Assessment of Preschool Preparedness Intervention Package on Adoption of Nutrition Friendly School Initiative in Rural Sindh, Pakistan: An Exploratory Sequential Mixed Method Design

doi:10.21203/rs.3.rs-2343724/v1

Background

Early years of life are crucial for growth and development; any adverse events (such as nutrition deficiencies) during this period significantly influence children’s life-course developmental trajectories to maturity. In 1995, the World Health Organization launched its Global School Health Initiative with the aim of expanding the Health Promoting School (HPS) approach globally. Therefore the primary objective of this study is to assess the preschool preparedness intervention package in adoption of Nutrition Friendly School Initiative.

Methodology:

An exploratory sequential mixed method study design was carried out in three campuses of Aga Khan School (Mirpur Sakro, Junior Campus Vur, community-based school Sujawal) in the Sindh province of Pakistan. Study participants (children & parents) were selected using purposive sampling. Data collection includes in-depth interviews with the school community, pre & post assessment of knowledge of parents, baseline and end-line nutrition status of preschool children of age 24-59 months and beyond, and baseline & end line assessment of Preschool preparedness using checklist

Results/outcomes:

The qualitative findings has informed additional measures (setting up nutrition theme corner, including parenting package in manual, aligning school nutrition policy with school handbook, launch of special campaign for engagement and awareness purpose with parents) that were adapted within the intervention package. Preschool preparedness also improved from 10 points to 22 points out of 26 indicators (with some indicators labeled at not applicable). The knowledge of parents on nutrition and health promoting manual has been enhanced with mean improvement of 7.17 points (out of 25 points). Also the mean increase in MUAC, height and weight of preschool children are 0.27cm, 0.6cm and 0.26kg respectively.

Discussion and conclusion:

This initiative has improved preschools preparedness in creating an enabling environment in addressing health and nutritional problems within and beyond the classroom. Program implementers should not ignore this nexus of health, nutrition, and early child development by utilizing school platforms to improve the nutrition status and prevent all forms of malnutrition. Policy takeaway include initiating a school accreditation program to certify schools as Nutrition friendly and utilized the developed school nutrition policy developed to feed the development of National Nutrition Friendly school policy

Early Child Development

Nutrition interventions

malnutrition

School Community

Nutrition Friendly School Initiative

Preschool (annexure 1)

1. Background of the Study

According to the Joint Child Malnutrition Report 2021, globally, approximately 149.2 million children were affected by stunting (22.3% of the total under-five children), while 45.4.0 million (6.7% of total under-five children) were wasted. More than two-thirds (70.26%) of all wasted under-five children lived in Asia¹. Furthermore, 38.9 million (5.7% of total children under five years) around the world are overweight¹. Additionally, an estimated 46% of children in Southeast Asia and 33% of children in the Pacific suffer from micronutrient deficiencies². According to Sindh Multiple Indicators Cluster Survey (MICS), 2018, the prevalence of stunting and wasting are 50.2% and 14.8% respectively, whereas the prevalence of being underweight is 40.7%. Only 32.7 % of children of age 24-35 months had received all vaccinations recommended in the national immunization schedule³. The early child development index is 47.5%, it means more than half of the children of age 36-59 months are developmentally off-track in at least three of the following four domains: literacy-numeracy, physical, social-emotional, and learning. Similarly, only 46.2% of children 24-59 months of age are provided with early learning simulation and care by any adult household member in the last three days³ (annexure 2).

Early life events, including nutritional deficiencies and toxic stress, can have differential effects on developing brain regions depending on the timings, dose, and duration of those events. Neuroscientists used the term “critical period” and “sensitive period” to describe time periods of opportunity and vulnerability to environmental factors including nutritional deficiencies⁴

Early childhood development (ECD) interventions delivered to children aged less than 59 months have been shown to have substantial and sustained impacts on long-term cognition and neuro-developmental outcomes⁴.

In 1995, the WHO launched its Global School Health Initiative (GSHI) with the aim of expanding the Health Promoting School (HPS) approach globally⁵. This initiative was guided by the Ottawa Charter of Health Promotion, promulgated in 1986⁵. It is designed to improve the health of students and the school community through schools at all levels⁶.

As an effort to halt the progression of chronic, non-communicable diseases, the WHO called upon countries to adopt school policies and programs that promote a healthy diet and physical activity, under a school policy framework⁷ followed by the Nutrition-Friendly Schools Initiative (NFSI) having expert consultations on childhood obesity held in Kobe, Japan in 2005⁶. The benefits of adopting NFSI include, but are not limited to: i) helping schools to build an enabling environment for promoting the overall health and nutritional well-being of children; ii) strengthening the capacity of schools in addressing the health and nutritional problems of the children, their families and communities; and iii) strengthens the capacities of and network between the school community, including school personnel, students, parents, education authorities in alleviating the burden of malnutrition⁶.

A review by the WHO on nutrition actions in schools documented several published meta-analyses and systematic reviews respecting the outcomes of nutrition actions in schools⁸. Among these meta-analyses, Brown et al.’s paper⁹ included 153 obesity prevention studies applying various approaches (e.g., educational, environmental, policy, parental involvement), of which 91 were school-based and an additional 22 took place in kindergartens or preschools. A Significant effect was found on the BMI z-score from combined diet and physical activity interventions (-0.04; 95% CI: -0.08, -0.01) in children aged 6 to12 years.

An observational panel study using the Young Lives data in Peru found that concurrent stunting (stunting in early years and continues until ages 4.5–6 years) was more strongly associated with vocabulary deficits than stunting in 6-18 months of age only¹⁰. The authors’ inferred that interventions preventing linear growth faltering should focus not only on children under 2 years but continue to focus children up to 5 years of age¹⁰.

Finally, the pilot projects of the Nutrition-Friendly School Initiative (NFSI) in Ouagadougou, Burkina Faso, and Cotonou, Benin, in West Africa describe the experiences and lessons learned from the implementation and concluded that the NFSI has the potential to mobilize schools and communities for improved nutrition and health, provided the approach is adapted to the local conditions of limited human and material resources⁶.

1.2 Objectives of the Study

Schools provide the most effective and efficient way to reach young children at influential stages in their lives when lifelong nutritional patterns are formed⁵. Furthermore, schools may provide a setting to introduce nutrition information and technologies to the community and support them in advocating for policies and services that promote good nutrition⁵. Therefore, the primary objective of this study was to assess the preschool preparedness intervention package in the adoption of NFSI in selected schools of Rural Sindh. The secondary objectives were; i) to explore the perceptions of school communities regarding the roles of nutrition in early years and school-based nutrition interventions in preschool settings ii) to assess pre & post intervention knowledge of parents of preschool children regarding the importance of nutrition in early years of life and health-promoting behaviour & iii) to assess pre & post intervention nutrition status of preschool children of age 24-83 months using mid-upper arm circumference (for children 24-59 months), height, weight, and bilateral pitting edema.

1.3 Specific Aims

Given malnutrition is a critical link to child development and consequently to national development, there are clear synergies in integrating nutrition interventions into the preschool setting by responding to family demands for the provision of holistic care, leveraging common caregiving competencies, and building an enabling environment that supports early child nutrition and development outcomes.

Figure 1 depicts a self-designed action framework⁸ that has provided a road map toward attaining study objectives. This study aimed at preventing different forms of malnutrition (specifically wasting, micronutrient deficiencies, and over-nutrition addressing five focus areas (pillars) conceptually outlined in NFSI that include nutrition-friendly school policy, awareness, and capacity building of school community (defined under operational definitions), development of health and nutrition promoting curriculum, enabling environment, and support school nutrition and health services. These pillars were utilized for self-appraisal (baseline & end line) of preschool readiness.

By adopting the NFSI framework, preschool readiness in adopting intervention package outlined in NFSI checklist and have improved the knowledge of parents on nutrition and health promoting behaviors/messages, furthermore, NFSI has potential in preventing different forms of malnutrition among children 24-59 months of age and beyond.

An exploratory sequential mixed-methods design that utilizes qualitative (qual) and quantitative (quan) data collection and analysis in a sequence of phases¹¹ has been employed to achieve research objectives. In exploratory sequential design, timing for qualitative and quantitative data collection will follow a sequential manner, such that qualitative data are collected and analyzed first and then quantitative data are collected and analyzed¹¹. The mixing will be done by connecting the data between the two phases¹¹. Finally, the weighting refers to the strength of which data collection method best suited to address study objectives. In this study quantitative findings will be more emphasized and notated as qual àQUAN¹¹, this indicates unequal weighting (QUAN emphasized over qual)¹¹.

The rationale for this design is based on the premise to have that initial exploration to acquire the subjective viewpoint that to determine the need and taking into account the intent to deliver, feasibility to adopt and resources to sustain nutrition friendly initiatives. Moreover, the initial qualitative phase will informed the successor quantitative phase and refinement of pre-developed intervention package as outlined by NFSI checklist.

This study was carried out in three Aga Khan School campuses [Mirpur Sakro, Vur (junior campus), and Sujawal (community-based school)] managed under Aga Khan Education Service - Pakistan (AKESP), an entity of Aga Khan Development Network (AKDN). These campuses are located in Sindh province. Study sites were selected purposively in consultation with the head of programs. The rationale behind selecting a private school is feasibility and readiness to adopt innovations, willingness, and flexibility in mobilizing resources for change. Within the private sector, AKESP has the largest network of schools operating across Pakistan, Since NFSI is a community-based model and AKESP schools also operate a community-based model that represents a balanced population-based reflection of rural and urban settings.

To support the implementation process, a committee was constituted (referred to as the school community) with the consultation of school management (based on criteria) that has representation from each campus. It comprised of (but not limited to) representatives from the school management committee, parent-teacher committee, principal, head teacher, and identified preschool teachers. The qualitative data was collected with the representative member from School community. Study participants for quantitative data collection were selected using a population-based approach this includes parents of preschool children for assessment of nutrition status using Mid Upper Arm Circumference (for children 24-59 months), weight, height, and edema, and their parent for health and nutrition promoting training session. The eligibility criteria were set for participation for both type of data collection (annexure 3).

The intervention package includes a) development of nutrition and health promotion manual, b) training sessions for parents of preschool children, c) consultative workshops and meetings the with school community, d) active case findings through anthropometric assessment of pre-school children through MUAC (for children 24-59 months only), weight, height and bilateral pitting edema, developing referral linkages and need based counseling, e) development of school Nutrition Policy, f) establishing a nutrition theme corner in each study site and implementation of other activities as outlined in NFSI checklist.

2.2 Data Collection method and process:

In the initial phase, Qualitative data was collected using in-depth interviews (IDIs) and findings recorded during consultative meeting with school community. The purpose of IDI was to explore their perception of school community in implementing school based nutrition initiative in preschool setting. Total five IDIs were conducted in English or Urdu (or both) language depending on the convenience of the study participant for their ease to comprehend. A self-developed and structured IDI interview guide using open-ended questions was applied to encourage better discussion (Annexure 4).

In phase 2, quantitative data was collected through following means:

Anthropometric assessment: Anthropometric assessment of eligible preschool children was carried out twice (Baseline & end-line). Anthropometric measures including MUAC (for children of age 24-59months only), presence of bilateral pitting edema, weight, and height were assessed.
Knowledge assessment of parents (Pre- and post-assessment): Knowledge assessment of the parent was carried out before and after the training session using a questionnaire. Parents who consented to participate and present during scheduled training underwent knowledge assessment. The differential scores in pre- and post-assessment will determine the change in level of knowledge. The level of interaction with parents includes understanding and signing of consent form for participating in this study, attending the training as per plan, and responding to pre & post assessment knowledge questionnaire (annexure 5).
Preschool Preparedness assessment using NFSI Checklist: The NFSI checklist has been adopted from the WHO report on nutrition actions in school (Annexure 1). This checklist has five components and 27 items¹². Each item has three options (Yes, no, and not applicable). The items that were not applicable was discussed and agreed upon during consultative workshop with school community before conducting the baseline assessment. The total score was assigned out of the applicable number of items. This assessment was carried out jointly during consultative workshops.

2.3 Qualitative and Quantative data Analysis:

The data was analyzed sequentially. In the first phase, Qualitative data were recorded and analyzed using thematic analysis. Each interview was audio recorded and transcribed into verbatim responses. Comments and responses were imported into word file. After a thorough reading of the transcribed content, coding was carried out followed by the formulation of sub-sub-categories, categories and themes. Furthermore the discussion points under the consultative workshop during the implementation phase were also documented separately and henceforth considered in refining intervention package and linked activities.

The quantitative data obtained through pre-and post-knowledge assessment, anthropometric assessment (MUAC, weight, height, and edema), and assessment of preschool readiness using the NFSI checklist. Except for NFSI checklist which is analyzed manually by using differential scores, data from anthropometric and knowledge assessment will be entered via the Statistical Package for Social Sciences (SPSS™) version 19. The anthropometric and knowledge assessment data was analyzed using descriptive statistics. Descriptive statistics for continuous variables (MUAC, weight, and height) were presented as mean change in number; whereas categorical variables (test scores) were presented as numbers and percentages.

The difference in MUAC (for children 24-59 months only), height, and weight of children 24-83 months were tested by employing inferential statistics using a t-test for a dependent sample (as the outcome is continuous). The change (difference in mean score pre- and post-) in knowledge of parents of preschool children was assessed using Paired T-Test.

2.4 Ethical Approval:

This study was approved by the Ethics Review Committee (ERC) of The Aga Khan University (AKU), Pakistan (AKU-ERC-2022-6622-21217) (annexure 06). This study complied with ethical considerations aligned with the main principles of the Declaration of Helsinki (DoH). Informed consent (written) from study participants was taken and providing them clear and concise detail about study purpose, risks and benefits for participation. Separate consent form was designed for IDI participants (annexure 07) and parents (annexure 08).

3.1 Qualitative findings

A total of five (n=5) IDIs were conducted. One each from three study sites and one with head teacher and school principal respectively, The transcriptions of the IDIs were thoroughly reviewed to formulate the codes. Then codes were combined to form sub-categories and the sub-categories were merged to formulate the main categories. Finally, the analysis established five major themes that represent the participants’ perception of school-based nutrition interventions in preschool settings. These five themes include i) Challenges in health and nutrition for pre-school age children, ii) Clarity in roles and responsibilities for school-based nutrition intervention, iii) Advancing school-based nutrition activities and interventions, iv) Recognizing resources requirements, v) Opportunities and challenges for the way forward in school-based nutrition (table 1).

Based on the analysis of findings obtained from in-depth interviews and suggestions proposed during a consultative meeting enabled the researcher in refining the intervention package (refer figure 2)

3.2 Quantitative findings:

3.2.1 Anthropometric assessment

Out of 171 preschool children, a total of 164 are eligible for anthropometric assessment (Height and Weight) with the exception of MUAC and bilateral pitting edema for which only those children are eligible who are below 59m of age at the time of pre and post-MUAC assessment. Out of 171 children, 92 (56.1%) were boys and 72 (43.9%) were girls. In terms of Age wise segregation, 76 children (47%) were of age <59 months whereas 87 (53%) of children are elder than 59 months.

Out of 171 pre-school children, 16 were identified as stunned (prevalence of 9.8%) of which 56.25% (n=9) were girls and rest (n=7) were boys. Among identified stunted children 75% (n=12) were age 5 years and above, whereas only remaining 25% (n=4) were of age less than 05 years. Total 17 children were labelled as underweight which accounts for 9.94%. Out of which 10 were girls (58.8%) and remaining 07 were boys (41.2%), among underweight children, all (except 01 child) were above 05 years of age which accounts for 94.1%.

The acute malnutrition was assessed through wasting (by MUAC, among children 24-59 month, and weight for height, among children of age 5 years and above) and presence e of bilateral pitting edema of any severity, no single child was identified with wasting (by MUAC) but based on weight for height z-scores, including those of age 05 years and above, only 02 children (prevalence of 1.2%) identified as wasted of moderate severity. Both were above the age of 5 years, and both were boys.

Finally with overweight/obesity, total 05 children were identified (prevalence of 3%) of which 80% (n=4) were boys and 60% (n=3) were below age of 05 years. It is also notable to highlight that the prevalence of all forms of malnutrition remained same during end line (when compare with baseline) except for wasting (by WFH z-scores) where 1 child improved out of 2 identified (50% improvement) turn to normal during end line. Table 2a summarized the baseline and end line findings.

The comparative assessment of MUAC, weight and height in term of mean difference along with p-value were given in table 2b.

3.2.2 Pre and post-assessment of knowledge among parents of preschool children

Training was imparted to parents of pre-school children on essential areas of health and nutrition promoting curriculum, of the 164 parents of preschool children invited, only 84 (51.2%) had participated in a one-day training. The knowledge of parents was assessed using an objective-based questionnaire having twenty-five questions. The mean test scores of parents improved significantly from 50.44% (12.61/25 ± 4.92) to 79.1% (19.77/25 ± 3.03). The P value < 0.001 (table 2b), suggests significant improvement is knowledge of parents on health and nutrition-promoting behaviors after attending one-day training.

3.4.3 Assessment of pre-school preparedness for NFSI

During Baseline assessment, Out of 27 indicators only 10 indicators were fall under “Yes” (score of 10 points). There were 04 indicators that are not applicable in context of school setting and therefore 12 indicators that were fall under ‘NO’ category (through consensus). During end line school preparedness score raised from 10 to 22 points, reflecting significant improvement in preparedness in adopting NFSI (table 3).

4.1 Discussion

This study findings has demonstrated how selected preschool sites have transformed to nutrition friendly and potential role performed in improving its readiness (from 10 points to 22 points) towards achieving nutrition friendly environment after meticulously worked with the school management in developing nutrition policy for school, health and nutrition-promoting behavior manual, support from school in establishing the mechanism of nutrition screening, learn with fun by establishing nutrition theme corners, imparted training to mothers, engaging parent with awareness campaign and detail orientation of school community.

A study conducted in Gaza and West bank, Palestine aimed to improve nutrition wellbeing of school age children through NFSI revealed that, after implementing their context specific intervention package that include incorporated NFSI into national school nutrition strategy, developed referral system between school and health care system, developed school nutrition packages for parents on school nutrition under the guideline of NFSI for parents; these all efforts resulted in bringing school nutrition among a national priority agenda and elevated the commitment of Palestinian authorities in building the foundations of future interventions for its scalability¹³

Analysis of anthropometric data highlighted that the chronic malnutrition (stunting) and underweight were more prevalent among age above five years and slightly higher prevalent among girls than boys, it means that targeting preschool has the potential to prevent the irreversible growth and development loss from stunting and from underweight which is considered as potential risk factor for child mortality.Reduction in deaths and increases in years of life lived and QALYs were greatest when reducing both underweight and overweight/obesity followed by reducing overweight/obesity alone and underweight alone¹⁴. Moreover, younger children had a significantly higher risk of mortality with underweight and stunting than older children¹⁵. Where resources are limited, prevention programs may be justified in targeting younger children¹⁵ and therefore NFSI has potential to prevent different forms of malnutrition.

One of the secondary objectives of this study was to assess the knowledge of parents of preschool children regarding health and nutrition. Study findings have confirmed the improvement in knowledge of parent participated in training session by 28.7% (from 50.44% to 79.1%). Study findings clearly indicates the potential role of school in educating parents towards health and nutrition promoting behavior to foster positive parenting for healthy future of child. This study finding was supported by another study conducted in Taguig city of Philippines that has evaluated the effects of nutrition education in improving knowledge, attitude, and practice of mothers, they found significant improvement of knowledge among mothers who attended the training session by 22.2% (from 18.2% to 42.4%), particularly for preparation of nutritious food¹⁶. Effective utilization of knowledge and skills gained from health and nutrition education is, therefore, expected to improve the health and nutritional status of children through improved knowledge and care practices¹⁶.

Through this initiative, two additional output that include the school nutrition policy and health and nutrition promoting manual were accomplished with imperative to sustain such initiative. The school nutrition policy will guide the school to plan their annual calendar keeping activities outlined under policy under consideration and budget such initiative to ensure quality and effectiveness of such initiatives. The Nutrition theme corner (established one in each campus) under this initiative is providing a platform to preschool children and school community to engage children and promote learning with fun by fully utilizing the provided resources in establishing these corners.

This initiative not only benefit preschool children in improving nutrition wellbeing and preventing from all forms of malnutrition but also benefits schools in building an enabling environment for promoting the overall health and nutritional well-being of children, It also strengthens the capacity of schools in addressing the health and nutritional problems of the children, their families and communities which acts both within and beyond the classroom; and finally it enables schools to become accredited as ‘Nutrition-Friendly Schools’, which will enhance the schools’ reputation for making an effective investment in the future generation.

4.2 Strengths and Limitations of the study

Study limitations include, unlike RCT or quasi experimental design, there is no control group for this study; therefore it may limit the internal validity of the study. However, internal validity is strengthened when techniques of varying strength are used in lieu of randomization, including pre- and post-assessment of outcomes. Moreover, due to time and budget constraints, this feasibility study only considers three study settings in rural Sindh; however, there might be different implementation experience and outcomes in urban context or in public school settings.

Among study strengths, mixed methods research involves the intentional collection of both quantitative and qualitative data while optimizing the strengths of each other and dilutes the weaknesses inherent in standalone approach of data collection. The mixed method study allows a pragmatic worldview seeking a practical or situational approach which may avoid sole alignment with either positivism or constructivism. Furthermore, to the researcher’s best knowledge, this study is the first of its kinds particularly in rural settings of Sindh in exploring the feasibility of implementation of NFSI activities.

The implementation of NFSI has improved preschool preparedness towards achieving nutrition-friendly schools. Furthermore, this initiative has significantly improved the knowledge of parents and understanding among preschool teacher and school management about nutrition and health-promoting behaviors. Program implementers should not ignore this nexus of health, nutrition, and early child development by utilizing school platforms to improve the nutrition status of children and reduce the burden of different forms of malnutrition on the health system, and ultimately improved the productivity of an individual, family, society, and country. This study has strong potential to replicate in a public school setting and has an opportunity to initiate a school accreditation program to certify schools as Nutrition friendly. The nutrition policy developed for the school has potential to scale up and feed the development of National Nutrition Friendly school policy.

NFSI is a preventive approach and prevention should be the priority of public health programs to tackle the triple burden of malnutrition and chronic diseases among children under five years of age to ensure and foster healthy lifestyles among future adults.

NFSI has the potential to mobilize schools and communities for improved nutrition and health. Efforts should now be devoted towards sensitization and advocacy by multi-sector actors (Education, Health, local government, etc), as well as potential donors and funding partners, to scale up and sustain this initiative.
The developed school-based nutrition policy should be reviewed at the provincial and national levels through multi-sector stakeholder consultation to feed the development of the “National Nutrition School Policy”
It is also recommended that education stakeholders and relevant regulatory bodies initiate or design a “School Accreditation program” towards setting minimum quality standards for implementing NFSI to not only achieve better health and nutrition outcomes but also improved learning and holistic child development.
This initiative must be better explained and presented as an endogenous and self-sustaining approach, rather than as an external project bringing in money.
It also offers an opportunity for private sector engagement to contribute towards alleviating this major public health problem of malnutrition.

AKESP: Aga Khan Education Services, Pakistan; AKU: Aga Khan University; BMI: Body Mass Index; ECD: Early Child Development; ERC: Ethical Review Committee; FHS: Faculty of Health Sciences; GoP: Government of Pakistan; GSHI: Global School Health Initiative; HPS: Health Promoting School; IDI: In-depth Interview; IED: Institute of Education Development; IQ: Intelligence Quotient; MAL-ED: Malnutrition and the Consequences for Child Health and Development; MUAC: Mid Upper Arm Circumference; NCSS: National Council for Social Studies; NFSI: Nutrition Friendly School Initiative; NNS: National Nutrition Survey; PP: Pre-Primary; PTC: Parent Teacher Committee; RCT: Randomized control trail; SMC: School Management Committee; SMD: Standard Mean Difference; UNICEF: United Nations Children’s Funds; WHO: World Health Organization; DoH: Deceleration of Helsinki

Ethics approval and consent to participate

The study protocol was approved by Ethical Review Committee (ERC) of Aga Khan University (AKU) to legitimize the conduct of study (Reference # 2022-6622-21217) and author will follow the precepts of the Declaration of Helsinki. A written informed consent will be obtained from stud participants. Participants will be provided clear and concise detail about study purpose, risks and benefits for participation.

Consent for publication: Not applicable

Availability of data and materials: The datasets that will be collected and/or analyzed during the current study will be available from the corresponding author on reasonable request.

Competing interests: The authors declare no conflict of interest.

Funding: Not applicable

Authors' contributions: AA has proposed the idea, design and operational framework of this study and conducted the literature search. AA is the corresponding author and also prepared the manuscript. Remaining authors (RR, RN, PP & SS) has provided technical support towards methodology, framework, review of data collection tools, analysis of findings and review of manuscript. PP also supported in editing the manuscript. All authors have approved the final version of manuscript.

Acknowledgements: I would like to acknowledge Mr. Aien Shah- Head of Programmes (AKES, P) & Head teacher Mr. Sharif Baig (AKESP) for ensuring full support and facilitation for smooth conduct of this study. AKU HDP team for sharing the available training manuals and materials that has supported me to prepared a Health & Nutrition promoting training manual. My wife Mehak Samnani for standing beside me and devoting their time and efforts to help me accomplished this task.

Authors' information: Amir Ali Samnani is PhD fellow- Population & Public Health from The Aga Khan University, Pakistan (email: [email protected])

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Table 1: Thematic analysis of Qualitative findings

Categories	Sub- Categories	Codes
Theme 1; Challenges in the health and nutrition for preschool-age children [59 responses]
Health and nutrition issues among pre-school children aged 24-59 months [24 responses]	Identifying health issues [12 responses]	frequent illness [2], vision issues [1] general weakness [4] vomiting [1], diarrhea [1], seasonal/viral illnesses [1], low immunity [1], feel sleepy [1]
	Identifying nutrition issues [4 responses]	malnutrition [1], anemia [1], short height for age [2]
	Identifying behavioral and related issues [8 responses]	Increase absenteeism because of illness [1], children coming to school without breakfast [2], attention deficit [1], poor hygiene issues [1], increase junk consumption [2] less preference for home-made food [1]
Activities, Measures and mechanism are in placed (or in practice) in school for optimal pre-school children’s health and nutrition status [20 responses]	Promoting physical activity [5 responses]	sports [1], yoga [1], exercise [2], meditation [1]
	Applying health and hygiene measures [10 responses]	Invoke junk food restrictions [3], apply COVID measures (temp check, hand sanitizer) [1], conduct annual/ad-hoc health assessment [3], promote hygiene practices [2], encourage home-made foods [1]
	Employing check and balance mechanism [5 responses]	check and balance over lunch box [3]and hand washing before and after having lunch [2]
Knowledge of parents/caregivers regarding healthy diet and nutrition status for pre-school children [15 responses]	Parents/caregivers have minimal knowledge [4 responses]	parents are well aware [2], parents have superficial/ insufficient knowledge (about healthy diet [1], nutrition status of child) [2]
	Parents/caregivers lack knowledge [3 responses]	parents are unwitting [1], lack knowledge/ awareness [2]
	Other related aspects [8 responses]	compliance issue [1], incapability to manage or adopt good practices [1],parents don’t have time to look after their child/ren [2], need to sensitize parents [2] (on child development, healthy upbringing, milestone tracking), parenting issues [2]
Theme 2: Clarity in roles and responsibilities for school based nutrition intervention [102 responses]
Roles and responsibilities as implementors of nutrition initiatives [48 responses]	Parents as stakeholders [25] responses]	overall care of child [3], nurturing of child [2], taking care of hygiene [2], healthy lunch/ diet (home-based)[2], child development [1], quality parenting [3], adopting messages and guidance provided by school [1], nutritional care [2] and safe drinking water [1], ensure quality sleep of child [1], monitor child routine [1], take interest in school activities [1] restrict junk food [1], discourage giving lavish food [1], develop a taste preference for child [1], meal modification to it more palatable [1], parental attention towards child [1]
	Teachers and school committee as stakeholders [19 responses]	remain vigilant [1], provide proper menu for lunch box [1], encourage parents to adopt schools’ initiatives [1], communication with parents [2], bridge between parents and school [3], awareness raising [2], sharing circular to keep parents informed [1], adopting this initiative [2], contributing towards school nutrition policy [1], guide the child [1], work on sustainability of this initiative [1], monitoring compliance [3]
	Role of Children as stakeholders [2 responses]	Direct beneficiaries [1], main recipient [1]
	Others (think tanks and policymakers) [2 responses]	work to sustain such initiatives [1], work on nutrition policy, and make this happen [1]
Role of school/ management in improving the nutrition status of children [23 responses]	Engaging with parents [3 responses]	awareness raising session with parents; include hygiene [1], benefits of home made lunch [1], health session [1], motivate parents [1]
	Employing check and balance mechanism [2 responses]	monitoring [1] and compliance [1] for lunch box and proper hygiene
	Promoting enabling environment for health and nutrition [18 responses]	physical activity [4] (exercise [1], yoga [1], sports [1], events [1]) handwashing [1], discouraging/restrict junk food [2], school-based regular health checkups/ nutrition screening [2], special days celebration [2], identify medical issues/ conditions [1], seek expert opinion from AKU, AKHES,P) [1], setting up referral mechanism [1], encourage home-made lunches [2], healthy food sharing [1], nutrition policy for school [2] develop structured food list [1] (emphasis on ’to do’ rather than ‘not to do’)
Measures to ensure an enabling environment for improved nutrition [31 responses]	Improving engagement with parents [16 responses]	awareness session with parents [4]- (on hygiene, healthy lunch, parenting, child care ); counseling of parents [2] - (for healthy food alternatives, practical alternatives to parents); engaging parents to discuss health needs of child [1]; improve communication gap regarding child health condition between teachers and parents through circular and brochures [1], awareness raising campaign [1], display awareness banners [1]), creating Whatsapp group [3], putting health and nutrition as separate agenda in parent-teacher meeting [1], continuous feedback on child progress [1], appreciation for parents as an incentive [1].
	Check and balance [3 responses]	Introducing a monitoring system [1], controlling junk food consumption [1], establishing task-specific committees [1]
	Translating ideas and innovations into action (implementation measures) [12 responses]	routine planner activities [1], prepare a list of healthy lunch box recipes [2] celebrating special days and weeks [3], school improvement plan (health and nutrition) [1], nutrition theme room/corner [2], learn with fun to introduce health eating [1], school nutrition assessment [2]
Theme 3: Advancing school-based nutrition activities and interventions [42 responses]
Additional measures to promote health and nutrition [14 responses]	Sustain ongoing efforts in practice [09 responses]	special days celebration [3], hygiene awareness [1], health inspection by the School Management committee[2], promoting Physical activities [1], & inspection of lunch box (healthy & homemade) [2]
	Additional measures for consideration [10 responses]	Activate certain task-specific committees [1], awareness on parenting [1] parental education and awareness program using a structured manual [2] developing the nutrition policy [3] translating policy into action [1] vitalization of school health program (including nutrition assessment) [2]
Supporting parents to improved health and nutrition status of children through curriculum [6 responses]	Existing curriculum as facilitator [2 responses]	school curriculum as facilitators [1], school attempt to follow activities through curriculum that respond to nutrition and health [1]
	Existing curriculum as barrier [4 responses]	lots of flows in curriculum [1], curriculum not supporting nutrition [1] curriculum lacking health interaction [1], few activities are linked but not directly related to curriculum [1]
Prioritizing interventions for future consideration [22 responses]	Prioritizing intervention at system level (AKES,P) [6 responses]	need for school nutrition policy for planning and guidance [1], make parents and children bound for screening [1], childhood vaccinations for admission eligibility and in checklist [1], routine school nutrition assessment [2], support adoption of NFSI through this project [1]
	Prioritizing intervention at school level (campus) [6 responses]	linking our examples with healthy food items [1], food item distribution [1], control on junk food consumption [1], food days celebration [1], exposure visit to markets [1], diet friendly educational poem and screening videos [1]
	Prioritizing interventions related to parental engagement [10 responses]	awareness raising for parents [3], awareness on parenting [2], focusing on parental engagement [2], school-based competition [1], improve compliance measures [1], needs-based counseling and feedback to parents [1]
Theme 4: Recognizing resources requirement [25 responses]
Capacity building of the school committee [9 responses]	Capacity building/ orientation [9 responses]	capacity building/ orientation for School committee [7] (on growth monitoring [3], child development [1], nutrition [2], parenting [1]) trained HR [1] to support the establishment of nutrition theme class [1]
Funding requirements [8 responses]	Funds/finances [8 responses]	funds are required [8] for: activities [1], refreshments or food distribution [1] human resource (nurse, doctor, food technologist) [1], communication materials [1] requires school policy embedding funding for school nutrition programming: [1] need to incorporate in annual activity calendar for sustained funds [1], funds for setting nutrition corner/theme class [2]
Others [8 responses]	Others [8 responses]	experts support from outside [2], technical support for setting nutrition corner [2], trained professional volunteer [1], additional HR (nurse) [2], IEC material [1]
Theme 5: Opportunities and challenges for the way forward in school-based nutrition [38 responses]
Identifying the Opportunities [11 responses]	Opportunities [11 responses]	Need is there [1], facilities and resources available for implementation [3], supportive leadership [2], opportunity to have a healthy child [1], well informed parents [1], pro-nutrition school environment [1], school platform available [1], some good practices already exist so just need to build on that [1]
Identifying the Challenges/ gaps [12 responses]	Demand side (parents/caregivers) [4 responses]	parental engagement and participation (response) [3], acceptance level of parents differ [1]
	Supply side (school/AKES,P) [5 responses]	Teacher engagement/time [2] until it become part of policy, don't have nutrition policy [1], capacity gap in teachers and management to deliver nutrition initiatives [1] setting mechanism for routine assessment [1]
	External factors (COVID/Lockdown) [3 responses]	unexpected school closure due to COVID [2], time shortage due to frequent off/lockdown, and frequent vaccine campaigns by government [1]
Making the Recommendations [15 responses]	System/ policy level (AKES,P) [9 responses]	established nutrition assessment mechanism [1], include this initiative in annual school planner and budgeting [2], need for comprehensive school nutrition policy [2] , setting up nutrition corner/ theme class [2] include nutrition assessment for ECD class admission checklist [1], referral system/linkage need to be developed [1],
Making the Recommendations [15 responses]	School/implementation level [6 responses]	orientation of School Committee on Nutrition-friendly school initiative interventions for implementation [1], orientation of parents [3] (on positive parenting [2], nutrition [1]) training of teachers on nutrition assessment [1], Nutrition manual/package as a reference document and guide [1]

Table 2a: Summary findings from Anthropometric assessments

Indicators	Stunted HFA Z score <-2SD		Underweight WFA Z score <-2SD		Overweight/Obesity WFA Z score >+2SD		Wasting WFH Z score <-2SD
	Baseline	end line	Baseline	end line	baseline	end line	baseline	end line
Total malnourished identified	16	16	17	17	5	5	2	1
Child (< 5 years of age)	4	4	1	1	3	3	0	0
child (> 5 years of age)	12	12	16	16	2	2	2	1
# of boys	7	7	7	7	4	4	2	1
# of girls	9	9	10	10	1	1	0	0
Moderate (Z-score <-2SD and > -3SD) or (Z-score >+2SD and <+3SD)	14	14	17	17	3	3	2	2
Severe (z-score <-3SD)	2	2	2	2	2	2	0	0

Table 2b: Summary findings from quantitative data analysis

Indicators	Mean value/score	Mean difference	P value (95% CI)
Knowledge assessment scores (in points) of parents
pretest	12.61/25	7.167	p value <0.001 (95% CI: 6.185, 8.149)
post test	19.77/25
Anthropometric measurements
MUAC (in cms) for Children 23-59m		0.27 cm	p value <0.001 (95% CI: 0.23, 0.31)
Baseline	15.6
End line	15.9
Weight (in Kgs) of preschool children		0.26 Kg	p value <0.001 (95% CI: 0.19, 0.34)
Baseline	17.14
Endline	17.4
Height (cm) of preschool children		0.6 cm	p value <0.001 (95% CI: 0.53, 0.68)
Baseline	106.94
Endline	107.54

Table 3: Comparative assessment of preschool readiness based on activities outlined under NFSI checklist

		Baseline			End line			Comments
Code	Essential Criteria	Yes	No	N/A	Yes	No	N/A	Comments
1	Having a written nutrition-friendly schools policy
1.1	Development of a written nutrition-friendly schools policy that addresses all five points described in this framework, and includes elements described in 1.2 to 1.5		X		X			A draft policy developed and submitted to Head of Programs and also presented with AKDN sister organization for review and officiation
1.2	Rationale		X		X
1.3	Objectives: with timelines and clear milestones		X		X
1.4	Action plan: Outline of the whole-school approach contributing to healthy living and lifestyles to include description of processes, organizational structure, roles and responsibilities, principles of rights/ equity/ non-discrimination and strong commitment by all concerned stakeholders, including families and communities		X		X			Action plan will be developed once policy will be endorsed and embedded within annual school calendar planning
1.5	Monitoring and evaluation plan for the nutrition-friendly schools policy.		X		X			embedded in policy document
2	Enhancing awareness and capacity building of the school community
2.1	Dissemination of the nutrition-friendly schools policy			X			X	Endorsement, dissemination and adoption will be as per AKESP policy
2.2	Activities for families and community, community involvement and outreach in the area of nutrition and health related issues.		X		X			Activities proposed to be aligned with action plan that mainly includes awareness session for parents on thematic areas outline in Health & Nutrition promoting behavior, periodic health assessment of children and creating referral linkages
2.3	School staff training in nutrition and health-related issues.		X		X
3	Developing a nutrition and health-promoting school curriculum
3.1	Culturally appropriate and effective nutrition education.		X		X
3.2	Age, sex and culturally appropriate physical education curriculum.	X			X
3.3	Healthy living and life-skills education curriculum	X			X
3.4	Regular monitoring of school curriculum relevant to NFSI, and evaluation of impact of how well the education meets the objectives.			X			X
4	Creating a supportive school environment
4.1	School meals, food vendors and snack bars (if present) promote healthy eating.			X			X
4.2	Positive messaging towards nutrition and active living. .		X		X			Day wise rolling out of 22 key family care practices (parenting package) in Month of April, 2022 Rolled out weekly Health Diet and Health Eating messages on account of National Nutrition Month (in March, 2022). Copies of essential material (NNS-2018, Dietary needs of children with 0-8 years and parenting package has been provided to school and place over Nutrition Theme classroom to continue roll out positive messages.
4.3	Absence of marketing of foods and beverages at school	X			X
4.4	Access to an adequate eating place if the school provides food and/or beverages to the children	X			X
4.5	Adequate school cooking facilities			X			X
4.6	Access to safe drinking water.	X			X
4.7	Promotion of safe hygiene and sanitary behavior.	X			X			Safe hygiene and sanitary behaviours are already in practiced however through NFSI these areas were further reinforced through sessions with parents and school community.
4.8	Availability of clean and separate toilets, for boys and girls.	X			X
4.9	Opportunity for all age groups to access space and school sporting facilities for physical activity within and outside of the curriculum.	X			X
4.10	Affirmative action against bullying, stigmatization and discrimination.	X			X
4.11	School staff as role-models in encouraging healthy eating and healthy lifestyle.	X			X
5	Providing supportive school nutrition and health services
5.1	Regular monitoring of children’s growth development. Comment:.		X		X			Incorporated in policy document. Furthermore, the school community has been oriented on growth monitoring of child (Height, Weight & MUAC) and AKHS,P health staff is also engaged as volunteers to further support the periodic monitoring (semi-annually). The required supplies (MUAC tapes, weight machine and height tape) were provided to each campuses
5.2	Effective feedback system for parents and children on findings of the regular monitoring.		X		X			Incorporated in policy document, moreover, referral contacts with AKHS,P has been established and AKHS,P staff nurse were also involved in anthropometric assessment.
5.3	Supportive school health service, including a referral system.		X		X			Linkages with Aga Khan Health Service, Pakistan (AKHS,P) health facilities have been developed and in addition to school community, AKSH,P staff were engaged as volunteers to support assessment component. Currently no government program is ongoing in intervention district therefore focal point contact details from Karachi and Hyderabad district has been provided to school for referral point (for essential nutrition commodities. AKHS,P facility will be serve as referral point to ensure continuum of care.
Total Score		10			22

No competing interests reported.

SupplementalfileAnnexures.docx

Assessment of Preschool Preparedness Intervention Package on Adoption of Nutrition Friendly School Initiative in Rural Sindh, Pakistan: An Exploratory Sequential Mixed Method Design

Status:

Version 1

Abstract

Figures

Introduction

Methods

Results

3.2 Quantitative findings:

3.2.1 Anthropometric assessment

3.2.2 Pre and post-assessment of knowledge among parents of preschool children

3.4.3 Assessment of pre-school preparedness for NFSI

Discussion

Conclusion And Implications For Translation

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1