الفهرس 
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Abstract
Good health is an important indicator of the quality of life, in which healthy nutrition and physical activity take an important place. Healthy nutrition and physical activity according to the guidelines of WHO are closely related to lower general and specific mortality rates due to heart and coronary diseases and cancer, which are the top reasons for mortality from non-communicable diseases (NCDs). Every year, 41 million people die from NCDs, which represents 71% of the total number of global deaths. This largely invisible epidemic is more serious in low- and middle-income countries, where 85% of NCD premature deaths occur (1) As unhealthy diet, physical inactivity and tobacco use are common risk factors of the NCDs, elimination of these modifiable risk factors would prevent 80% of premature heart disease, 80% of premature stroke, 80% of type 2 diabetes and 40% of cancer (2) Studies indicate that good nutrition is especially important during adolescence, which is a period of biological and social change. These are crucial years for normal physical and mental development, and the diet and eating behaviors that develop during these years tend to persist throughout life. During adolescence, body size and composition, bodily functions and physical abilities change rapidly, and under-nutrition can slow height and weight growth and may delay puberty (3). In addition, healthful eating habits in young people not only help to prevent under-nutrition, growth retardation and acute nutritional problems, but also can enhance students’ educational performance and learning (4). Nutrition-related health problems among the youth are apparent in developing countries where, paradoxically, both over- and under-nutrition can coexist (3). At the global level, major modifications in the dietary habits have occurred since the second half of the twentieth century; first in industrial regions and more recently in developing countries. The concept of ‘food’ has changed from a means of nourishment to a marker of lifestyle and a source of pleasure as portrayed by media. A large proportion of televised food advertisements are of highly processed foods/convenient foods with, high caloric content, large amounts of fat and sugar, and with little or no micronutrient content (5). Also, due to low cost and easy availability, people are increasingly consuming high-saturated-fat snacks, refined carbohydrates and sweetened carbonated beverages. There is an increased inclination to replace traditional meals with energy-dense imbalanced foods(6). Irregular meals, snacking, eating away from home, and following alternative dietary patterns have already been frequently reported among adolescents in many countries (7). The traditional Egyptian diet has also been modified in the recent decades with introduction of new foods and eating habits (8).Such dietary patterns with inadequate physical activity trigger the onset of fat deposition and lead to early metabolic derangements such as the metabolic syndrome and type 2 diabetes mellitus (9). A previous Egyptian study in Mansoura revealed unhealthy dietary habits of adolescents; as fast foods and carbonated drinks were consumed on daily bases by more than two thirds and one fifth of the participating students; respectively. It was also found that the majority of students drink tea more than 3 times daily. Excess salt and excess sugar/sweet intake were reported by more than half of the study participants (10). Another study in the United Arab Emirates found that the majority of children and adolescent participants had less than the recommended number of servings from milk and vegetables(11). A study in Saudi Arabia showed that large proportions of Saudi adolescent school students never consumed protein food sources or fresh fruits during the previous week, while the most frequently consumed food items were rice and bread(12). Moreover, the majority of Arab adolescents do not meet the recommended guidelines for daily physical activity. It has been reported that more than 85% of girls and 75% of boys aged 13–15 years in seven Arab countries (Djibouti, Egypt, Jordan, Libya Morocco, Oman, and the United Arab Emirates) did not engage in a sufficient amount of daily physical activity (obtaining at least 60 minutes of physical activity per day) (13). A cross-cultural study on perceived barriers to healthy eating among adolescents in seven Arab countries revealed that there are several personal, social, and environmental barriers to healthy eating among adolescents in Arab countries; Lack of information on healthy eating, lack of motivation to eat healthy diets, and not having time to prepare or eat healthy foods due to school commitments were found to be the main barriers to healthy eating (14). In order to promote healthier eating habits, nutrition knowledge is believed to be important (15). However, nutrition knowledge alone may not be sufficient to change dietary habits hence in addition there is need to mold a positive attitude toward healthy eating early in childhood. With the current change in dietary habits to the western diet and increase in televised food advertisements targeting children, there is even greater need to empower children with the right knowledge and attitudes for making proper food choices. There is a growing evidence suggesting that young children from developing countries are increasingly making unhealthy food choices especially due to lack of knowledge and wrong perception towards healthy foods (16, 17). However, children do not always choose what they eat; very often parents decide and prepare food for them. Clearly, parents, peers and teachers can play a crucial role in shaping each child’s outlook towards health (5, 18). Nutrition knowledge alone does not influence behavior, but does provide individuals with the ability to know how to select a healthy diet. The nutritional knowledge and skills need to be taught during childhood when firm eating practices are being established. Therefore, school is the major area for providing young people with nutrition knowledge and skills(19). Some previous studies revealed that school based nutritional education programs resulted in significant positive changes in both nutrition knowledge and behaviors(9, 20), while other studies revealed non-significant changes (21). Strategies are more effective when they include efforts to increase parental or family support. Family involvement enhances the effectiveness of programs for younger children. Objectives for the family component in successful programs focus on stimulating awareness and gaining parental support to encourage variety in the diet and availability of healthy foods at home. Methods used include brochures and activities with the Parents’ Association and the Parent-Teachers’Association(22). Environmental interventions are important components of intervention programs, that contribute to the creation of opportunities for action by removing barriers to following a healthy diet (22). School-based nutrition education should address the needs and interests of students, the teachers and the school; take into account what children already know and can do; be culturally appropriate; be delivered in a way children can understand and teach the skills and knowledge required to improve or strengthen healthy eating habits. Several studies have shown that using different teaching and learning strategies can enhance the learning outcomes of school children as small group discussions, group work, demonstrations, art educational drawing help in the success of the intervention program (22). Efficacy of nutrition education interventions also depends on the duration and frequency of intervention. Two systematic review concluded that educational interventions that are sustained for a longer are more likely to be effective than those conducted for a short period (23, 24). Adequate time, intensity of the intervention, resources, as well as the provision of suitable materials and teacher training opportunities are essential to program success. Moreover having support from policy makers and school management affect the success of the program (25, 26). Rationale of the study As many healthy (or unhealthy) life-long practices begin in adolescence, it is important to study the nutritional knowledge and behavior in this age group. There is evidence that adolescent girls are more likely to follow unhealthy eating patterns, including breakfast skipping and higher fast food consumption (27). Adolescent girls are particularly vulnerable to malnutrition because they need protein, iron and other micronutrients to support the adolescent growth spurt and meet the body’s increased demand for iron during menstruation. Addressing girls, nutrition has a range of positive effects because women are often responsible for producing and preparing food for the household, so their knowledge about nutrition can affect the health and nutritional status of the entire family(28). Also, studying the barriers of healthy eating from the adolescents and their parents perspectives would help to develop a feasible and applicable educational program focusing on targeting the detected barriers. As some previous studies revealed that school based nutritional education programs resulted in significant positive changes in both nutrition knowledge and behaviors(9, 20), while other studies revealed non-significant changes (21), we are in need for more evidence about the components of effective program in our society. Goal: Improve dietary knowledge, attitude and practices of adolescents. Objectives: To assess dietary knowledge, attitude and practices of female preparatory school students in Assiut city. To identify the determinants of dietary practices of female preparatory school students in Assiut city To identify the barriers to healthy eating among female preparatory school students in Assiut city from the students and their parents perspectives. To compare the impact of sustainable multi-component school-based educational program with a single educational workshop on dietary knowledge, attitude and practices of female preparatory school students in Assiut city. Research hypothesis: Female preparatory school students in Assiut city have poor nutritional knowledge and attitude and adapt unhealthy eating practices. Adapting healthy eating practices by female preparatory school students has social, cultural and economic barriers in Assiut city. Dietary knowledge, attitude and practices are better in female adolescents who receive sustainable multi-component school-based educational program than female adolescents who receive a single educational workshop and those who don’t receive any intervention. Subjects and Methods: Study design: The conducted study was a mixed quantitative (randomized controlled field trial) and qualitative study. Study site: The study will be carried in three public preparatory schools for girls in Assiut city. Study population: Second year preparatory school female students in Assiut city. A group of female preparatory school students’ mothers will be invited to participate in focus groups discussions from each school. Sampling and sample size:- Sample size: The sample size was calculated using Epi-Info7, as a total of 207 students; 69 in the multi-component intervention group, 69 in the single educational workshop group and 69 in the control group. It was calculated based on change of the mean of behaviour assessment score before and after intervention in an Indian study among government school adolescents (12-14 year)(9). Behaviour score changed from 3.6±3.3 to 5.3±3.8 confidence level 95%. The sample size was 207 that will be increased to 270 student to cover 30% DROP out, 90 female students in each groupSampling technique The study will be carried out in three public preparatory schools for girls in Assiut city. The first school will be selected randomly and the other two schools will be selected in a nearby region to avoid the socioeconomic differences between regions. The selected schools will be randomly assigned into a school receive a sustainable multi-component school-based educational program, a school receive three days educational workshop and a control school who receive no intervention. Two or three classes will be chosen randomly from the second year of preparatory school at the three schools. Intervention protocols for the intervention groups: The three days intervention school will receive a nutritional and physical activity educational workshop; that will be held on three days through one week; one hour session each dayThe sustained multi-component education program school will receive the following: Nutritional and physical activity educational workshop Enhanced physical educationInvolvement of the morning broadcast Educational brochure will be sent to the parents A monthly telephone call or a text message will be sent to the parents Message to school administration to prevent selling of soft drinks and to sell healthy food A monthly session 3. The third school will receive no intervention Study methods: Baseline assessment of the study participants: A - Quantitative part of the assessment The three groups; the multi-component intervention, single educational workshop and control groups will be subjected to the following: Filling in a self-administered semi structured questionnaire which will cover the following: Socio-demographic characteristics as age, residence, parent education, parent occupation Nutrition knowledge: The level of nutrition knowledge will be determined using questions concerning nutrients and their functions, food sources, dietary needs and concept of balanced diet, healthy eating, diet-related health risks and diseases. Nutrition attitude: Nutrition attitude will be assessed through questions including attitudes towards the importance of nutrition and developing healthy dietary habits. The subjects will be asked to state their level of agreement or disagreement with statements using a Likert scale. Dietary practices: Dietary practices will be evaluated through food frequency questionnaire and questions on some dietary habits as regularity of meals and main type of snacks. Barriers to healthy eating: as lack of information, lack of motivation, lack of time to choose and prepare healthy food, economic barriers, and unavailable healthy food. Physical activity: questions on time spent doing physical activity. Explanation of the way of filling the questionnaire will be done page by page to be filled in by the students at their classes. Two well-trained data collectors and class teacher will help the researcher to watch and keep understanding and completeness of data in every class. Anthropometric measurements: Body mass indexWeight will be measured by the nearest 0.1 kg using a portable digital scale. A portable stadiometer will be used to obtain height measurements to the nearest 0.1 cm. Body mass index (BMI) will be calculated using the standard formula (kg/m2). BMI percentile will be used to classify weight status (i.e., underweight, normal weight, overweight, and obese) according to World Health Organization data (de Onis, 2007). B - Qualitative part of the assessment: four meetings with mothers. Focus group discussions will be carried out with 10 to 15 mothers of students of the selected schools to discuss the following points: Dietary habits of the students. Barriers of changing the unhealthy dietary habits. How parents could support their children to adapt healthy dietary practices. Reviewing the nutritional topics in preparatory school’s curriculum The multi-component intervention program will be applied in one school and only a single workshop will be applied in the other intervention school. After four months, post intervention assessment will be carried out in the 3 selected schools by filling in a structured questionnaire and assessing their anthropometric measurements. The content of the single workshop: information on the following items Healthy diet: Nutrients and their functions Food sources Dietary needs How to compose a mixed and balanced diet by low cost and available foods. Diet-related health risks and diseases Physical activity Importance of physical activity WHO recommendation of physical activity among adolescents Encouragement to participate actively in physical activity periods in school every week for at least 30 min. Information of methods of practicing physical activity outside schools. After each educational session, the researcher will divide the students in each class into small groups and ask them to perform activity as preparing a poster, carrying out small group discussions or playing games to check understanding of the students to the given information e.g. Puzzle of food: build a food pyramid Who am I: answer the question given My plate: create two menus either for breakfast, lunch, dinner Students will be asked to discuss with their parents on the subject of each class session as parents’ participation can increase parental support for education program. The sustained multi-component program will be based on: The nutritional and physical education workshop Enhanced physical education: physical education teachers will be trained to provide physical activity health related messages and to encourage the participation of students in physical activity sessions through one hour session with the physical education teacher. The physical education teacher will give the messages twice monthly. The researcher will attend the physical education sessions once monthly to observe the process. Involvement of the morning broadcast in provision of messages for students about nutrition and physical activity once weekly. The messages will be prepared by the researcher and disseminated by the students. The researcher will attend the morning broadcast once monthly to observe telling the messages. Brochure including key messages about diet and physical activity will be designed and sent to parents of the intervention classes of students to reinforce healthy dietary and physical activity practices. A monthly telephone call or a text message will be sent to the parents to remind them about the commitment to the dietary health practices provided in the health educational course and the sent brochure. Message to school administration to prevent selling of soft drinks and to sell healthy food A monthly session for three months will be held to remind the students with the messages through showing videos, drawing pictures and playing games. Time schedule of the intervention 1st mon 2nd mon 3rd-5thmon 5thmon
Baseline assessment ***
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3 days workshop ***
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Sustained program activities ***
Post intervention assessment ***
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*** Sustained multi-component program school ### Three days workshop school Control school Technical design: Preparatory stage and administrative design: The proposal will be revised by the Ethics Review committee of Assiut Faculty of Medicine seeking their approval to conduct this study. Literature Review about the topic will be carried out through search in the electronic libraries, Medline database and medical journals. Preparation of the questionnaires. Administrative approvals will be obtained from the CAPMUS and the Ministry of Education. Communication with the directors and teachers of the selected schools to facilitate data collection and participate in the designed intervention under the researcher supervision. Pilot study to identify administrative procedures and testing the questionnaire. Statistical analysis: Data entry and analysis will be carried out using SPSS version 21. Descriptive statistics will be done such as (frequency, %, standard variation… etc.).Knowledge and attitude scores will be calculated. Differences between the intervention and control group will be assessed using chi square test and t test (student &paired) whatever is suitable and ANOVA for normally distributed continues variable. Regression analysis will be done for identifying the predictors of KAP. Ethical considerations: Reviewing the proposal will be carried out before starting data collection via the Ethical review Committee of Assiut Faculty of Medicine. Privacy and confidentiality of all the data will be assured. The aim of the study will be explained to each participant before starting data collection. Informed consent (written or verbal) will be obtained from those who welcome to participate in the study.