level of nutrition knowledge was determined using 10 multiple choice questions concerning food, nutrition and healthy eating. For each question, a correct response was coded as 1 and an incorrect response as 0. The total score for every child was calculated from all correct responses with a maximum of 10. This was then converted to a percentage. Those who scored below 40 % were categorized as having low nutrition knowledge, 41-69 % moderate, and >70 % high nutrition knowledge which was predetermined before the study.
A food frequency questionnaire (FFQ) with foods arranged into 9 categories based on food grouping was used to assess dietary practices. A list of commonly available soft drinks and fast foods were provided for the children to indicate the frequency of consumption in the last seven days prior to the study . Total frequency of consumption of all sweetened drinks, fast foods and fruits was computed. Consumption of sweetened beverages, fruits and fast foods more than four times in a week was considered excess consumption while consumption of fruits less than four times in a week was considered inadequate intake as provided by Food and Nutrition Technical Assistance . In addition, eating habits like eating in front of the television (TV), eating with other family members, eating breakfast and sharing food in school with other children and presence of food vendors in the school were used to assess influence of home and school environment to children’s dietary practices. To assess the attitude towards good dietary practices, the study children were asked whether they were concerned about what they ate.
Data were analysed using SPSS version 20 [22, 23]. Pearson product moment correlation and chi-square tests were used to establish relationships and associations between nutrition practice, knowledge and attitude. Results were considered significant at P < 0.05. Qualitative data from FGD and KII were coded by assigning labels to variable categories. Common themes were then established and clustered in a patterned order to clarify variables. Inferences were made from particular data under each theme then conclusions were drawn from the findings. The findings were triangulated with the reported quantitative data. The study was approved by the Kenyatta University Ethical Review Committee. Written informed consent was sought from the children’s parents and assent sought from the study children.
Demographic characteristics of study pupils
Demographic characteristic of the study pupils
Nutrition knowledge of the study pupils’
Nutrition knowledge level among the school children
Nutrition knowledge (percentage)
Proportions of respondents with correct scores in various nutrition knowledge aspects
Nutrition knowledge aspect tested
% correct answers
Fruits are healthy snacks
When you eat too much fat you can become fat
Is eating fruit and vegetables every day good for our bodies to fight against illnesses like colds and flu?
Eating a lot of sugar, sweets and sweet food, is good for health
Eating a lot of sugar, sweets and sweet food can make you fat
Food group that you should eat the most of every day
Food group that you should eat the least of every day
Food group that gives your body the best energy
Food group that your body uses to build muscles
Food group that best protects the body against illnesses
Attitude toward healthy eating
The study pupils were asked their feelings towards what they ate. Only 35.1 % of them reported that they were concerned about the foods eaten, while 64.9 % of them reported that they did not care about what they ate since they were still young. Figure rating scale established that more than half of the girls (59.6 %) had the perception that they were of lean size despite some of them being big from observation. A similar proportion (52.3 %) felt that they wanted to remain in that body shape, therefore felt no need to check their diet in relation to their body size and shape. From the FGDs, boys had a perception that being thin is not good since other boys would bully them and this made them eat a lot of food to be energetic in case other boys want to fight them.
Frequency of consumption of various foods among the children
From a 7 day food frequency questionnaire, 28 % of the children consumed sweetened drinks 4–7 times in a week while 49.0 % consumed sweetened drinks 1–3 times in a week. Fast foods were consumed by 40.6 % of study children 4–7 times and 32.7 % 2–3 times in a week. Some of the soft sweetened drinks consumed by the study children were carbonated sweet drinks (sodas) and artificial juices such as Afia, Quencher, Minute maid (brand names). Fast foods consumed by the children were smokies, sausages, chips (French fries), fatty doughnuts (mandazi) sweets, cakes, chocolate and popcorns.
Frequency of consumption of various food items in the last 7-days
Not consumed in the last 7 days
Snacking habits of the study children
Choice of snacks made by the study children
Chips (French fries)
Smokies (smoked sausage)
Practices associated with food intake
Carry lunch box
Sometimes (2–3 times per week)
Share lunch with others
Sometimes (2–3 times a week)
Carry money to school
From the results, 68.3 % children carried lunch box daily to school. The study noted that majority of those who carried lunch to school (77.3 %) usually shared with other children. This shows that what children ate was also greatly influenced by what other children carry to school. Almost all of the study children (95.5 %) carried money to school to buy either mid morning snacks or lunch for those who did not carry lunch box to school. All schools had a parent-funded feeding program whose participation was not compulsory as reported by key informants hence most children preferred carrying lunch box to school and/or money to buy food. From the key informants, there were many food vendors adjacent to the schools. The schools did not have food policy to regulate food items sold in the surrounding shops. Key informants reported that children had easy access to variety of snacks from the shops. Moreover, the schools did not have shops within the school compound and therefore children relied on what was available in the surrounding shops. In addition, the products were also easily available and in various packaging sizes, which children would afford.
Eating environment at home
Eating environment among the study pupils at home
Home eating environment aspect
Ate in front of TV
Sometimes (2–3 times a week)
Eating meals with the family
Sometimes (2–3 times a week)
Consumption of breakfast
Sometimes (2–3 times a week)
Relationship between nutrition knowledge, attitude and practices
Relationship between knowledge, attitude, home environment and dietary practices
Relationship between overall nutrition knowledge score and frequency of food consumption
r = −0.101; p = 0.061
r = −0.112; p = 0.059
r = − 0.115; p = 0.062
r = −0.157; p = 0.078
r = −0.101; p = 0.061
r = −0.114; p = 0.060
r = − 0.129; p = 0.063
r =−0.165; p = 0.058
r = −0.154; p = 0.69
r = −0.185; p = 0.06
r = −0.165; p = 0.06
r = (0.101–0.170); p > 0.05
Relationship between attitude and frequency of food consumption
X 2 = 101.7 df = 6, P = <0.001
X 2 = 64.738 df = 6, P = <0.001
X 2 = 70.969 df = 6, P = <0.001
X 2 = 181.8 df =6, P = <0.001
X 2 = 185.8 df = 6, P = <0.001
X 2 = 71.836, df = 6, P = <0.001
X 2 = 172.0 df = 6, P = <0.001
X 2 = 62.778, df = 6, P = <0.001
X 2 = 163.7 df = 6, P = <0.001
X 2 = 111.7 df = 6, P = <0.001
X 2 = 125.5 df = 6, P = <0.001
p > 0.05
Relationship between home environment and attitude towards healthy eating
X 2 = 4.5215 df = 1, P = 0.002
Eating with family members
X 2 = 2.5462 df = 1, P <0.001
The aim of this study was to establish nutrition knowledge and attitudes of school going children in relation to dietary practices. Overall, children in this study had moderate nutrition knowledge. in contrast to previous studies which reported low nutrition knowledge among school children [6, 13, 24]. This current finding could be attributed to the fact that at present health lessons were offered in school. School children however felt that they needed not be concerned about what they ate as they were still young.
Nutrition knowledge had no significant relationship with dietary practices in this study. This implies that even though study children had some level of knowledge on the effect of unhealthy diet on their health, they still continued to consume unhealthy diets. This finding is similar to that of another study which found poor dietary practices even among children with good nutrition knowledge . Other studies have shown nutritional knowledge as a factor that influence the decisions individuals make about food [20, 24, 25]. Lack of nutrition knowledge has been implicated as a cause of poor dietary habits . However, knowledge alone may not be adequate to have proper dietary practices. Positive attitude and behaviour change toward healthy eating early in childhood contributes immensely in adopting healthy food habits . Studies also confirm that linking knowledge and practice in nutrition education is a challenge and need behaviour and attitude change .
Findings that dietary practices among children were characterized by excess consumption of fast foods and sweetened beverages, an indication of unhealthy food choices and the main reason for consumption of these foods being sweet taste and ease accessibility, are in agreement with other studies which found that young children from developing countries are increasingly making unhealthy food choices especially due to lack of knowledge and negative attitude [15, 28]. Previously, over consumption of sweetened drinks/beverages was a trend observed among American population . However, current studies indicate increased consumption of fast foods among children in developing countries, with increased consumption of sugar-sweetened beverages, contribute to a greater number of total caloric intake and directly to obesity epidemic [29–31]. Contribution of total energy intake from fast foods and sweetened beverage in relation to obesity has been supported by other studies [10, 32, 33]. There is supporting evidence that excessive sugar and fat intake from soft drinks and junk foods increases energy intake, which is likely to increase the risk of overweight and obesity .
Availability of cheap snacks in the environment surrounding the school encouraged consumption of the junk foods by the pupils as reported in the FGDs and by the key informants. Other researchers support that easy access to soft drinks from local vendors contribute to their increased consumption . Research has also demonstrated the importance of not only food availability but also accessibility of healthier foods as a measure to promote good dietary practices among children. This is because whichever foods are easily accessible and ready to be eaten, children are more likely to eat them . From the focus group discussions, sweet taste was highlighted as among the main reasons for consumption of soft drinks and fast foods. Children in Nairobi have easy access to numerous fast food outlets . Children also reported that some of the sweet snacks such as juices, biscuits, cakes chocolate were hardly bought at home by the parents and therefore once given money for lunch they preferred buying such. In addition, the products were easily available in local kiosks and in various packaging sizes, which children could afford even without the knowledge of the parents. This shows that children have an opportunity to make food choices, thus with good nutrition knowledge and positive attitudes, there exists an opportunity to make healthier choices.
The findings that most children in this study ate their meals at home without parent’s supervision are in agreement with other studies that showed that the proportion of school age children spending more time away from their parents is increasing thus parents miss out the opportunity to impact good nutritional knowledge and practices [8, 36]. Another study showed that about 60 % of 8–12-year-old children chose their own foods yet studies have associated children’s eating alone with poor dietary practices due to lack of parental guidance . Family environment has the potential to influence and enhance good dietary practices as children are likely to mimic their parents’ practices . Recent research conducted with Irish children indicated that parents were major influencers in their children’s diets and that frequency of shared meals has a positive effect on children’s food knowledge .
Majority of the children in this study ate while watching television and those that had access to TV had higher consumption of fast foods and sweetened beverages. While the television is an avenue for food advertisement and promotion [39, 40] most of the televised foods are junk and highly processed with high sugar, fat and salt content. These televised adverts greatly influence dietary habits of children [40, 41]. A study on chronic non-communicable diseases in Brazil noted that a considerable number of the foods requested by children were advertised on TV during the 6 previous months . Further, another study reported that exposure to TV food advertisement brought negative changes in dietary behaviour especially among school children . In this current study, both quantitative and qualitative methods were used to support this discussion. However, the results in this study are limited to urban day public schools only.
Children had moderate nutrition knowledge. Knowledge had no association with practices. However, attitude significantly influenced dietary practices. Children did not translate nutrition knowledge into practice. The main factors that influenced dietary practices were mainly the taste of foods (sweet taste) and the feeling that they did not have to be concerned about what they ate since they were still children. This study concludes that there was a disconnect between nutrition knowledge, dietary practices and attitude. Children had money and made independent decisions on what to buy while away from home. At home children mainly ate food alone, unsupervised. Availability of unhealthy snacks contributed to their high consumption.
Since children at this age make more independent decision on food choices, this study recommends creating awareness on the effect of poor dietary practices on overweight and obesity and associated health risks. This should aim at improving nutrition knowledge, positive attitudes and appropriate dietary practices. Parents are encouraged to monitor their children’s eating process and expenditure of pocket money. This study recommends availability tuck shops within the school environment and appropriate policies if school children must bring lunch money to school.
Food and nutrition technical assistance
Food frequency questionnaire
Focus group discussion
Key informant interview
Statistical package for social sciences
The International Atomic Energy Agency (IAEA) is acknowledged for partial funding of the larger study; RAF6042 in which this study was nested. Also acknowledged is Kenyatta University as the coordination centre. Research assistants and especially Grace Munthali are thanked for their assistance in data collection. The teachers of study schools and study children are greatly thanked for responding to data collection tools. Parents and guardians to the study children are acknowledged for consenting to this study.
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