Interpretation (in light of other evidence)
The findings of this study are consistent with prior studies that suggest that nutrition education in schools can improve knowledge and awareness about anaemia; increase demand and improve compliance with IFA supplements; and change adolescent dietary behaviour.29-33 The pedagogical approach employed in the education sessions differed from conventional approaches in schools and was designed to be interactive and participatory, which we believe crucially contributed towards greater acceptance of the intervention and a positive impact on knowledge and attitude.34 Similar studies conducted in school settings in India using varied approaches, such as single or multiple interactive education sessions delivered by doctors, trained experts using flipcharts, videos and other interactive methods have been found to improve knowledge and/or change behaviours related to anaemia and its prevention. 29-32Evaluation of the Weekly Iron and Folic Acid Supplementation (WIFS) programme in India and other low-and-middle-income countries found that one of the key factors influencing increased uptake of IFA supplements was implementation of a coordinated and timely information education and communication strategy that dispelled misconceptions and rumours, and capitalised on the positive effects. 25, 35-39Moreover, as indicated by Joe et al (2022), increased awareness and subsequent demand-generation by target groups will help address other institutional barriers related to the supply and distribution of IFA supplements.16
The present study also reported knowledge about anaemia to be low among boys before the start of the intervention, in concordance with several other studies.40-42 Although recent data indicate no major gender disparities in the coverage of IFA supplementation in schools, being aware of anaemia itself acts as a motivation for consumption of IFA tablets.17, 18 Equal emphasis must therefore be given to educating both boys and girls about anaemia and its prevention.
The inclusion of nutrition education in formal education programmes targeted to children in primary schools is one of the most commonly recommended strategies because of its potential in developing positive health, eating, and lifestyle habits that may persist into adulthood.43, 44 Murimi et al (2018) highlighted several features of successful school-based nutrition education interventions: engagement of parents, identification of specific behaviours to be modified, ensuring fidelity by training educators, adequate dosage, and age-appropriateness of interventions.45 Several of these features warranted more attention in the present study, including training, appropriateness of content, dosage and engagement of parents. For example, the role of teachers was essential to intervention success, but they expressed difficulties related to time constraints and training. To resolve time limitations as well to ensure continuation and viability, they suggested the content be included in the national curriculum. Gaining an understanding of anaemia motivated teachers, to help ensure fidelity and realise project objectives, but this could be further improved by providing adequate training, endorsement and implementing a teacher-friendly intervention.25, 46-48
Despite co-development of the content of the education sessions, some teachers were hesitant to focus on topics related to menstruation and pregnancy, particularly in the presence of boys. In patriarchal societies like India where gender norms are strict, menstruation and pregnancy are considered as ’women’s’ topics and exclusion of boys from related discussions can further increase gender disparities.49, 50 Hence, research needs to be conducted to understand how best to include these topics in sessions involving both boys and girls.
One of the benefits of school-based health and nutrition education programmes is that children act to spread the information, bringing it to their homes to achieve transmission of the information to the whole family.51, 52 Our findings reveal the same with students discussing and sharing topics learnt with friends and families. However, to achieve better impact, studies recommend involvement of families and communities in the nutritional education programmes from the beginning. 52-55