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Public Health Nutrition: 24(S2), s72–s83 doi:10.1017/S1368980020001299
School readiness to adopt a school-based adolescent nutrition
intervention in urban Indonesia
1,2, 1,3 4
Yessi Octaria * , Apriningsih Apriningsih , Cesilia M Dwiriani and
Judhiastuty Februhartanty2
1Centre for Public Health Innovation, Udayana University, Denpasar, Bali 80232, Indonesia: 2Southeast Asian
Ministers of Education Organization Regional Centre for Food and Nutrition (SEAMEO RECFON)/Pusat Kajian Gizi
Regional,UniversitasIndonesia,Jakarta,Jakarta104303,Indonesia:3UniversitasPembangunanNasional“Veteran”
Jakarta, Depok,WestJava16415,Indonesia:4DepartmentofCommunityNutrition,IPBUniversity,Bogor,WestJava
16680, Indonesia
Submitted 7 October 2019: Final revision received 23 March 2020: Accepted 7 April 2020: First published online 7 May 2020
Abstract
Objective: To identify school community readiness to adopt a school-based ado-
lescent nutrition intervention.
Design: Cross-sectional study: mixed-methods design. The community readiness
model was used to guide instrument development and qualitative analysis.
Quantitative data are presented using descriptive statistics. Each statement was
rated on a seven-point Likert scale, thereby producing scores between 1 (strongly
disagree) and 7 (strongly agree).
Setting: Ten of the twenty current public secondary schools in Bogor, Indonesia.
Participants: Ninety teachers and ten school principals.
Results: Eating behaviour problem awareness was present among all participants;
awareness of efforts to improve eating habits was also present, but these efforts
were perceived as having low efficacy; support from the City Education
Authority and Health Authority was present, but the support type did not match
the perceived needs; nutrition education had not been implemented across the
entire school community due to competing priorities; existing nutrition policies
did not provide concrete scenarios and clear guidelines for nutrition-friendly
schools; the availability and accessibility of healthy foods at schools were consid-
ered to be key factors in improved adolescent nutrition; positive attitudes existed
amongrespondentstowardstheimplementationofvariousnutritionprogrammes,
and the median and mode were seven in all types of school-based intervention.
Conclusions: The school community readiness level regarding school-based ado-
lescent nutrition interventions is currently in the action phase, implying that com- Keywords
munity leaders have begun organising efforts to address issues in adolescent Schools readiness
nutrition and are aware of their consequences. Future support should be directed Adolescent
towards improving existing efforts and offering concrete ideas and clear policy Nutritional status
guidelines for implementation. Diet
Asadevelopingcountry, Indonesia is experiencing a dou- definition, approximately one-fifth of Indonesians are ado-
(4)
ble burden of malnutrition, consisting of both under- and lescents, 70% of which currently attend school . Thus,
over-nutrition, both of which have long-lasting negative the school could be an effective setting to deliver nutrition
consequencesforthequalityofitspublichealth,itsresour- interventions(5).
ces and productivity(1). Adolescent health and nutrition Nutrition interventions in adolescents are believed to be
may represent new frontiers for endeavours to improve essential for two main reasons. First, they may bolster the
the quality of life of present and future generations and quality of life and educational achievements of adolescents
areemergingprioritiesinthenationaldevelopmentagenda byprovidingadequatenutritionduringtheperiodsofdevel-
in this country(2). The WHO defines adolescence as span- opmentandgrowthspurts. Second, it represents an invest-
(3)
ning the age range of 10–19years . According to this ment for the future generation and may impart healthier
Disclaimer: This supplement received a publication grant from Global Alliance for Improved Nutrition (GAIN).
*Corresponding author: Email yessicrosita2@gmail.com
©TheAuthor(s) 2020. Published by Cambridge University Press on behalf of The Nutrition Society. This is an Open Access article, distributed
under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-
use, distribution, and reproduction in any medium, provided the original work is properly cited.
https://doi.org/10.1017/S1368980020001299 Published online by Cambridge University Press
School readiness for nutrition intervention s73
(6,7) construction of dimensions and other indicators to assess
habits onto this cohort as it moves into adulthood .
However, as with many other adolescent health interven- readiness of school communities, and to determine respon-
tions, implementing nutrition programmes can be expected dentsfortheDelphistudy.Thedeskreviewresultsinformed
to be more complex than similar interventions for younger the Delphi procedure through formulation of questions to
(8)
children . In 2013, the Indonesian Basic Health Research enableexpertconsensus.Thefinaloutputsofthisstagewere
showed that 35·1% of all adolescents aged 13–15years instruments that could be used for field data collection, in
old were stunted, while 11·1% were underweight and particular the structured interview guide, self-administered
10·8% were either overweight or obese. Furthermore, in questionnaires and an observation list as well as list of
regard to eating habits, the same report stated that 93·6% respondents. The second stage of the current study con-
of individuals aged 10 or over consumed an inadequate sisted of field data collection, which started with a short
amountoffruits and vegetables, while more than half often pre-structured interview by trained interviewers, followed
(9) by administration of self-questionnaires completed on the
consumedfoodsrichinsugar,fatandsalt .Inaddition,data
from the Indonesian Global School Health Survey in 2015 same day in the respondents’ workspace. The question-
showedthatonlyone-thirdofstudentsalwayshadbreakfast, nairespassedfacevalidity(threeexperts),test–retestreliabil-
only 3·81% always brought their own food to school and ity from a small sample of thirty respondents (r=0·91) and
morethanhalfofteenagersconsumedfastfoodatleastonce validity and reliability test between variables from seventy-
(10)
per week . Therefore, to improve health promotion and fivesamples(validitytestr>0·232,where0·232isthertable
prevention,theIndonesiangovernmentlaunchedanational for seventy samples; reliability test with the Cronbach’s
campaign to promote healthy lifestyles ‘Germas’ (Gerakan α=0·951). The school environment was checked for avail-
(11)
Masyarakat Hidup Sehat) in 2017 . However, widespread abilityofrunningwaterandsoapforhandwashing,thepres-
adoptionofsuchasetofmessagesanditssubsequentimple- enceoftrash cans in the classroom and school canteen and
mentationas‘achange’inschoolsettingsrequiresreadiness toilets, designatedspacetodisplayadolescenthealthposters
(12,13) orotherhealth-relatedinformation,aswellastheavailability
from the school community .
Numerous school-based nutrition interventions have offreedrinkingwater.Wealsoobservedwhethertheschool
been conducted in Indonesia previously. The focus of canteensoldhealthyandnutritiousfoodssuchasfruitslices,
attention was often directed at the type of media used vegetable dishes and bottled water as well as unhealthy
for intervention,forexample,theuseofcardgamesorpuz- snacks, for example, high-energy, low-protein snacks,
(14–17)
zles aimed at improving knowledge in nutrition . deep-fried snacks and sweetened beverages. This school
Meanwhile,studies toexplorethepotentialofschoolcom- environment observation was done simultaneously with
munities as contexts and actors of change for the imple- the interviews by trained enumerators (Fig. 1).
mentation of nutrition programmes have been rare.
School communities are, in themselves, agents of change, Respondents and settings
with pivotal roles in sustaining a school environment that The respondents for the current study included ninety
supports nutrition, health and learning. Hence, the sup- teachers and ten school principals from ten secondary
ports from schools often determine whether an interven- schools in the urban city of Bogor, West Java, Indonesia.
tion may work in certain schools(18)
. Given the current The initial design was to involve both public and private
paucity of research on this topic, the current study aimed schools;however,manyoftheprivateschoolsrefusetopar-
to identify the readiness of urban, public, secondary ticipate in the study. All public schools in Indonesia are
schools to adopt school-based adolescent nutrition inter- mixed schools, with no separation for boys and girls.
vention, explore the perceptionsofteachersandprincipals Experts in the Delphi study suggested a potentially effective
regarding their school community readiness and identify mix of teachers who should be made responsible for con-
opportunities for future improvements. These information ducting the nutrition education programme. This included
might be used to facilitate the impact of school-based ado- the school principal, four classroom teachers, two science
lescent nutrition intervention. teachers, one physical education teacher, one counselling
teacher and one art-and-culture teacher. Thus, from each
Methods school,oneschoolprincipalandnineteacherswerepurpos-
ivelydesignatedaskeyinformantsbytheresearchteam.The
Study design ten schools were selected randomly from a total of twenty
A cross-sectional study with a mixed-methods design was public secondary schools in Bogor using the Microsoft
conducted, involving two stages. The first stage consisted Excel2013randomnumbergeneratortorepresenttheread-
of instrument development, using two methods, that is, a iness of the Bogor city school community.
desk review followed by a Delphi procedure involving
seven experts in nutrition and education. The desk Data collection and data analysis
review was conducted to precisely define the concepts of The in-depth interview guide was constructed based on
‘school community’ and ‘readiness’, thereby enabling the the community readiness tool (CRT) developed by the
https://doi.org/10.1017/S1368980020001299 Published online by Cambridge University Press
s74 YOctaria et al.
Stage 1a: Desk review
Objectives:
a. To define ‘school community’ and ‘readiness’
b. To select dimensions and indicators to assess school community readiness
c. To formulate guideline and identify respondents for the Delphi study
Stage 1b: Delphi study involving seven experts in nutrition and education
Objectives:
a. To find consensus on the respondents for the field data collection
b. To find consensus on key questions for the in depth interview guide
c. To find consensus on key questions for the questionnaire
d. To find consensus on key indicators included in the school observation list
Stage 1c: Questionnaire validation
Face validity (three experts)
Test–retest reliability from a small sample of 30 respondents (r=0·91) and
the validity and reliability test between the variables from 75 samples
(Validity test r>0·232; Cronbach’s a=0·951)·
Stage 2: Field data collection
Ten secondary schools
Ninety teachers and Ten
school principals from Triangulation
Ten secondary schools
In-depth interview to School and canteen
measure school environment
community readiness observation list
Interview with two
random students
Self-filled questionnaire exiting the canteen
to identify allocations of
supports needed
Fig. 1 Research stages
Tri-Ethnic Centre for Prevention Research (Colorado State Therefore, the research team made some adjustment to
University)(19,20). The CRT was designed for the planning the CRT tool to serve the programme needs. The CRT
andevaluationofcomplex,community-basedhealthinter- adaptation, performed by the research team, was further
ventions(21) but has also been usedandvalidatedinvarious validated by the Delphi procedure. The resulting, adapted
(22–24) tool is presented in Table 1.
community-based nutritional intervention studies .
The school CRT enables the assessment of six dimensions Theinitial CRT dimensions are community efforts, com-
of readiness, providing a qualitative score based on nine munity awareness of the efforts, leadership, community
(25,26)
stages of readiness . The study was designed to help knowledge about the issue, resources allocated for the
the Southeast Asian Ministers of Education Regional issue and the community climate while the current study
CentreforFoodandNutrition,inmappingtheschoolcom- only assesses five dimensions, leaving out the community
munities readiness to adopt and build collaborative efforts climate dimensions. A simplified, three-stage model of
for the school-based adolescent nutrition programme. readiness was used, based on previous study by
https://doi.org/10.1017/S1368980020001299 Published online by Cambridge University Press
School readiness for nutrition intervention s75
Table 1 Semi-structured interview items
Questions
1. Which nutritional problems do you consider to be important to tackle in this school?
2. Why do you think these problem(s) is (are) important?
3. Are any efforts being made by the school to tackle the problem that you have identified?
4. For how long have these efforts been made?
5. Who is responsible for these nutrition-related efforts?
6. Have the school principals been involved in these efforts?
7. How are the school principals involved in these efforts (fund raising, management, assigning task force, etc.)?
8. Are there special resources allocated for nutrition efforts in this school? Can you describe them?
9. Does your school receive sufficient support (training, funds, monitoring and evaluation) from the city health authority? Was the support
appropriate for your need? What do you need from them?
10. Doesyourschoolreceivesufficientsupport(training,funds,monitoringandevaluation)fromthecityeducationauthority?Wasthesupport
appropriate for your need? What do you need from them?
11. What are the barriers you experience in the implementation of the current nutrition-related efforts?
12. Whatareyoursuggestionstoimprovenutritionprogrammesandactivitiesforstudentsinyourschool?Whatareyourneedsandconcerns
in this respect?
Table 2 Readiness phase and criteria
Readiness phase Suggested collaborative intervention
Phase 1: Pre-action
Communities have little to no awareness of adolescent nutrition Supply evidence based on the importance of nutrition in
problem and eating behaviour problem. No efforts have been adolescence, advocate the issue of adolescent nutrition
conducted to address the problem, and the community is not and eating habit, support efforts to identify and address
aware of ongoing efforts done, if any. No resources are allocated issues in nutrition and eating behaviour at school and
for the issue identify internal and external resources
Phase 2: Action
The community and leaders are beginning to organise and conduct Focus on supporting and/or facilitating ongoing efforts and to
efforts related to adolescent nutrition and problematic eating improve the quality of implementation. Initiate mobilisation
behaviours. They have a sense of how nutrition problem in and/or coalition development to increase support from
adolescent affects the school community. Some resources have identified internal and external stakeholders
been allocated for efforts of addressing the issue and building
collaboration although adequacy and sustainability are still a
problem. There is interest in partnership development of
partnerships and mobilisation of the school community to address
the issues of adolescent nutrition
Phase 3: Maintenance
The community leaders have been engaged in continuous efforts to Focus on sustaining the quality of programme
address issues regarding adolescent nutrition and eating habit. implementations. Consider rallying support from diversified
Community-wide initiatives involving all of the school elements coalitions and from new sectors. Support the dissemination
maybeunderway. The school community has built partnerships of best practices and lessons learned from the school
and may have built name recognition for their adolescent nutrition community to new communities for further scale-up
programme and secured a funding stream
(27) the issue, as well as the suggestions from respondents on
Martinez et al. on community-based collaborative
efforts. The adapted, three-stages scoring format is shown how to improve nutrition interventions at their school.
in Table 2. To ensure agreementinscoring,threeindepen- Each interview with teachers and the school principals
dent raters read the qualitative result in order to create a was conducted by trained enumerators and lasted about
consensus on the school community readiness level. The 30–50min. Semi-verbatim transcription notes from the
inter-rater agreement of scores in the five dimensions interviews were grouped according to predetermined
was calculated in IBM SPSS v24 (two-way mixed, average themes based on the community readiness dimensions
measures and absolute agreement), and the result was and rated by an open code for identification of readiness
moderate with an interclass correlation average measure levelusingaMicrosoftExcel2013worksheet.Alltextswere
of 0·75 (P<0·05). written and processed in Bahasa Indonesia, and selected
The structured in-depth interview guide was aimed to quotes were then translated into English for further use.
explorefiveofthesixdimensionsofcommunityreadiness, Following the in-depth interviews, respondents were
namely community efforts, community knowledge of the given time to complete questionnaires on (i) the attitude
efforts, leadership, community knowledge about the issue regardingtheimportanceofvariousnutrition-relatedactiv-
of adolescent nutrition and resources allocated related to ities to be conducted in their school, (ii) self-perceived
https://doi.org/10.1017/S1368980020001299 Published online by Cambridge University Press
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