A questionnaire assessment of nutrition knowledge--validity and reliability issues

Breakfast Consumption and Diet Quality of Teens in Southwestern Ontario

Background

Breakfast skipping has previously been associated with worse diet quality among adolescents; the latter increases the risk of chronic disease. However, many studies do not consider diet quality as a function of calories, which is problematic as skippers tend to consume less energy than consumers. Additionally, due to the lack of one accepted definition of both breakfast skipping and diet quality, it is unclear how differences found may change when using varying definitions.

Objectives

We aimed to compare the Healthy Eating Index-2015 (HEI-2015) scores and nutrient intakes of teen breakfast skippers and consumers in Southwestern Ontario, Canada.

Methods

Cross-sectional, baseline data were used from SmartAPPetite, an ongoing nutrition intervention study. Singular 24-h dietary recalls and sociodemographic data from 512 adolescents aged 13-19 y were used to compare HEI-2015 scores and nutrient intakes via multivariable linear regression.

Results

Previous day breakfast skippers had significantly lower HEI-2015 scores (-4.4; 95% CI: -8.4, -0.4) and significantly lower intakes of calories, saturated fat, and vitamin C, as well as significantly higher intake of sodium and total fat.

Conclusions

Previous day breakfast consumers had significantly higher diet quality scores and better nutrient intakes than breakfast skippers, although, on average, both had poor diet quality. Consequently, it is unlikely that simply advising teens to consume breakfast will result in meaningful change in diet quality, and more effort should be placed on promoting nutritious breakfasts.

Development and validation of a quality assessment tool to assess online nutrition information

Setting

The internet is an important source of health information but is unregulated. Little research has focused on the assessment of digital information related to nutrition.

Aim

To develop and validate a novel online quality assessment tool (OQAT) for quality assessment of online nutrition information.

Method

The OQAT was developed and validated in six distinct stages. After reviewing the literature, a framework and criteria were developed and formalised. Next, the quality assessment criteria were piloted on a subset of data and criteria refined. The established criteria were then validated against a previously validated assessment tool, and reliability was tested. Finally, the validated OQAT was used to assess the quality of articles from a 24-h collection period, 19 April 2021.

Results

The final OQAT consisted of 10 key questions. Twenty-six news articles were assessed independently by two raters. Comparison of scores found moderate internal consistency (α = 0.382). Cohen's Kappa coefficient demonstrated high interrater agreement (k = 0.653, p < 0.001). The OQAT was tested on 291 relevant Uniform Resource Locators (URLs), which were determined to be either poor 3% (n = 9), satisfactory 49% (n = 144), or high-quality 48% (n = 139) articles. There was a statistically significant difference in OQAT scores between blogs, news articles, and press releases, χ2(2) = 23.22, p < 0.001, with a mean rank OQAT score of 138.2 for blogs, 216.6 for news articles, and 188.7 for press releases.

Conclusion

This novel tool provides a reliable and objective method for assessing the quality of nutrition content online. It could potentially be used by researchers to assess the quality of online information in different settings and by organisations to inform readers of the quality of information being accessed.

Adherence to emerging plant-based dietary patterns and its association with cardiovascular disease risk in a nationally representative sample of Canadian adults

BACKGROUND

Little is known about the role of emerging plant-based dietary patterns in cardiovascular disease (CVD) risk at the national population level.

OBJECTIVES

The objectives of this research were to assess the validity and reliability of newly established plant-based dietary indices, and to evaluate their associations with CVD risk among Canadian adults.

METHODS

Data were obtained from repeated 24-h dietary recalls of adult participants in the cross-sectional, nationally representative Canadian Community Health Survey cycle 2004 linked to health administrative databases (n = 12,323) and cycle 2015 (n = 14,026). Plant-based diet quality was assessed with a revised Plant-based Dietary Index (PDI), EAT-Lancet Reference Diet (ERD) score, and the latest Dietary Guidelines for Americans Adherence Index (DGAI) 2020. Weighted multivariate analyses were used for testing associations between diet quality and lifestyle characteristics, and weighted multivariable-adjusted Cox proportional hazards models for associations with CVD risk.

RESULTS

Construct validity was confirmed for the revised PDI and DGAI 2020 (but not the ERD) because participants in the highest (healthiest) quartile, compared to those in the lowest (least healthy), were more likely to be female (mean ± SE: 52.63% ± 1.27% compared with 44.80% ± 1.65% for revised PDI; 59.37% ± 2.01% compared with 40.84% ± 1.71% for DGAI 2020), older (mean ± SE: 50.55 ± 0.39 y compared with 45.56 ± 0.43 y for revised PDI; 51.57 ± 0.39 y compared with 46.35 ± 0.54 y for DGAI 2020), to have postsecondary education (mean ± SE: 32.36% ± 1.55% compared with 21.12% ± 1.31% for revised PDI; 34.17% ± 2.69% compared with 17.87% ± 0.98% for DGAI 2020), and less likely to be daily smokers (mean ± SE: 8.21% ± 1.0% compared with 17.06% ± 1.45% for revised PDI; 7.36% ± 1.71% compared with 21.53% ± 1.58% for DGAI 2020) (P-trend < 0.0001). No significant associations were observed between dietary index scores and CVD risk.

CONCLUSIONS

The revised PDI and DGAI 2020 provided valid and meaningful measures of plant-based eating among Canadians, whereas the validity of the ERD was not directly confirmed. Adherence to the plant-based dietary patterns was not associated with CVD risk. Future large-scale studies are necessary to further evaluate the role of plant-based eating in CVD prevention.

Self-Care Instruments to Measure Nutrition Practices in Children and Parents: Psychometric Analysis

The purposes of this study were to evaluate the psychometric properties of English and Spanish instruments that measure the nutrition behavior and practices of children and their parents. Orem's self-care deficit nursing theory was used in this methodological study. A convenience sample of 333 children and 262 mothers participated from two schools in Washington, D.C. and two schools in Santiago, Chile. Principal component analysis indicated three component per instrument corresponding to Orem's Theory of operations demonstrating construct validity of the instrument. The study findings showed evidence for validity and reliability of the English and Spanish versions and indicated that the instruments appropriately represented Orem's operations. The results have implications for the development of health behavior measurement instruments that are valid, reliable, designed for children, culturally appropriate, and efficient. Measuring the nutrition behavior of children and parents is critical for determining the effectiveness of nutrition intervention programs. Furthermore, instruments are needed so that researchers can compare corresponding child and parent behaviors or compare behaviors across cultures.

Psychometric Validation of a Nutrition Knowledge Questionnaire among Parents of 3-6-Year-Old Asian Indian Children in East Barddhaman District, West Bengal, India

Background:

In India, virtually, no study was aimed to develop a psychometrically valid and reliable questionnaire to assess the nutrition knowledge and practice among parents of children aged between 3 and 6 years.

Objective:

The present study describes an evaluation of validity and reliability measures in a questionnaire designed for the assessment of nutrition knowledge among parents of children participating in a study finding relationship between physical growth and development and nonverbal intelligence quotient development being undertaken in a semi-urban area.

Design:

This was a cross-sectional school-based reliability and validity study.

Setting:

This study was conducted in seven primary schools within the limits of Purba (East) Barddhaman district legislation, West Bengal, India.

Participants:

One hundred and thirty-four parents of children aged 3–6 years were included in the study.

Results:

The final questionnaire consisted of 32 questions that were selected on the basis of content validity. Questions included closed-ended and multiple-choice items which could be answered correctly by 5%–95% of the target population with a difficulty index of 0.33–0.87, discrimination index of 0.12–0.44, and validity index of 0.10–0.86. Internal reliability of each item as measured by Cronbach's α of 0.87 was also significant.

Conclusions:

The test comprises basic psychometric criteria of a valid and reliable 32-item knowledge questionnaire which further forms an instrument for measuring current scenario and interpreting changes associated with intervention work aiming improvement of dietary and nutrition knowledge-practice in the middle-to-low socioeconomic community.

Effectiveness of Healthy Foodie Nutrition Game Application as Reinforcement Intervention to Previous Standard Nutrition Education of School-Aged Children: A Randomized Controlled Trial

Objective

Games promoting nutrition education are helpful tools to improve nutrition knowledge. Healthy Foodie is an interactive web-based nutrition game for Filipino children. This study aimed to determine the effectiveness of Healthy Foodie on the nutrition knowledge of children aged 7 to 10 years old.

Methodology

This study had 2 phases. In Phase 1, we developed and validated the Healthy Foodie nutrition game application and Nutrition Knowledge Questionnaire involving 46 participants. The Nutrition Knowledge Questionnaire was divided into 2 15-item questionnaires: Part 1 pertained to Food Group Knowledge and Part 2 on Food Frequency Knowledge. Phase 2 was the implementation of the game and questionnaire. This was a randomized controlled trial conducted in two elementary schools in Manila, involving 360 participants divided equally into control and experimental groups.

Results

For Phase 1, internal consistency of the questionnaire using the Kuder-Richardson Formula 20 was 0.75 for part 1 and 0.70 for Part 2. In Phase 2, comparing the adjusted posttest mean Food Group Knowledge scores, there was statistically higher score (F=111.84, p=0.0001) in the experimental group (11.57±0.20) compared to the control (8.51±0.20). In the adjusted posttest mean Food Frequency Knowledge scores, there was a statistically higher score (F=56.12, p=0.0001) in the experimental group (10.70±0.15) compared to the control (9.07±0.15).

Conclusion

A nutrition game-based intervention such as Healthy Foodie is effective as a reinforcement intervention to previous standard nutrition education of school-aged children.

Validity and Reliability of a Food Skills Questionnaire

OBJECTIVE

Develop, validate, and assess reliability of a food skills questionnaire.

DESIGN

Phase 1: Questionnaire development categorized questions into domains (Food Selection and Planning, Food Preparation, and Food Safety and Storage). Phase 2: Content validity included expert panel quantitative and qualitative feedback. Phase 3: Face validity involved pilot testing. Phase 4: Reliability assessed test-retest and inter-item reliability.

SETTING

Phase 1: The authors developed a draft questionnaire in London, Ontario, Canada.

PARTICIPANTS

Phase 2: Dietitians, home economists, academics, and chefs completed content validity (n = 17; 57% response rate). Phase 3: A convenience sample of students completed face validity (n = 20; 17% response rate). Phase 4: Randomly selected students completed test-retest reliability (time 1: n = 189, time 2: n = 165; 9% response rate).

MAIN OUTCOME MEASURES

Lawshe content validity ratio, Lawshe content validity index, intraclass correlation coefficients (ICCs), and Cronbach α.

ANALYSIS

Test-retest reliability was evaluated using ICC, and inter-item reliability by Cronbach α coefficient.

RESULTS

In phase 2, Lawshe content validity index was 0.80 (90% expert panel consensus). In phase 3, 85% of respondents identified the main construct. In phase 4, Cronbach α coefficients were .67-.88 for domains and .90 for the questionnaire overall, and ICC scores ranged from 0.67-0.92 for questions, 0.86-0.93 for domains, and 0.92 for the questionnaire overall.

CONCLUSIONS AND IMPLICATIONS

This questionnaire demonstrated strong content validity, face validity, test-retest reliability, and good inter-item reliability. It is appropriate for evaluating food skills in a population with basic to intermediate skills (eg, young adults).

A sequential, exploratory, mixed-methods approach for development and validation of a context-specific knowledge, attitude and practice questionnaire on micronutrients for literate mothers of school-age children

OBJECTIVE

To develop and validate a context-specific comprehensive knowledge, attitude and practice (KAP) questionnaire for literate mothers on factors affecting micronutrient status of 6-10-year-old children.

DESIGN

Sequential exploratory mixed-methods study using focus group discussions (FGD) and psychometric validation.

SETTING

Seven randomly selected villages with &gt;500 households with three to five family members each, in Ghatkesar sub-district, Medchal district, Telangana state, India.ParticipantsLiterate mothers from middle-income households with at least one child (6-10 years) for FGD (n 44), for testing the internal consistency (n 80) and for test-retest reliability (n 30).

RESULTS

The themes for FGD were diet diversity, micronutrients, cooking and eating practices, national programmes and sunlight exposure. Knowledge among caregivers about sources of micronutrients, deficiency symptoms, cooking/eating practices was low, while attitude towards diet diversity and sunlight was good. Non-availability of fruits and vegetables was a barrier to diet diversity. About 72 % of the questions from the item pool were based on FGD. After content validity, 125 items were selected for the questionnaire which, upon psychometric validation, was reduced to an eighty-eight-item questionnaire with difficulty index of 0·10-0·91, discrimination index of 0·09-0·68, Cronbach's α of 0·78 (reliability of knowledge and attitude) and 0·50 (practice). A Bland-Altman plot showed good agreement between test and retest scores.

CONCLUSIONS

The questionnaire developed and validated using a sequential exploratory mixed-methods approach can be used for assessing KAP on micronutrients and factors affecting consumption of diverse diets in rural Indian households.

Towards the measurement of food literacy with respect to healthy eating: the development and validation of the self perceived food literacy scale among an adult sample in the Netherlands

Background

Food literacy refers to the capability to make healthy food choices in different contexts, settings and situations. The aim of this study is to develop and validate the self-perceived food literacy (SPFL) scale, to assess individuals’ level of food literacy, including a knowledge, skills and behavior to plan, manage, select, prepare and eat food healthfully.

Methods

An initial set of 50 items for the SPFL scale were generated based on expert insights and literature. A cross-sectional online survey was conducted among a sample of Dutch adults (n = 755) in order to determine convergent, divergent and criterion validation against psychosocial variables that were expected to correlate with food literacy (self-control, impulsiveness) and against the expected outcome of high food literacy, namely healthy food consumption. Principal Component Analyses (PCA), Pearson correlation tests and linear regression analyses were conducted. The capacity to distinguish of the SPFL scale was determined by comparing SPFL scores of the general population with that of a sample of dieticians (n = 207).

Results

The participants in the general sample had an average age of 44.8 (SD:16.1), the majority were women (90.7%), they had a healthy weight (61.4%) and were highly educated (59.1%). Of the initial 50 items, 29 items remained after PCA and reflected eight domains of food literacy. SPFL was positively correlated with self-control (r = 0.51, p = <.001) and negatively with impulsiveness (r = − 0.31, p = <.01). Participants with higher levels of food literacy reported a significantly higher frequency of fruit consumption (≥5 times/week), vegetable consumption (≥5times/week) and fish consumption (≥1times/week) and consumed larger portions of fruit (≥2pieces/day) and vegetables ≥200 g/day) in comparison with participants who had lower levels of food literacy. Dieticians had slightly higher scores on SPFL than general adults (B = 0.08, SE = 0.03, t = 2.83, 95%-CI = 0.03 to 0.14).

Conclusions

The 29 item SPFL scale is a validated, expert-based and theory-driven tool for measuring self-perceived food literacy with respect to healthy eating among adults. Higher levels of food literacy were associated with more self-control, less impulsiveness and healthier food consumption. Additional research is needed to validate the SPFL scale in different populations (different age groups, socioeconomic groups, male populations) and in different contexts.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0687-z) contains supplementary material, which is available to authorized users.

Relationship between nutrition knowledge and dietary intake among primary school children in Japan: Combined effect of children's and their guardians' knowledge

Background

Improving the dietary habits of children is important to decrease the future burden of noncommunicable diseases. While various food education programs have been implemented worldwide, evaluation of nutrition knowledge is difficult, even at baseline. Further, the relationship between nutrition knowledge and dietary intake has not been clarified in non-western countries.

Methods

After developing nutrition knowledge questionnaires for Japanese primary school children and adults, we examined whether higher nutrition knowledge of children and their guardians was associated with better dietary intake in children. A total of 1210 children in four public primary schools and 319 guardians were included in this cross-sectional study.

Results

Nutrition knowledge questionnaires were developed for children in lower and higher grades and adults. Higher nutrition knowledge of the children was significantly associated with higher vegetable intake (p for trend = 0.024 for boys and <0.0001 for girls in lower grades, <0.0001 for boys and 0.020 for girls in higher grades). Higher nutrition knowledge of the guardians was also associated with higher vegetable intake, except for boys in higher grades. The relationship between guardians' nutrition knowledge and intake of staple foods and fruits in children differed by children's sex.

Conclusions

We developed nutrition knowledge questionnaires for Japanese children and adults and identified a relationship between higher nutrition knowledge and healthier dietary habits. The child's own nutrition knowledge of dietary intake might be as important as that of the guardian for some foods. Sex differences in the effect of nutrition knowledge should receive greater attention in food education.

•

Nutrition knowledge questionnaires were developed for Japanese children and adults.

•

Higher nutrition knowledge was associated with healthier dietary habits in children.

•

Both children's and guardians' nutrition knowledge affected food intakes in children.

•

Sex differences in the effect of nutrition knowledge were suggested.

A valid and reliable nutrition knowledge questionnaire for track and field athletes

Background

Establishing an understanding of an athlete’s nutrition knowledge can inform the coach/practitioner and support the development of the athlete. Thus the purpose of the study was to develop a psychometrically valid and reliable tool to assess general and sport nutrition knowledge.

Methods

An 85 question questionnaire was developed in consultation with a panel of experts. Ninety-eight participants from the UK completed the questionnaire, and again 3 weeks later. The participants were classified into two groups: those with nutrition (NUT, n = 53) training (sport nutritionists and dietitians who were either practicing or undertaking a postgraduate qualification in the field), and those without (NONUT, n = 48) training (professionals and postgraduate students with no exposure to any form of nutrition training). The questionnaire was then administered to a pilot cohort of UK based track and field athletes (n = 59) who were requested to time how long it took to complete the questionnaire.

Results

Psychometric statistical analysis of the results was completed, resulting in the removal of 23 questions for a total of 62 questions in the final questionnaire. The validated questionnaire was then administered to 58 track and field athletes. Internal consistency was assessed using Chronbach’s alpha (α > 0.7), Pearson’s correlation (p < 0.05) was used to assess reliability. Construct validity was evaluated using a t-test (p < 0.05). A total test retest correlation of 0.95 was achieved (sub-section range: 0.87–0.97). Internal consistency was accepted in each sub-section (α = 0.78–0.92) and the nutrition-trained group scored significantly higher on the overall questionnaire (80.4 vs 49.6%). The overall score for the athletic group was 61.0%.

Conclusion

The questionnaire satisfied all psychometric measures and provides a new valid and reliable tool to assess general and sport nutrition knowledge of track and field athlete.

Electronic supplementary material

The online version of this article (doi:10.1186/s40795-017-0156-0) contains supplementary material, which is available to authorized users.

Development and validation of an Arabic questionnaire to assess psychosocial determinants of eating behavior among adolescents: a cross-sectional study

BACKGROUND

There is a scarcity of studies that evaluate the psychosocial determinants of eating behavior among adolescents in the Eastern Mediterranean region. The availability of such data is limited by the lack of valid culturally appropriate tools. The current study aims to develop and validate an Arabic questionnaire that measures psychosocial determinants of eating behavior among adolescents.

METHODS

A cross-sectional study was carried out to validate a five-scale questionnaire developed to measure nutrition-related knowledge, attitude, practices, and self-efficacy and social norms. Content validity was assessed by Lawshe's method, factor analysis was used to assess construct validity, and Cronbach's α was used to test internal consistency. Temporal stability was assessed by test-retest reliability. A random sample of public and private school students participated in the validation study.

RESULTS

All the five scales demonstrated excellent content validity (content validity ratio, CVR ≥0.778). Factor analysis revealed several dimensions for each scale. Cronbach's α for the identified dimensions or subscales ranged between 0.495 and 0.809 indicating acceptable internal consistency. Cronbach's α for the total scales ranged between 0.759 and 0.836. Test-retest analysis revealed good temporal stability (intraclass correlation, ICC >0.7).

CONCLUSIONS

A psychometrically valid tool to measure psychosocial determinants of eating behavior was developed. This tool can serve as a potential instrument for pretest and impact evaluation of ongoing nutrition education interventions and curricula. Based on results obtained from this tool, efficacious modifications can be instilled for nutrition policies and interventions.

Development and validation of a nutrition knowledge questionnaire for a Canadian population

Objective

The present study aimed to develop and validate a nutrition knowledge questionnaire in a sample of French Canadians from the province of Quebec, taking into account dietary guidelines.

Design

A thirty-eight-item questionnaire was developed by the research team and evaluated for content validity by an expert panel, and then administered to respondents. Face validity and construct validity were measured in a pre-test. Exploratory factor analysis and covariance structure analysis were performed to verify the structure of the questionnaire and identify problematic items. Internal consistency and test–retest reliability were evaluated through a validation study.

Setting

Online survey.

Subjects

Six nutrition and psychology experts, fifteen registered dietitians (RD) and 180 lay people participated.

Results

Content validity evaluation resulted in the removal of two items and reformulation of one item. Following face validity, one item was reformulated. Construct validity was found to be adequate, with higher scores for RDv. non-RD (21·5 (sd2·1)v. 15·7 (sd3·0) out of 24,P<0·001). Exploratory factor analysis revealed that the questionnaire contained only one factor. Covariance structure analysis led to removal of sixteen items. Internal consistency for the overall questionnaire was adequate (Cronbach’sα=0·73). Assessment of test–retest reliability resulted in significant associations for the total knowledge score (r=0·59,P<0·001).

Conclusions

This nutrition knowledge questionnaire was found to be a suitable instrument which can be used to measure levels of nutrition knowledge in a Canadian population. It could also serve as a model for the development of similar instruments in other populations.

The 2015 Dietary Guidelines for Americans is associated with a more nutrient-dense diet and a lower risk of obesity

BACKGROUND

Dietary pattern analysis represents a departure from the traditional focus on single foods and nutrients and provides a comprehensive understanding of the role of the diet in chronic disease prevention and etiology. Dietary patterns of Canadians have not been evaluated comprehensively with the use of an updated a priori dietary quality index.

OBJECTIVES

We aimed to update the Dietary Guidelines for Americans Adherence Index (DGAI) on the basis of the 2015 Dietary Guidelines for Americans (DGA), to evaluate the construct validity and reliability of the revised index, and to examine whether closer adherence to this index is associated with a lower risk of obesity with or without an accompanying chronic disease.

DESIGN

Data from 11,748 participants (≥18 y of age) in the cross-sectional Canadian Community Health Survey cycle 2.2 were used in weighted multivariate analyses. Multinomial logistic regression was used to test the association between diet quality and obesity risk.

RESULTS

With the use of principal component analyses, the multidimensionality of the 2015 DGAI was confirmed, and its reliability was shown with a high Cronbach's α = 0.75. Moving from the first to the fourth (healthiest) quartile of the 2015 DGAI score, there was a trend toward decreased energy (2492 ± 26 compared with 2403 ± 22 kcal, respectively; ±SE) and nutrients of concern (e.g., sodium), whereas intakes of beneficial nutrients increased (P-trend < 0.05). In the age- and sex-adjusted model, a lack of adherence to the 2015 DGA recommendations increased the OR of being unhealthy obese from 1.42 (95% CI: 1.02, 1.99) in quartile 3 to 2.08 (95% CI: 1.49, 2.90) in quartile 2 to 2.31 (95% CI: 1.65, 3.23) in the first quartile of the 2015 DGAI score, compared with the fourth quartile (healthiest) (P-trend < 0.0001). The odds of being obese without a chronic disease (healthy obese) and having a chronic disease without being obese also increased in the lowest DGAI quartile compared with the highest DGAI quartile, albeit not as much as in the unhealthy obese group.

CONCLUSION

The 2015 DGAI provides a valid and reliable measure of diet quality among Canadians.

Impact of cooking and home food preparation interventions among adults: outcomes and implications for future programs

OBJECTIVE

Cooking programs are growing in popularity; however, an extensive review has not examined their overall impact. Therefore, this study reviewed previous research on cooking/home food preparation interventions and diet and health-related outcomes among adults and identified implications for practice and research.

DESIGN

Literature review and descriptive summative method.

MAIN OUTCOME MEASURES

Dietary intake, knowledge/skills, cooking attitudes and self-efficacy/confidence, health outcomes.

ANALYSIS

Articles evaluating the effectiveness of interventions that included cooking/home food preparation as the primary aim (January, 1980 through December, 2011) were identified via Ovid MEDLINE, Agricola, and Web of Science databases. Studies grouped according to design and outcomes were reviewed for validity using an established coding system. Results were summarized for several outcome categories.

RESULTS

Of 28 studies identified, 12 included a control group with 6 as nonrandomized and 6 as randomized controlled trials. Evaluation was done postintervention for 5 studies, pre- and postintervention for 23, and beyond postintervention for 15. Qualitative and quantitative measures suggested a positive influence on main outcomes. However, nonrigorous study designs, varying study populations, and the use of nonvalidated assessment tools limited stronger conclusions.

CONCLUSIONS AND IMPLICATIONS

Well-designed studies are needed that rigorously evaluate long-term impact on cooking behavior, dietary intake, obesity and other health outcomes.

Psychosocial measures used to assess the effectiveness of school-based nutrition education programs: review and analysis of self-report instruments for children 8 to 12 years old

OBJECTIVE

To identify the psychometric properties of evaluation instruments that measure mediators of dietary behaviors in school-aged children.

DESIGN

Systematic search of scientific databases limited to 1999-2010.

MAIN OUTCOME MEASURES

Psychometric properties related to development and testing of self-report instruments for children 8-12 years old.

ANALYSIS

Systematic search of 189 articles and review of 15 instruments (20 associated articles) meeting the inclusion criteria. Search terms used included children, school, nutrition, diet, nutrition education, and evaluation.

RESULTS

Fourteen studies used a theoretical framework to guide the instrument's development. Knowledge and self-efficacy were the most commonly used psychosocial measures. Twelve instruments focused on specific nutrition-related behaviors. Eight instruments included over 40 items and used age-appropriate response formats. Acceptable reliability properties were most commonly reported for attitude and self-efficacy measures. Although most of the instruments were reviewed by experts (n = 8) and/or pilot-tested (n = 9), only 7 were tested using both rigorous types of validity and with low-income youth.

CONCLUSIONS AND IMPLICATIONS

Results from this review suggest that additional research is needed to develop more robust psychosocial measures for dietary behaviors, for low-income youth audiences.

Methodology for the evaluation of the Stephanie Alexander Kitchen Garden program

ISSUES ADDRESSED

Community and school cooking and gardening programs have recently increased internationally. However, despite promising indications, there is limited evidence of their effectiveness. This paper presents the evaluation framework and methods negotiated and developed to meet the information needs of all stakeholders for the Stephanie Alexander Kitchen Garden (SAKG) program, a combined cooking and gardening program implemented in selectively funded primary schools across Australia.

METHODS

The evaluation used multiple aligned theoretical frameworks and models, including a public health ecological approach, principles of effective health promotion and models of experiential learning. The evaluation is a non-randomised comparison of six schools receiving the program (intervention) and six comparison schools (all government-funded primary schools) in urban and rural areas of Victoria, Australia. A mixed-methods approach was used, relying on qualitative measures to understand changes in school cultures and the experiential impacts on children, families, teachers, parents and volunteers, and quantitative measures at baseline and 1 year follow up to provide supporting information regarding patterns of change.

RESULTS

The evaluation study design addressed the limitations of many existing evaluation studies of cooking or garden programs. The multistrand approach to the mixed methodology maintained the rigour of the respective methods and provided an opportunity to explore complexity in the findings. Limited sensitivity of some of the quantitative measures was identified, as well as the potential for bias in the coding of the open-ended questions.

CONCLUSION

The SAKG evaluation methodology will address the need for appropriate evaluation approaches for school-based kitchen garden programs. It demonstrates the feasibility of a meaningful, comprehensive evaluation of school-based programs and also demonstrates the central role qualitative methods can have in a mixed-method evaluation. So what? This paper contributes to debate about appropriate evaluation approaches to meet the information needs of all stakeholders and will support the sharing of measures and potential comparisons between program outcomes for comparable population groups and settings.

Development and test-retest reliability of a nutrition knowledge questionnaire for primary-school children

OBJECTIVE

To evaluate a web-based nutritional knowledge questionnaire for primary-school children.

DESIGN

Children's nutritional knowledge was assessed in five domains: healthy choices (twenty-seven items), estimated recommended portions/servings (eight items), nutrient content (five items), main food function (five items) and categorization of food items (eight items).

SETTING

The questionnaires were completed in school.

SUBJECTS

A convenience sample of 576 Belgian children (aged 7-12 years) from fourteen primary schools completed the questionnaire once, 386 completed the questionnaire twice.

RESULTS

Healthy choices could be answered correctly by 73 % of the children, nutrients by 59 %, food categorization by 49 %, main function by 38 % and portion estimation by 36 %. Children's test-retest intra-class correlations were 0·75 for healthy choices, 0·33 for nutrients, 0·61 for food categorization, 0·44 for main function, 0·47 for portion estimation and 0·76 for the total scale. The intra-class correlation was lower in the youngest age group (grade 2: 0·51, grade 4: 0·65, grade 6: 0·66). The total score was significantly lower in the retest. The instrument was in general positively evaluated by the children.

CONCLUSIONS

The instrument is a promising, practical, inexpensive tool with acceptable test-retest reliability in fourth and sixth graders.

Psychometric validation of a knowledge questionnaire on micronutrients among adolescents and its relationship to micronutrient status of 15-19-year-old adolescent boys, Hyderabad, India

OBJECTIVE

To develop a psychometrically valid questionnaire for testing knowledge on micronutrients and to assess the relationship between knowledge and biomarkers of micronutrient status among adolescents.

DESIGN

Cross-sectional, institution-based, validity and reliability study.

SETTING

Seven higher secondary schools were covered in the limits of Greater Hyderabad Municipal Corporation, Hyderabad, India.

SUBJECTS

Students aged 15-19 years, n 92 for the pre-test, n 108 for test-retest and n 109 for studying the relationship between knowledge and biomarkers of Fe, retinol, ascorbic acid, α-tocopherol, folic acid and vitamin B12 status.

RESULTS

From an item pool of 106, thirty-one items were selected based on content validity. Statistical tools to obtain a valid and reliable questionnaire among adolescent boys and girls resulted in eighteen items with a difficulty index of 0·11-0·86, discrimination index of 0·20-0·72 and validity index (point bi-serial correlation) of 0·10-0·62. Reliability as measured by Cronbach's α was 0·71 and the intra-class correlation coefficient was 0·80. A Bland-Altman plot showed good agreement between test and retest scores. The mean response score to the eighteen-item questionnaire was 5·2 (sd 2·68). The mean values of serum retinol were significantly different (P = 0·022) between groups below (24·8 (sd 6·64) μg/dl) and above (28·0 (sd 7·67) μg/dl) the 50th percentile of knowledge score. The relationship persisted after controlling for economic status as a covariate using analysis of covariance (P = 0·018). Other micronutrients did not show any significant relationship.

CONCLUSIONS

A valid and reliable eighteen-item knowledge questionnaire was constructed and found to have a significant positive relationship with plasma retinol status alone.

Cook It Up! A community-based cooking program for at-risk youth: overview of a food literacy intervention

BACKGROUND

In Canada, there are limited occasions for youth, and especially at-risk youth, to participate in cooking programs. The paucity of these programs creates an opportunity for youth-focused cooking programs to be developed, implemented, and evaluated with the goal of providing invaluable life skills and food literacy to this potentially vulnerable group. Thus, an 18-month community-based cooking program for at-risk youth was planned and implemented to improve the development and progression of cooking skills and food literacy.

FINDINGS

This paper provides an overview of the rationale for and implementation of a cooking skills intervention for at-risk youth. The manuscript provides information about the process of planning and implementing the intervention as well as the evaluation plan. Results of the intervention will be presented elsewhere. Objectives of the intervention included the provision of applied food literacy and cooking skills education taught by local chefs and a Registered Dietitian, and augmented with fieldtrips to community farms to foster an appreciation and understanding of food, from 'gate to plate'. Eight at-risk youth (five girls and three boys, mean age = 14.6) completed the intervention as of November 2010. Pre-test cooking skills assessments were completed for all participants and post-test cooking skills assessments were completed for five of eight participants. Post intervention, five of eight participants completed in-depth interviews about their experience.

DISCUSSION

The Cook It Up! program can provide an effective template for other agencies and researchers to utilize for enhancing existing programs or to create new applied cooking programs for relevant vulnerable populations. There is also a continued need for applied research in this area to reverse the erosion of cooking skills in Canadian society.

Development of a nutrition knowledge questionnaire for obese adults

BACKGROUND AND OBJECTIVE

The aim of this study was to develop a questionnaire for assessing nutritional knowledge among overweight adults. The questionnaire should reveal knowledge about current dietary recommendations, sources of nutrients, everyday food choices, and conditions related to overweight.

DESIGN

The first draft of the nutrition knowledge questionnaire (113 items) was based on literature review. To ensure content validity and expert-assessed face validity, an expert panel examined the questionnaire. Thereafter, the questionnaire was tested for user friendliness and ambiguity by five students. The questionnaire was pilot tested in a group of obese adults, similar to the target group. The results were analyzed for item difficulty and internal consistency and comments made by respondents were taken into account. Two student groups, differing in nutritional expertise, answered the questionnaire on two occasions to test construct validity and test-retest reliability. After the retest, a total overview of the questionnaire was made by the expert panel. The final questionnaire consisted of 91 items.

SUBJECTS

The pilot study was conducted in obese adults waiting for a gastric bypass operation (n=33). Construct validity (n=34) and test-retest reliability (n=27) was tested in two student groups: public health nutrition students and construction students.

RESULTS

Results from the pilot study showed that internal consistency of the three first sections together was 0.84, measured by Cronbach's α. Test of construct validity showed that public health nutrition students scored significantly better than construction students (p<0.001 for all sections), and test-retest reliability for all sections together was 0.82 (Pearson's r).

CONCLUSION

The knowledge questionnaire had reasonable content-, face-, and construct validities and overall good reliability. The questionnaire can be a useful tool for measuring nutrition knowledge among obese adults.

Validity and reliability of a short questionnaire for assessing the impact of cooking skills interventions

BACKGROUND

Food skills programmes are widely used as a means to improve confidence in food preparation, the use of basic food skills and food selections amongst low income communities. However, the impact of such interventions are rarely evaluated as a result of a lack of validated assessment tools appropriate for use within this target group.

METHODS

A two-page questionnaire utilising a closed-question format was designed based on key domains known to be influenced by cooking skills programmes. Content validity was assessed by a panel of public health experts and face validity by individuals, typical of those who may attend cooking skills classes. Internal and repeat reliability were assessed with groups of adults attending community-based classes. The feasibility of using the tool in community settings was also assessed.

RESULTS

The draft questionnaire was amended as appropriate subsequent to content and face validity testing. Cronbach's alpha for confidence and knowledge sections was 0.86 and 0.84, respectively, indicating good internal consistency. Spearman correlation coefficients for repeat reliability testing between time 1 and time 2 for each item were in the range 0.46-0.91 (all significant at P < 0.001), indicating that the questionnaire elicited stable responses for repeated use. Feasibility testing highlighted the need for detailed instructions for course tutors on how to distribute and check questionnaires for completion.

CONCLUSIONS

This tool provides a standardised method of evaluating cooking skills interventions that could be utilised in the development and evaluation of multicentre cooking skills interventions.

A novel school-based intervention to improve nutrition knowledge in children: cluster randomised controlled trial

BACKGROUND

Improving nutrition knowledge among children may help them to make healthier food choices. The aim of this study was to assess the effectiveness and acceptability of a novel educational intervention to increase nutrition knowledge among primary school children.

METHODS

We developed a card game 'Top Grub' and a 'healthy eating' curriculum for use in primary schools. Thirty-eight state primary schools comprising 2519 children in years 5 and 6 (aged 9-11 years) were recruited in a pragmatic cluster randomised controlled trial. The main outcome measures were change in nutrition knowledge scores, attitudes to healthy eating and acceptability of the intervention by children and teachers.

RESULTS

Twelve intervention and 13 control schools (comprising 1133 children) completed the trial. The main reason for non-completion was time pressure of the school curriculum. Mean total nutrition knowledge score increased by 1.1 in intervention (baseline to follow-up: 28.3 to 29.2) and 0.3 in control schools (27.3 to 27.6). Total nutrition knowledge score at follow-up, adjusted for baseline score, deprivation, and school size, was higher in intervention than in control schools (mean difference = 1.1; 95% CI: 0.05 to 2.16; p = 0.042). At follow-up, more children in the intervention schools said they 'are currently eating a healthy diet' (39.6%) or 'would try to eat a healthy diet' (35.7%) than in control schools (34.4% and 31.7% respectively; chi-square test p < 0.001). Most children (75.5%) enjoyed playing the game and teachers considered it a useful resource.

CONCLUSIONS

The 'Top Grub' card game facilitated the enjoyable delivery of nutrition education in a sample of UK primary school age children. Further studies should determine whether improvements in nutrition knowledge are sustained and lead to changes in dietary behaviour.

Assessing the impact of the primary school-based nutrition intervention Petits cuistots--parents en réseaux

OBJECTIVES

This study sought to provide an intermediate impact assessment of the nutrition intervention Petits cuistots--parents en réseaux (Little Cooks--Parental Networks) on: 1) knowledge, attitude, capacity and experience with regard to nutrition, diet and cookery, and 2) parental and/or family participation in school.

PARTICIPANTS

A total of 388 students from grades 5 (participants) and 6 (non-participants).

SETTING

The evaluation of the nutrition intervention took place in each of the seven participating elementary schools, all of which are located in Montreal's most disadvantaged neighbourhoods.

INTERVENTION

The program component "Little Cooks" is a nutrition workshop run by community dieticians. Each of the eight annual workshops features a food item and nutrition theme with a recipe for a collective food preparation and tasting experience. Classroom teachers participate to provide classroom management and program support. The "Parental Networks" component of the program invites parents to assist with the nutrition workshop, and offers additional parent and family activities which link to nutrition workshop themes (e.g., dinners or visits to local food producers).

OUTCOME

The program had some impact on knowledge of the nutrient content of food, food produce and cooking; attitude and experience with tasting of new or less common foods; and perceived cooking capacity. Families with students participating in the program participated more in school activities than did families of students not in the program.

CONCLUSIONS

Our assessment indicates a potential program impact upon several intermediate impact measures, and in so doing highlights a promising nutrition capacity-promoting intervention.

The impact of a community-based food skills intervention on cooking confidence, food preparation methods and dietary choices - an exploratory trial

OBJECTIVE

To evaluate the feasibility of undertaking a food skills intervention study in areas of social deprivation aimed at altering cooking confidence, food preparation methods and dietary choices.

DESIGN

A standardised skills programme was implemented in community-based settings. Pre- (T1) and post-intervention (T2) and 6-month follow-up (T3) measures (7-day diaries and self-administered questionnaires) were undertaken in intervention and comparison groups.

SETTING

Eight urban communities in Scotland.

SUBJECTS

One hundred and thirteen adults living in areas of social deprivation.

RESULTS

It was clear that many subjects led fragmented lives and found commitment to intervention classes problematic. Sixty-three subjects completed the final (T3) assessments. The response to each component varied due to inability to attend sessions, illness, study requirements, employment, moving out of the area, change in circumstances, loss of interest and loss of postal questionnaires. At baseline, reported consumption of fruit and vegetables was low (mean frequency 8.1 +/- 4.78 times per week). Fruit intake increased significantly (P < 0.05) between T1 and T2 in the intervention group (1.7 +/- 2.36 to 2.7 +/- 3.28 times per week) only. Between T1 and T3, there was a significant increase (P < 0.05) in intervention subjects who reported confidence in following a recipe (67-90%,).

CONCLUSIONS

This exploratory trial shows that a food skills intervention is likely to have a small but positive effect on food choice and confidence in food preparation. A full-scale randomised controlled trial in this hard-to-reach group would require a range of flexible approaches rather than a fully defined intervention, and presents challenges for trial design.

Knowledge of dietary and behaviour-related determinants of non-communicable disease in urban Senegalese women

Objective

To assess knowledge of dietary and behaviour-related determinants of non-communicable disease (NCD) of urban Senegalese women.

Design

A cross-sectional, population study using an interviewer-administered knowledge questionnaire, developed and validated for this study. The questionnaire consisted of 24 items with six scores measuring knowledge of: (1) diet- and behaviour-related causes of NCD; (2) diet quality–NCD relationship; (3) fruit and vegetable link with NCD; (4) health consequences of obesity; (5) causes of cardiovascular disease (CVD); and (6) causes of certain cancers.

Subjects

A random sample of 301 women aged 20–50 years.

Results

The knowledge scores developed suggest that the health consequences of obesity (mean score of 65.4%) were best understood followed by causes of CVD (mean score of 60.6%), because obesity, smoking, high blood cholesterol and dietary fat were well recognised as risk factors for CVD. Subjects scored least for their knowledge of the protective effect of fruit and vegetables (mean score of 19.9%). Knowledge of causes of certain cancers (mean score of 36.1%) was also low. Women who worked outside the home had better knowledge for two scores but otherwise no relationship was found between knowledge and literacy, formal education or body mass index.

Conclusions

Findings suggest reasonable overall knowledge concerning diet and behaviour with NCD, especially given the relatively new context of the obesity epidemic in Senegal. However, there was poor knowledge of the benefit of eating fruit and vegetables and other preventable causes of certain cancers. Education targeting the benefits of vegetables and fruit may have the greatest impact on NCD prevention.

The 2005 Dietary Guidelines for Americans Adherence Index: development and application

The sixth edition of the Dietary Guidelines for Americans (DGA) was released in January 2005, with revised healthy eating recommendations for all adult Americans. We developed the 2005 Dietary Guidelines Adherence Index (DGAI) as a measure of adherence to the key dietary intake recommendations. Eleven index items assess adherence to energy-specific food intake recommendations, and 9 items assess adherence to "healthy choice" nutrient intake recommendations. Each item was scored from a minimum of 0 to a maximum of 1, depending on the degree of adherence to the recommendation. A score of 0.5 was given for partial adherence on most items or for exceeding the recommendation for energy-dense food items. The DGAI was applied to dietary data collected at the fifth examination of the Framingham Heart Study Offspring Cohort. The mean DGAI score was 9.6 (range 2.5-17.50). Those with higher DGAI scores were more likely to be women, older, multivitamin supplement users, and have a lower BMI and less likely to be smokers. The DGAI demonstrated a reasonable variation in this population of adult Americans, and by design this index was independent of energy consumption. The DGAI also demonstrated face validity based on the observed associations of the index with participant characteristics. Given these attributes, this index should provide a useful measure of diet quality and adherence to the new 2005 Dietary Guidelines for Americans.

Tradução, adaptação e avaliação psicométrica da Escala de Conhecimento Nutricional do National Health Interview Survey Cancer Epidemiology

OBJETIVO: O estudo objetivou traduzir e adaptar, para a língua portuguesa, a escala de conhecimento nutricional aplicada no National Health Interview Survey Cancer Epidemiology e avaliar sua validade e precisão. MÉTODOS: Após sua tradução e retro-tradução, a escala foi adaptada, substituindo-se alimentos tipicamente americanos por outros típicos do Brasil. Ela foi aplicada em 39 mulheres com transtornos alimentares e 57 estudantes de Nutrição. Esperava-se uma maior pontuação destas últimas, atestando a validade discriminatória do questionário. O instrumento foi reaplicado em 50 estudantes e obteve-se o coeficiente de correlação entre as duas aplicações. RESULTADOS: As estudantes fizeram 10,5 pontos, com desvio-padrão de 1,7 pontos, enquanto as pacientes fizeram 7,4, com desvio-padrão de 2,6 pontos (p=0,0000001). Apenas 1,75% das estudantes apresentou baixo conhecimento, versus 34,21% das pacientes (p<0,005). Encontrou-se alto conhecimento em 57,90% das estudantes e em 13,16% das pacientes (p<0,005). O coeficiente de correlação de Spearman foi 0,52 (p=0,00009). CONCLUSÃO: O teste preencheu os critérios psicométricos para validade, mas sua precisão deve ser reavaliada. Sugere-se que o reteste seja feito em menor intervalo de tempo. Dado que as estudantes ainda estão no processo aprendizado, seria interessante aplicar a escala em nutricionistas, com conhecimento mais sedimentado.

Knowledge of dietary restrictions and the medical consequences of noncompliance by patients on hemodialysis are not predictive of dietary compliance

OBJECTIVE

To investigate whether knowledge of the diet and medical consequences of noncompliance influences dietary compliance among patients on hemodialysis.

DESIGN

An interviewer-administered questionnaire assessed patients' knowledge of foods restricted in their diet (four separate scores for knowledge of foods restricted for: potassium, phosphorus, sodium, and fluid); overall knowledge of restricted foods (one composite knowledge score); and knowledge of medical complications of dietary noncompliance (one composite knowledge score). Patients' mean monthly serum phosphorus and potassium and weight charts provided an estimate of dietary compliance.

SUBJECTS/SETTING

Seventy-one of the eligible 82 patients on hemodialysis at Nottingham City Hospital, Nottingham, UK, participated in the study (87% response rate).

STATISTICAL ANALYSES

Chi(2) tests determined associations between dietary compliance and knowledge scores.

RESULTS

More than one third of patients were noncompliant with at least one dietary restriction. Phosphorus dietary restrictions were the most commonly abused and potassium the least. Patients' knowledge of the medical consequences of noncompliance was poorer than knowledge of renal dietary restrictions (mean scores 29.4%; 74.7%). There was no association between compliance with potassium or sodium/fluid restrictions and knowledge of these dietary restrictions. However, patients with better knowledge about phosphorus were less likely to be compliant (P=.03). Patients with better knowledge about the medical complications of noncompliance were less likely to be compliant for phosphorus (P=.002) and sodium/fluid (P=.008) restrictions.

APPLICATIONS

These findings question the value of current dietary education techniques in motivating patients to comply with dietary restrictions. Instead of the more traditional approach of information-giving, effective educational methods that focus on motivating patients to comply with dietary restrictions are needed to improve compliance.

Department of Health Research Initiative on Nutrition Phase 2: overview of findings and recommendations

OBJECTIVE

The purpose of this overview is to synthesise and summarise the findings and recommendations of all 14 projects funded between 1997 and 2002 under Phase 2 of the Department of Health's Policy Research Programme Nutrition Initiative. This is aimed at end users, including policy makers, practitioners, researchers and research funding bodies.

DESIGN

The main findings and recommendations for policy and practice, as well as for future research, contained in the peer-reviewed final report of each project are summarised under headings identified as being useful for policy groups and practitioners: Maintenance of a healthy weight; Functional outcomes related to different markers of iron status; Nutritional aspects of bone health in humans; and Dietary interventions.

RESULTS

The overview draws together the key findings and recommendations for current and future policy and practice from the second phase of the research programme and identifies research gaps.

CONCLUSIONS

The findings and recommendations of the Department of Health's Nutrition Research Initiative have contributed to the scientific evidence base for policy development, policy evaluation, and will inform practitioners as well as researchers and research funding bodies.