This cross-sectional interventional study was conducted in various schools of Delhi, Gurgaon, Faridabad and Mumbai from April 2018 to February 2019. The study population were males and females children of class 4^th and above in the age range of 8-14 years. As mentioned in the introduction, nutrition requirements in adolescent age group increases and therefore nutrition education at this age will provide right direction to children in making correct food choices and thus help in reducing health issues in later stages of life. A target of 0.4 million school children was set for this awareness program. This target was based on the reach of PepsiCo and its partners to around 200 schools in Delhi NCR and Mumbai regions.

The impact assessment study of nutrition education was done through a pre and post-survey for a statistically acceptable sample size of 10% of the decided target [25]. A total number of 34,773 students got enrolled after their schools agreed to participate in this educational program. Participating schools then registered [26] on Eat Right School portal created by FSSAI. Since this study was a part of Eat Right School, a program by FSSAI which is a government organisation no separate ethical approval was sought for this study. Also, school registration on FSSAI portal was considered as a consent and no individual consent was taken from parents and students.

Inclusion criteria: Both male and female children in class 4^th-9^th (age range of 8-14 years) from the school willing to participate in both pre and post-nutrition education intervention were included in the study.

Exclusion criteria: Male and female children below and above the selected age range were excluded from the study.

Data collection tool employed in this survey was a self-developed questionnaire. This questionnaire covered information on demographic parameters like age and gender along with questions to assess knowledge and awareness of a children in 5 key elements related to iron including- role, sources, iron deficiency anaemia, iron absorption, and knowledge of fortification. This questionnaire was designed on the basis of questionnaires used in similar surveys conducted by other researchers [5,19,20,27] and by the experts of PepsiCo India Pvt., Ltd. The validity and reliability of the questionnaire was verified by the panel of professionals consisting of Nutritionists, Dieticians and Academicians in nutrition field. It was found to be acceptable by this panel based on their vast experience in the nutrition research. All the questions designed were closed ended. Sample questionnaire is given in [Table/Fig-1]. Students were asked to complete this questionnaire in maximum 30 minutes as a part of pre-intervention assessment to obtain the baseline data.

Following this pre-intervention assessment a training session was conducted for the SNF Fellows by FSSAI on Safe and Nutritious Food (SNF) program and SNF portal navigation and by PepsiCo Nutrition Sciences team on the nutrition topic “Importance of Iron”. SNF Fellows visited the schools and briefed the children about the program. This was followed by an awareness session on importance of iron using techniques like, interactive activities and quizzes [28] developed by PepsiCo and FSSAI. Session also included presentation on sources and inclusion of iron rich foods in daily diet, inhibitors of iron absorption, symptoms of iron deficiency, etc., followed by a video covering the same topics. Calendars and classroom posters delivering the key messages of the session were distributed to students for reinforcing the importance of iron in diet [Table/Fig-2].

[Table/Fig-2]:

Awareness session conducted in schools.

After a minimum gap of seven-days, the children were asked to complete the same questionnaire in maximum 30 minutes as a part of post-intervention assessment. Pre and post-training assessment were done by scoring method which involved use of mean, standard deviation and percentage as described by Nimbalkar P et al., [29].

Both pre and post-education questionnaire results were analysed using SPSS statistical software, version 10. A chi-square test [27] with 0.001 as level of significance was applied for pre and post-intervention comparison.

A total of 34,773 students participated in this survey. However, by the end of study, there were 223 dropouts due to absenteeism and 34,550 (99.3%) students completed the survey successfully by undertaking both pre and post-intervention assessments. Age group considered for this survey was between 8 to 14 years. On statistical evaluation, it was found that 54.0% of the children were in the age group 11-14 years followed by 35.7% of 10 years of age and 10.2% of 9 years of age. [Table/Fig-3] below highlights the age wise distribution of students.

On analysis of gender distribution, it was observed that only 27,355 students (79.4%) opted to answer this question, out of which 58.1% (n=15899) of the children were males and 41.9% (n=11456) of the children were females.

The self-developed questionnaire used for this study was designed to assess the preliminary knowledge of children about iron and iron deficiency anaemia [Table/Fig-1]. These questions were multiple choice based and students had to select correct answer. Since, it was not mandatory to answer all the questions, analysis was performed on the basis of the number of students answering particular question. All the questionnaires which presented answers to both pre and post-intervention assessment attempted were considered as completed questionnaires. Questionnaires were not rejected on the basis of unmarked questions. The results of pre-interventional survey in 5 identified areas are shown in [Table/Fig-4].

The results for first two areas of importance/role of iron and iron deficiency anaemia highlight that students were aware about what is anaemia and what are its causes. However, percentage of participants knowing the sources of iron rich food, concept of fortified food was comparatively less. The results of sources of iron, iron absorption and knowledge of fortification clearly reveal that there was lack of awareness about importance of iron in many students which could be the major contributing factor for negative attitude and lack of good eating practices for preventing iron deficiency anaemia. Pre-intervention study was followed by a session which was designed to create awareness about ‘importance of iron’.

After the initial assessment and educational intervention; post-assessment was performed to evaluate the impact on the awareness of the study participants about importance of iron and iron deficiency and significant improvement in knowledge (p-value <0.001) was seen. [Table/Fig-4,5] indicates that in the post-intervention assessment; students showed statistically significant increase in knowledge when analysed for responses to the questions based on five key elements namely importance/role of iron (32.2% increase), iron deficiency anaemia (25.82% increase), sources of iron in food (26.5% increase), nutrients that enhance iron absorption (25.20% increase), and concept of fortification (21.5% increase).

According to United Nations International Children’s Emergency Fund (UNICEF), child hunger is a very significant issue today and approximately 149 million children world-wide are malnourished [1]. Malnourishment can be the result of non-availability of food or lack of knowledge about nutrition. One step to contribute towards reduction of malnourished cases is to impart knowledge to the young children. Research evidence suggests that nutrition education in schools is more likely to bring about positive behaviour changes in terms of adapting nutritious eating habits [8,30-32]. In a survey published by Tuuri G et al., “The Smart Bodies research program demonstrated that a short-term school-based intervention could successfully improve knowledge of healthy nutritional practices and self-efficacy to consume fruits and vegetables [8]. With guidance from program leaders, cooperation from teachers, classroom activities, and school lunch foods, children can increase their preferences for fruits and vegetables and begin making behavioural changes to improve their diets”. The key findings of University of California Cal Fresh Nutrition Education Program [30] likewise emphasise that along with a focus on direct nutrition education, an emphasis on enhancing foods available on the school campus, establishing family and community partnerships, and empowering school stakeholders to implement the school district’s wellness policies will improve nutrition practices in children. It will also improve the healthy eating practices in children. Research by Passmore S and Donovan M, suggests that children who attend schools with well-developed food education programs (cooking and growing) have better knowledge about making healthy food choices and creates a positive impact on pupils’ healthy lifestyle behaviour [31].

The fundamental ideology of school education having a high success rate in community related issues than education offered on individual basis at home gets verified by a UNICEF report released in Oct 2012 on School Water, Sanitation and hygiene Knowledge, attitudes and Practices Survey [32]. Nutrition education should include all the educational activities that engage students, not only through direct classroom education but also through other venues throughout the school campus during the school day that are designed to motivate students and facilitate adoption of healthful food choices [14,33,34]. A comprehensive nutrition program run in schools in United States of America (USA) by The Academy of Nutrition and Dietetics, the Society for Nutrition Education and Behavior and School Nutrition Association [33] reveals that a promotion of healthful choices at school through nutrition standards, snack guidelines, and nutrition education can guide students to make life long healthful decisions in terms of food and nutrition.

Based on the above observations and findings from various researchers and published evidence [14,31-35], this study was designed with the objective of imparting education to school children on the importance of iron and iron deficiency anaemia in cities of India. A significant improvement was seen in the post-interventional results of this survey and indicates that the objective of this study is fulfilled. The age group 8-14 years was selected due to its high likelihood to suffer from anaemia due to various reasons [36]. It was decided to undertake this study in various schools of Delhi NCR and Mumbai region. In this way, maximum population could be educated in lesser time. For the purpose of this study, it was necessary to understand the baseline knowledge of children in the area of iron nutrition. Critical analysis of the data was performed to assess the level of knowledge children had. Findings were found to be consistent to a previous study stating that iron deficiency anaemia typically results from insufficient or wrong dietary intake [37]. The results for first two areas of importance/role of iron and iron deficiency anaemia are similar to a study conducted by Angadi N and Sanjitha A, where participants were aware about what is anaemia and what are its causes [38].

However, pre-interventional assessment also revealed a finding that matched to another study by Patimah S et al., about poor knowledge regarding diet associated with iron deficiency anaemia [39]. Based on the analysis as described in results above; weaker areas can be identified, and future intervention programs can be designed to educate children. It is necessary to assess the change in knowledge of participant’s post-educational intervention to study the impact of awareness program. In this population group, evidence suggests that nutrition education intervention was effective, as it improved the knowledge scores attained. Significant increase in knowledge on food-based strategies promoting consumption of iron-rich foods and foods that increase absorption of iron (vitamin C rich foods) was also observed in the study performed by Kapur D et al., [25].

Other findings of the study regarding nutrients enhancing iron absorption, concept of fortification, wrong combination of foods affecting iron absorption were found to be parallel to a similar study conducted by Jalambo M et al., [40]. Though statistically significant increase in percentage to responses in post-intervention phase in comparison to pre-intervention phase was seen, it was evident that conducting continuous sessions will help in improving not only knowledge but also attitude of children towards healthy nutritional habits. Guiding children on various aspects of iron, iron deficiency and problems associated with it and role of nutrition in preventing these problems can be of great use to improve eating habits in children. The findings of the present study match the findings of another study performed by Bandyopadhyay L et al., which highlights that knowledge of anaemia, knowledge regarding aetiology and harmful effect of anaemia, vegetable and animal source of iron, Vitamin C -rich fruits, and food preventing iron absorption considerably improved in post-test phase [27].

It can be inferred from this study that nutritional health education sessions driven by educational institutions can be a stepping stone to increase nutritional literacy in developing countries. Including such sessions in school curriculum with the help of expert nutritionists and health professionals can be advantageous for improving attitude of children towards healthy eating habits. Improvement in knowledge and attitude towards healthy eating will ensure increased healthy eating practices and improved nutritional status [41]. To strengthen this drive further and to reduce the gap existing in health and nutrition-related knowledge, few sessions can also be conducted for parents and children together [42]. It is evident in a study conducted by Shah P et al., that it is important to start early and sustain health education efforts throughout a child’s school experience. These efforts should appropriately include participation by parents as well as teachers in pre-school, elementary, and secondary schools [43]. Additional sessions can be conducted for adolescent girls [19,27] considering the supplementary demand for iron in young age.

Thus, results of the study with large sample size and multi-centric nature, rejected the null hypothesis. Hence, the alternate hypothesis highlighting the role of nutrition education in improving the nutrition literacy of school children in the area of iron and iron deficiency anaemia holds true.

The authors carried out knowledge intervention which was followed by end line testing after a gap of a minimum of 7 days. Repeated interventions would be required to sustainably enhance the knowledge about iron. Further in this study, the age wise analysis for each element, change in attitude or in the prevalence of anaemia as a result of the knowledge intervention were not studied.

Rejection of null hypothesis and thus acceptance of alternate hypothesis makes it evident that conducting nutrition education session in schools increased the knowledge of children with respect to role of iron as trace element in physiological function, iron deficiency and anaemia, nutrients that enhance iron absorption, methods of preventing iron deficiency anaemia, combination of foods not to be consumed, concept of fortification and food-based strategies promoting consumption of iron-rich foods. Continuous implementation of nutrition education programs on wider scale is very important to visualise the marked improvement in nutritional status of school children in the entire nation. Future studies in nutrition education with assessment of prevalence of anaemia before and after the intervention, as well as the changes in attitude and practice as a result of the intervention are thus required. This can be also supplemented with study assessing the knowledge level at different age groups and study of the changes in dietary pattern of children, haemoglobin assessment, changes in energy levels, improvement in concentration levels and increase in the consumption of iron rich foods.

Disclosure: Richa Bharti, Ankita Marwaha, Teena Badshah are employed by PepsiCo R&D. The views expressed in this manuscript are those of the authors and do not necessarily reflect the position or policy of PepsiCo, Inc. This is a self-funded study by PepsiCo R&D.

Since this study was a part of Eight Right School, a program by FSSAI which is a government organisation no separate ethical approval was sought for this study. Also, school registration on FSSAI portal was considered as a consent and no individual consent was taken from parents and students.