EXPLORING INNOVATIVE METHODS FOR ONLINE NUTRITION EDUCATION: A SCOPING REVIEW AND QUALITATIVE STUDY TO PROMOTE BEHAVIORAL CHANGE AMONG SCHOOL-AGED CHILDREN IN BEIRUT, LEBANON

Abstract

Background: Pediatric obesity remains one of the most serious global public health challenges of the 21st century that causes adverse consequences on children’s health and wellbeing in the short and long -term. The increase in obesity rates is particularly alarming in resource-poor settings. Schools have been long shown to be adequate settings to prevent pediatric obesity through promoting healthy eating and lifestyle behaviors among children using nutrition education (NE). Scientific literature shows the effectiveness of traditional NE programs and health promotion strategies in improving children’s eating and lifestyle behaviors, and in recent years, there has been an increase in the use of digital tools in health promotion and NE purposes. Over the last two years, the COVID-19 pandemic caused serious interruptions to the school year and accelerated the shift to online learning and the use of different digital tools to deliver educational material. However, there have been limited studies exploring the effectiveness of using digital interventions in promoting behavioral changes among school-aged children in Low-to-Middle-Income countries (LMICs) In Lebanon, as with other countries the Middle East and North Africa (MENA) region, there has been evidence documenting shifts in dietary intake of school-aged children and concomitant increase in sedentary behaviors contributing to the rise in childhood obesity over the last few decades. Lebanon has also been witnessing multiple economic, political, and health crises over the past two years that have been posing additional threats to the dietary habits of children and youth, which calls for effective and evidence-based interventions aimed at promoting children’s health and wellbeing.

Purpose: The aim of this study was to first explore the feasibility and effectiveness of using innovative online NE tools in promoting healthful dietary and lifestyle behaviors among school-aged children in LMICs and resource-poor settings, and to explore the perceptions and experiences of teachers towards using online NE in Lebanon.

Methods: The study was comprised of two phases: phase (1) was a scoping review and phase (2) was a qualitative exploratory study.

The scoping review aimed at identifying NE interventions that (1) aimed at improving children’s knowledge, attitudes, and practices related to healthy eating and active lifestyle behaviors, in an attempt to prevent excessive weight gain and obesity; (2) were delivered using online digital tools; and (3) were implemented among children from poor-resource settings or LMICs. A systematic search was conducted on three databases, namely Scopus, Embase, and Medline Ovid for relevant studies and the PRISMA protocol was followed. In addition, included studies and interventions in the scoping review were evaluated for data quality using critical appraisal tools. Results from the scoping review helped inform phase 2 of the study that further explored the perceptions of teachers towards using online NE in Lebanon. Phase 2 included an exploratory qualitative design using semi-structured interviews with key informants from public and private schools in Lebanon. A convenience sampling approach was adopted to recruit teachers and representatives from public and private schools in Lebanon. Interviews were conducted either via phone calls or through virtual platforms (ex. Microsoft Teams). Recordings of the interviews were transcribed verbatim and translated to English, as needed. The transcripts were coded and thematically analyzed using Dedoose software.

Results: For phase 1, a total of 16 studies met the scoping review criteria after removing the duplicates from the three databases and screening studies based on the pre-set inclusion criteria. The interventions included in the review adopted different digital interventions and varied in duration, sample size, and outcomes of interest. The digital tools used in these interventions included educational videos, websites, games, or the use of multicomponent approaches. Narrative synthesis showed that improvements in the knowledge, attitudes, eating behaviors, and lifestyle habits of school-aged children were evident in 15 out of 16 interventions. Three studies were identified in this scoping review that explored the impact of digital NE interventions in obesity prevention, yet none of these interventions contributed to significant decrease in body weight or waist circumference among school-aged children, whether they were of normal weight, overweight, or obese at baseline. Studies included in the scoping review were also assessed for their quality showing that 10 out of the 16 interventions were of moderate quality, three were of high quality, and remaining three were of low quality. Phase 2: Six semi-structured interviews were conducted with key informants from public and private schools in Lebanon. A total of 4 themes and 12 subthemes emerged from the data analysis, mainly related to the teachers’ perceptions of the need for and importance of NE in schools, the challenges faced with the use of online tools, their perceptions of the use of digital learning tools vs traditional classroom learning, and recommendations for effective digital NE implementation within the Lebanese schools. Findings showed that teachers support NE at schools and find videos helpful for message delivery and time-effective, given the ability to secure internet, electricity, and needed devices for children in the local context. The key informant representing public schools highlighted the importance and effectiveness of previous NE interventions in public schools and stressed on the importance of collaborations across various governmental ministries in addition to academic institutions to facilitate the implementation of digital NE.

Conclusion: Results from the scoping review conducted as part of this study highlight promising findings regarding the effectiveness of online NE in improving school-aged children’s eating and lifestyle knowledge, attitudes, and behaviors, albeit limited evidence on changes in weight status and other anthropometric measures. Worth noting that the data on digital NE interventions and their impact on the dietary and nutrition outcomes of school-aged children remains rather low from LMIC, with none identified from the MENA region. Findings from the exploratory qualitative phase of the study showed the acceptability of teachers and key informants towards the use of digital NE interventions in a context like Lebanon. Digital interventions such as educational videos to complement the educational curriculum along with the use of games and interactive modes of teaching were considered as interactive and fun methods of learning for children in the post COVID-19 era. Nevertheless, persistent technical, logistical, and financial challenges remain key challenges in Lebanon, amidst the multiple crises facing the country, and that need to be addressed. The study also highlights the need for future public health nutrition programs and school-based educational can help explore different modalities to overcome some of the raised challenges while also ensuring the buy-in of students, parents, teachers, and school administrators to the use of online digital tools and explore their effectiveness in preventing pediatric obesity within resource-poor settings.