IMNEP - Health and the Environment Journal - USM

Wan Dali et al. 2017 Health and the Environment Journal, 2017, Vol 8 No 1

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Development and Evaluation of Interactive Multimedia-Based Nutrition Education Package (IMNEP) to Promote Healthy Diet for Overweight and Obese Children Wan Putri Elena Wan Dali, Hamid Jan Jan Mohamed, Hafzan Yusoff Nutrition Programme, School of Health Sciences, Universiti Sains Malaysia, Kelantan, Malaysia. Corresponding author: [email protected] ________________________________________________________________________________________

ABSTRACT: The integration of interactive multimedia has been widely used especially in

medical and education fields, allowing the learning process to become easier and more effective than the traditional approach. The present study describes some of the theoretical backgrounds, development, and validation of Interactive Multimedia-based Nutrition Education Package (IMNEP). The IMNEP was developed and delivered through education video, healthy food flash game, and PC Dance Mat. The feasibility, acceptability, and applicability of IMNEP were then evaluated, involving school children (n=50), researchers (n=10), and parents (n=8) by distributing the evaluation questionnaire of IMNEP (EQ-IMNEP). The majority of the respondents gave positive responses and felt that IMNEP was interesting and engaging with regards to graphics, contents, animations, and its usage as a new medium in teaching nutrition for children and parents. Most of the students (96%) had some prior experiences in playing computer or mobile games and strongly felt that they would repeatedly play this healthy food flash game. These initial findings indicate early evidence that IMNEP was feasible, acceptable, and applicable with some modifications for the purpose of controlling obesity in the intervention phase later.

Keywords: obesity, school children, nutrition education, interactive multimedia-based

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Introduction

A number of studies have indicated significant evidences of the association between comorbidities with obesity during childhood including hypertension, coronary heart disease, insulin resistance, diabetes, lipid abnormalities, and sleep-disordered breathing (Daniels et al., 2005; Din-Dzietham et al., 2007; Uli et al., 2008). International recommendations suggest that the core elements of any initiatives taken to address paediatric obesity should involve family members’ intervention in the form of appealing attitude, behaviour modification, and the promotion of physical activities (Sacher et al., 2010; Spear et al., 2007).

As suggested in previous studies (Kim and Hyun 2006; Matheseon and Achterberg 2001), computer-assisted instruction or education could be an effective way for changing the nutrition knowledge and the behaviour among children. Application of educational games as a teaching strategy can be an effective method to create active learning environments by reinforcing knowledge as well as motivating learners in a fun and exciting environment (Strickland & Kaylor, 2016). Indeed, there were a few studies abroad (Baranowski et al., 2011; Maddison et al., 2011; Trost et al., 2014) which evaluating the effects of nutrition education through active video games and they reported significant increases in daily physical activity and reduction in body weight. The Nutrition Division of the Ministry of Health Malaysia has taken many initiatives to encourage the population of Malaysia to eat and live better. Following the technology trends, the Nutrition Division has launched the MyNutriApps application for mobile to disseminate knowledge of healthy eating and living to Malaysians. In September 2016, the Nutrition Division had recently launched another app called MyNutriDiari. MyNutriDiari has more advanced functions. These include a complete nutrition resource center in an app in mobile consisting of literatures, videos, guidelines, tutorials and even healthy cooking recipes, a built-in calculator to calculate Body Mass Index (BMI) and a built-in estimator that will estimate your daily calorie intake needs based on individual’s age, gender and program (e.g. if you want to lose a kg a week). This app is very useful especially to health enthusiast and those who are in the healthcare world. However, not everyone has smartphone to download this free application especially those from low income families.

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In Malaysia, various programmes and initiatives have been implemented among primary school children to help them improve their knowledge on nutrition, promote positive attitude towards good health and nutrition, as well as to practice a healthy lifestyle (Ministry of Education, 1998; Sahari, 1992). This includes School Health Education Programme, School Supplementary Feeding Programme, School Milk Programme, and Physical and Health Education Syllabus. However, the effectiveness of these implementations is still doubtful as the rate of obesity, according to statistics, keep increasing. For example, based on the studies conducted by Mohd Ismail et al. (2009) and Anuar Zaini et al. (2005), the obesity and overweight prevalence was ranged from 18.4% to 22.6% among school children. A study done in Kelantan reported 13.1% of overweight and obese cases among Malay children (Manan et al., 2012) while another study done among Chinese children recorded way higher prevalence of overweight and obesity at 24.8% (Soo et al., 2011). These data demonstrate a worrying trend of obesity in this country.

Validation and reliability testing of all intervention tools prior to delivery to the target population is a compulsory procedure in any intervention study to ensure that it is modifiable and can be used as an example of good practice (Joshi et al., 2001; Perkins, 2000). Therefore, the purposes of this study are; (1) to describe the content knowledge and summarise its development process, (2) to structure the Interactive Multimedia-based Nutrition Education Package (IMNEP), and (3) to test whether this IMNEP is feasible, acceptable, and practical as an effective tool for nutrition education and weight management intervention. Researchers hypothesised that IMNEP would be positively accepted among our respondents for its applicable nature besides being feasible for the obese and overweight children during the next intervention phase.

Material and Methods

Research Design and Sample Selection

This investigation was based on a cross-sectional design which employed convenience sampling method. The respondents consisted of university researchers from Universiti Sains Malaysia, parents and primary school children at Kubang Kerian 3 Primary School from seven different classes who fulfilled the following criteria; (1) standard five aged 11 years old and (2) generally healthy without any chronic diseases. Scott (2008) argued that children are able to complete 26


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questionnaires given; however, there is a certain age requirement for children to participate in a research with high level of trustworthiness and ability to complete standardised survey. This study was carried out in two phases. The first phase was the development of IMNEP and the second phase was the evaluation of its feasibility, acceptability, and applicability of IMNEP. Data collection was conducted from September 2015 until October 2015.

Phase I: Development of the IMNEP

This phase involved the discussions of IMNEP among developer and researchers who were highly experienced in nutrition and dietetics. The development and the contents of IMNEP were adapted from the Malaysian Dietary Guideline (MDG) for Children and Adolescents 2013 and other sources including myHealth (2008), NutriWeb portal (2014), World Health Organization (2000), Centres for Disease Control and Prevention (2015), and National Institute for Health and Care Excellence (2014). The development of multimedia (CD-ROM) for animation video was designed by using PowToon Video Maker and recorded with Screencast-o-Matic software and it was then converted into MP4 files. The education game was developed using Adobe Flash Program and ran on Windows, Mac OS X, and Linux operating systems. This multimedia-based intervention constitutes of multiple interactive elements including audio, text, simulation, and graphics. The IMNEP developed in this study was applicable for desktop application (Windows) only and was not applicable for use on smartphones and tablets.

Figure 1 illustrates the development process of IMNEP. A number of major modifications were done in Stage 1. The steps involved scripting and evaluation of information and terms used, sequences, characters, backgrounds, as well as sound and music. Minor modification based on re-evaluation was done on scripting and information and it took place in Stage 2 and Stage 3. Abbreviations or symbols were avoided in both video and game to prevent the misinterpretation of information.

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Identification of the requirements of an appropriate of IMNEP

Development of IMNEP framework

First version of IMNEP

Second version of IMNEP

Third version of IMNEP

Evaluation 1

Evaluation 2

Evaluation 3

Improvement 1

Improvement 2

Improvement 3

Figure 1: Development process of IMNEP

Healthy Food Flash Game Module

Education game is a flash game format opened to all users without any specific requirement on sex, age, education level, or experience. However, for the study purpose, this healthy food flash game is targeted for children aged 11 who are overweight and obese. There are six user interface screen namely start screen, body mass index (BMI) screen, a list of food screen, food table screen, quizzes screen, and correct answer interface. This healthy food flash game teaches players about choosing healthy food, allowing them to fill in a table of food consumption, and identify the total amount of calories of food consumption. The players would also insert their weight and height to obtain their BMI. Finally, the players must answer the quizzes that tested their knowledge about healthy food. The list of foods (more than 60 Malaysian traditional food and beverages) with total calories comprising carbohydrates, protein, and fat were yielded from previous guidelines (Suzana et al., 2009; Tee et al., 1997). The video game developed consists of four main activities. The details of each activity are indicated as follows in Figure 2 and Figure 3:

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i)

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Profile set up and BMI calculation -

Players enter their weight and height.

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The formula will calculate the BMI for the player.

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If the BMI is not normal, an awareness pop-up will appear and the avatar will also change.

ii)

Education on food content -

Players can hover on a food icon/art.

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A dialog box with all information about the hovered food will appear.

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Players can read the total values contained in a food.

iii)

Calculation of total calories based on daily consumption -

Players can select the dishes from the table of food list.

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The table will be divided into three main categories; breakfast, lunch, and dinner.

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Player fills in the table according to the categories.

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The game will calculate the total calories consumed in a day.

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If the total calories are beyond certain limit, an awareness pop-up will appear.

iv)

Quizzes section -

Players can answer quizzes regarding healthy eating.

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There are total 60 quizzes which are divided into six playing sessions (10 each) that the players need to answer.

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Each correct answer worth 1 or 2 points while 0 points for the wrong answer.

Education Video Modules (Figure 4)

The information in the video was divided into three separate videos for parents and children with a maximum of five minutes per video. The topics included in the parents’ video are as follows; (1) introduction of obesity and (2) healthy guidelines for overweight and obese children part 1 and part 2. The information available for children’s education video are as follows; (1) balanced food and healthy eating and (2) obesity and daily physical activities as stated in Table 1. The sub-topics and expected outcomes are also presented in Table 1.

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Figure 2: Healthy food flash game flow

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Figure 3: Healthy food flash game

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(a) parents

(b) students

Figure 4: Educational video (a) parents and (b) students

Table 1: Components of the education video for parents and students Education video Parents Video 1 Duration: 5 to 10 minutes per video

Topics

Contents

Expected outcomes

Introduction of obesity

- Definition of obesity

- Parent’s understanding of healthy home environment will improve.

- Statistics of obesity in Malaysia - Risk of obesity - Causes of obesity - Importance of balanced food - Tips to solve the obesity problem - Importance of breakfast

Video 2

Healthy eating guidelines for

- How to prepare healthy eating to

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overweight and obese children Part 1

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their children - How to encaurage their children to choose healthy eating - Introduce the latest of food pyramid and serving size - Do’s and dont’s in preparation of food

Video 3

Healthy eating guidelines for overweight and obese children Part 2

- How to serve the healthy food at home - Do’s and dont’s in preparation of food

Education video Students Video 1 Duration: 5 to 10 minutes per video

Topics

Contents

Expected outcomes

Balanced food and healthy eating for overweight and obese children

- Importance of balanced food

- Participants can make healthy food, beverage and exercise choices

- Food pyramid - Different of food and nutrient - Types of nutrient - Types of food in each food groups and serving sizes - Importance of breakfast

Video 2

Obesity

- Definition of obesity - Statistics of obesity in Malaysia - Risk of obesity - Causes of obesity - Body mass index (BMI) calculation - Importance of balanced food - Tips to solve the obesity problem

Video 3

Physically active daily

- Definition of exercise - Why must do the exercise? - Types of exercise and advantages - Pyramid of physical activity - Types of sedentary activities

- Children’s understanding of nutrition will improve - Participants will show health status improvement - Will increase their self-confidence, selfesteem and selfmanagement of their weight - Recognizing foods rich in proteins, carbohydrates, fats and calcium - Knowing the body’s requirement of proteins, carbohydrates, fats and calcium

- How to avoid sedentary activities

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PC Dance Mat

Besides that, a short video from YouTube source showing exergame called PC Dance Mat was also presented to the respondents. This commercially available exergame would be applied as physical activity component during the intervention phase later. This mat usually is at an affordable price, MYR15 per mat, and could be connected to the PlayStation 2 or computer. The PC Dance Mat is a fitness video game involving body movement by applying the mat slide on the floor, making it a challenge to keep in mind the position of the arrows to match the musical cues on the video screen. In the next intervention study, the PlayStation 2 will be provided and will be played in the schools for the study purpose.

Phase II: Feasibility, Acceptability, and Applicability of the IMNEP

This phase is aimed at evaluating the feasibility, acceptability, and applicability of the IMNEP which was developed during Phase I – content validity was evaluated by researchers (n=10) and face validity was evaluated by parents (n=8) and students (n=50). Each participated students was provided with a laptop and was required to watch all the videos and play the healthy food flash game. The parents needed to watch the educational videos only. Every video clip lasted for about 10 minutes. However, the researchers from nutrition and dietetics program needed to watch and play all the educational videos for parents and students and healthy food flash game. Then, their understanding of the contents, presentations, and illustrations showed in the educational video and video games were measured by distributing the evaluation questionnaire of the IMNEP (EQIMNEP).

Feasibility assessment was conducted to estimate the percentage of having computer or laptop among students and parents in their house. The acceptability of the IMNEP was tested by collecting data on the information and terms used, fonts, Malay language, sequences, characters, backgrounds, voices and music for all educational videos and healthy food flash game. Examples of questions as follow; “How would you judge the comprehension of the educational videos?”; “How would you judge the quality of the sound effect included in the educational game?”; “In your opinion, is the information contained in the educational enough?”. On the other hand, an 34


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example of question asked for applicability of the IMNEP was “Do you think this video is helpful for you to gain new knowledge on nutrition?”

Subsequently, the intervention was modified based on the inputs, comments, and feedbacks obtained from the respondents recruited. The overview of the study process, including its development, acceptability, and applicability of the IMNEP is summarised in Figure 5. Sources from: MDG for children & adolescents MyHealth, nutriWEB, MASO, NICE, WHO and CDC

Phase I: Development of the IMNEP

Education videos

Parents:  3 videos  5 minutes each

Instruments Information sheet EQ-IMNEP

Healthy Food Flash Game

Students:  3 videos  5 minutes each

Students:  1 game  30 minutes each

Phase II: Acceptability and applicability of the IMNEP

Face validity: parents and students

Content validity: researchers

Modification of the IMNEP

Figure 5: Overview the study process

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Instruments

Evaluation Questionnaire of the IMNEP (EQ-IMNEP)

Based on previous literatures, EQ-IMNEP was developed to evaluate the feasibility, applicability, and practicality of the IMNEP (Clayton 2010; Karupaiah et al., 2001; Ruzita and Rasyedah 2001; Siddique 2010). The EQ-IMNEP was filled out by students, parents, and researchers, consisting of 18 (evaluating all educational videos, educational game and PC Dance Mat), 16 (evaluating on educational videos only), and 48 (evaluating on all educational videos both students and parents, educational game and PC Dance Mat) questions, respectively (multiple choice answers and different responses from video evaluation, game, and PC Dance Mat separately). It evaluated the quality and clarity of wording, contents, audio, graphics, and colours of the CD-ROM and games. In general, feasibility assessment contained one question, applicability consisted of seven questions, and practicality consisted of three questions. Other than that, it also gathered suggestions and critical comments on the implementation of IMNEP.

Ethical Approval and Data Collection Procedure

The ethical approval was endorsed by USM Human Research Ethics Committee (USM/JEPeM/14110478), Ministry of Education (MoE) via Educational Research Application System, and Kelantan Education Department. Permission to conduct the study was also obtained from the Headmasters or Representatives of the participated schools once a brief meeting regarding the whole study process had been conducted. All participants were informed verbally and via the Information Sheet about the purpose of this study. They were then requested to complete the EQ-IMNEP.

Statistical Analysis

Results of the questionnaires were analysed using the licensed IBM Statistical Package for Social Sciences Version 20.0 for Windows (SPSS Inc., Chicago IL, USA) through the utilisation of descriptive statistics for all responses to check the feasibility, acceptability, and practicality. Findings were presented as frequencies and percentages. 36


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Results

There were a total of 68 respondents; 73.6% (n=50) were primary school children, 14.7% (n=10) were researchers, and 11.7% (n=8) were parents. Almost all of the respondents provided positive responses and feedbacks. They felt that IMNEP was interesting and engaging in terms of various topics namely graphics, contents, and animations.

Feasibility

From a total number of 50 students, 96.0% of them were found to possess either laptop or computer at home with internet access. They had prior experiences in playing computer or mobile games. Regarding the educational video game assessment, they liked playing this kind of newly developed healthy food flash game. They also informed us that they would love to play the game frequently (Table 2).

Table 2: Evaluation of education game for students Item Frequency of playing games Everyday Sometimes Never Comprehension Very good Good Poor Very poor Quality of the text Very good Good Poor Very poor Quality of the sound effects Very good Good Poor Very poor Quality of the colors Very good Good

Male (%)

Students Female (%)

All (%)

Researchers (%)

11 (47.8) 11 (47.8) 1 (4.3)

11 (40.7) 15 (55.5) 1 (3.7)

22 (44) 26 (52) 2 (4)

-

19 (82.6) 4 (17.4) -

22 (81.5) 4 (14.8) 1 (3.7) -

41 (82.0) 8 (16.0) 1 (2.0) -

9 (90.0) 1 (10.0) -

13 (56.5) 10 (43.5) -

21 (77.8) 6 (22.2) -

34 (68.0) 16 (32.0) -

3 (30.0) 6 (60.0) 1 (10.0) -

19 (82.6) 4 (17.4) -

18 (66.7) 8 (29.6) 1 (3.7) -

37 (74.0) 12 (24.0) 1 (2.0) -

4 (40.0) 6 (60.0) -

16 (69.6) 7 (30.4)

18 (66.7) 9 (33.3)

34 (68.0) 16 (32.0)

3 (30.0) 7 (70.0) 37


Item Poor Very poor Perceived usage Once Repeated Not use Enough information Yes No Not sure Provide new knowledge Yes No Not sure

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Male (%) -

Students Female (%) -

All (%) -

Researchers (%) -

2 (8.7) 21 (91.3) -

4 (14.8) 23 (85.3) -

6 (12.0) 44 (88.0) -

-

18 (78.3) 1 (4.3) 4 (17.4)

22 (81.5) 0 5 (18.5)

40 (80.0) 1 (2.0) 9 (18.0)

22 (95.7) 1 (4.3) 0

25 (92.6) 0 2 (7.4)

47 (94.0) 1 (2.0) 2 (4.0)

Acceptability Most of the school children ranked the education videos shown from ‘good’ to ‘very good’ with regards to the comprehension (98.0%), text (98.0%), sound (96.0%), voice (94.0%), and colours (94.0%). However, sixteen (16) of them requested for more graphics and figures to be included (32.0%), nine (9) preferred short sentences (18.0%), and the other six (6) were hoping for developer to reduce the use of scientific sentences (12.0%). Only a small number of them expressed their lack of understanding regarding the terms ‘sedentary’ (2.0%) and ‘obesity’ (8.0%), while most of them felt that this education video provides enough information with new knowledge.

In terms of education video for parents, all eight (8) respondents rated the video as comprehensive (good to very good) along with the text, sound, voice, and colours used, as stated in Table 3. They also received sufficient information in this video and almost all believed this video was helpful for them in reducing their children’s weight. There were some negative feedbacks relating to the sound of the education video – being described as annoying hence modification should be done. Other than that, as displayed in Table 4, other comments include; (1) inappropriate terms, (2) too wordy with long sentences, and (3) the speed of the slides and other contents should be revised and modified. In addition, ten researchers with nutrition background were invited to evaluate the IMNEP in terms of content suitability. 38


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Table 3: Evaluation of education video for students and parents using EQ-IMNEP Item

Education video for students

Comprehension Very good Good Poor Very poor Quality of the text Very good Good Poor Very poor Quality of the sound effects Very good Good Poor Very poor Quality of the voice Very good Good Poor Very poor Quality of the colors Very good Good Poor Very poor Perceived usage Once Repeated Not use

Education video for parents Parents Researchers n (%) n (%)

Healthy food flash game for students Students Researchers n (%) n (%)

Students n (%)

Researchers n (%)

40 (80.0) 9 (18.0) 1 (2.0) -

3 (30.0) 7 (70.0) -

5 (62.5) 3 (37.5) -

2 (20.0) 8 (80.0) -

41 (82.0) 8 (16.0) 1 (2.0) -

9 (90.0) 1 (10.0) -

30 (60.0) 19 (38.0) 1 (2.0)

2 (20.0) 7 (70.0) 1 (10.0) -

4 (50.0) 4 (50.0) -

3 (30.0) 7 (70.0) -

34 (68.0) 16 (32.0) -

3 (30.0) 6 (60.0) 1 (10.0) -

30 (60.0) 18 (36.0) 1 (2.0) 1 (2.0)

2 (20.0) 6 (20.0) 2 (20.0) -

3 (37.5) 5 (62.5) -

7 (70.0) 3 (30.0) -

37 (74.0) 12 (24.0) 1 (2.0) -

4 (40.0) 6 (60.0) -

22 (44.0) 25 (50.0) 2 (4.0) 1 (2.0)

3 (30.0) 4 (40.0) 3 (30.0) -

2 (25.0) 6 (75.0) -

3 (30.0) 3 (30.0) 4 (40.0) -

-

-

37 (74.0) 12 (24.0) 1 (2.0) -

4 (40.0) 6 (60.0) -

5 (62.5) 3 (37.5) -

4 (40.0) 6 (60.0) -

34 (68.0) 16 (32.0) -

3 (30.0) 7 (70.0) -

8 (16.0) 42 (84.0) -

-

8 (100.0) -

-

6 (12.0) 44 (88.0) -

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Table 4: Suggestion for improvement of the IMNEP Item

Students (%)

Researchers (%)

Parents (%)

Provide the healthy menus

-

-

1 (12.5)

Improve the quality of voice

-

-

1 (12.5)

Reduce the speed of slides and voice

-

1 (10.0)

-

Reduce the wording

-

1 (10.0)

-

Inappropriate terms

-

1 (10.0)

-

Video education for parents

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Item

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Students (%)

Researchers (%)

Parents (%)

-

1 (10.0)

-

Improve the quality of voice

-

1 (10.0)

-

Revise the content of food serving size

-

1 (10.0)

-

Incorrect term

-

3 (30.0)

-

5 (10)

-

-

Type of fonts

-

1 (10.0)

-

Need to add the correct answer

-

1 (10.0)

-

Classification of the body mass index need to be revised

-

1 (10.0)

-

Should have button to skip meal

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1 (10.0)

-

Should have button to cancel the food

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1 (10.0)

-

Put more pictures Video education for student

Healthy food flash game Put more tricky questions

Students were also asked about their opinions regarding healthy food flash game. Most of them found it to be very good in terms of quality of the text (68.0%), sound effects (74.0%), colours (68.0%) and 80.0% of them also agreed that the information contained in the educational game was enough (Table 2). However, five (5) among them suggested to put more tricky questions in the healthy food flash game to create more interesting activities (Table 4).

Applicability

IMNEP was also perceived as an advanced and effective medium in teaching the knowledge of nutrition to the overweight and obese school children and parents. The education video was helpful in reducing weight, especially for those under the category of overweight or obese. Surprisingly, 84.0% of them believed that they would continue and repeatedly watch the video, and none of them planned not to use the video. The researchers agreed that the information contained in the IMNEP was enough to be delivered to the target group and assumed IMNEP was helpful to increase their knowledge about healthy eating. Apart from that, a short video of a commercially available PC Dance Mat was shown and the results indicated that this kind of

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activity was attractive to help students reduce their weight. The respondents would like to make this PC Dance Mat as part of their physical activity routine.

Discussion

Generally, the present study focused on design and development of the IMNEP as well as evaluating the feasibility, acceptability, and practicality of the IMNEP among the students, parents and researchers. This study was conducted to provide unique data regarding the suitability of IMNEP in promoting a healthy diet and physical activity hence controlling the obesity problem among school children which now occurring in developing and developed countries. As there are mounting concerns regarding childhood obesity and its associated risk of chronic diseases, examining the intervention programs is crucial and it should begin from their childhood (Dietz 1992; Sharma et al., 2015).

Overall results indicated that all respondents were greatly satisfied with IMNEP. The main reason might be due to the novelty value of the variety tools used in delivering such education through videos and game. This interaction design allows for human learning process to grow, become easier, and more effective compared to traditional reading method. This nonconventional, interactive method is regarded as effective and practical for the current generation (Nazlena et al., 2013). A work by Cunha et al. (2013) demonstrated that by providing schoolbased interventions with combinations of playing games, staging theatre sketches, watching movies and puppet shows, as well as writing and drawing contests would present a positive improvement towards healthy eating habit. However, these methods did not necessarily lead to the reduction in BMI. This is inconsistent with other findings which combine health education, physical activity and parental involvement that revealed a significant reduction in BMI and body fat (Foster et al., 2008; Jiang et al., 2007; Savoye et al., 2007). These results suggest that the combination of delivering nutrition information through video and game, parental involvement, and physical activity enhancement might be an effective approach in reducing BMI especially for overweight and obese children. These components are best compiled as a package instead of individual components.

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In regard to the outcomes on acceptability as illustrated in Table 2 and 3, IMNEP was reported to be highly acceptable with regards to information, contents, graphics, text and sound effect among participants. They agreed that IMNEP has the potential to emerge as an effective education programme with specific target population – overweight and obese children. Comments such as “I like the variety of topics included”, “I like the sentence used”, “I like the graphics, content, and animation added”, “I like the purpose of the IMNEP as a new medium for teaching nutrition education”, and “this IMNEP would be helpful in reducing the children’s weight” were given by the participants, suggesting further supportive evidence of IMNEP’s acceptability.

Next, regarding the feasibility assessment, data from the current study also indicated that IMNEP was highly feasible to all respondents. The percentage of computer and internet ownership at home (96.0%) among the respondents was unsurprisingly high. This finding could be due to the increasing number of computer users in Malaysia from 56.0% in 2013 to 68.7% in 2015 (MCM, 2015). Researchers would also like to use IMNEP as an education tool in future. Nowadays, as typically most children are the active users of various computer applications and the internet, this tool is valuable for them to gain knowledge and at the same time effective for educators to deliver the nutrition education.

The evidence of validity was further supported by the fact of highly acceptable results regarding the appropriateness and proper language, sentences, fonts, and graphics used. The information delivered through IMNEP was adequate and clearly understood. However, five students were unclear with the term ‘obesity’ which had been clearly defined in the video. Besides, they had been learning about ‘obesity’ since Year Three. Her and Lee (2003) found that the major problems of dietary information for children include little interest, difficult content, and poor information. However, by using graphics to explain, including explaining the term ‘obesity’, they now understood better. Graphics usage became the major factor in affecting their understanding level. The graphics used, for example pictures, charts, lists, or graphs had also been proven to increase (1) user’s attention, (2) user’s comprehension, (3) user’s ability to recall what was explained, and (4) user’s adherence to health recommendation (Houts et al., 2006). Therefore, any information being delivered must be accurate, relevant to the target population, and should be based on their backgrounds. 42


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Furthermore, the sentences and font size were also two of the elements that should be improved to increase the attractiveness of IMNEP among children. Researchers found that majority of respondents gave at least ‘good to very good’ for the game and videos in terms of the text used. This could be because the IMNEP’s font size has a minimum of 36-point Akbar which helped users to see clearly, read, and understand the contents. Besides that, there were a few respondents in this study suggested on improving the quality of voice in the education videos to both parents and students. The quality of voice and speech actually assists the speaker to transfer knowledge and also helps students to build up their understanding level (Islam et al., 2015). Thus, the quality of voice in the video would be modified before being applied in the intervention phase later. Other than that, it was also found that the respondents – students and researchers gave positive feedbacks on the use of PC Dance Mat which was connected to PlayStation 2 or computer to increase their level of physical activities. This commercially available product was easier to be applied and considered as interesting game. Players should be following the virtual and musical cues on the video screen to match their movement. This intervention strategy is supported with a previous study that used almost similar product called ‘Just Dance’; indicating that children would be using greater movement and burned more calories during this particular activity (Quinn, 2013).

One of the limitations of this study is that it has a small sample size. Nevertheless, the feasibility and acceptability aspects of IMNEP did receive positive feedbacks. It is crucial to conduct this kind of preliminary study with process evaluation to provide feedbacks and for further refinement of program components prior to efficacy testing. Recruitment of parents was quite challenging and difficult due to less cooperation from them. Nevertheless, this was one of the lessons learned in this pilot study, indicating the need for using more creative or effective parent recruitment strategies.

Conclusion

The present study provides preliminary evidence that IMNEP is highly feasible, practical, and acceptable among children and parents to educate healthy diets with physical activities for the 43


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purpose of controlling obesity issue. However, the effectiveness of IMNEP had not been thoroughly measured due to its early implementation stage. Modifications are still opened and welcome to be made. It is expected that IMNEP would give benefits especially for overweight and obese school children who would become the target respondents in the intervention phase later.

Acknowledgement

We are grateful and greatly acknowledge the contributions made by USM Human Research Ethics Committee, Ministry of Education via Educational Research Application System, and Kelantan Education Department for their approval in all matters throughout the progress of this research. We express gratitude to all principals, teachers, and students from primary schools in Kota Bharu for their participation in this project. The authors would also like to personally thank Assoc. Prof Dr Nazlena Mohamad Ali from Universiti Kebangsaan Malaysia (UKM) for her expert view, advice, and guidance in this pilot project.

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