Growth Through Nutrition in School. Adolescent Nutrition Interventions and Effectiveness of Radio Spot Dissemination Related Activities Based on the CIPP Model

Table of Contents

Chapter One
INTRODUCTION
1.1. Introduction
1.2. Background of the study
1.3. Identification of the problem
1.4. Purpose statement
1.5. Significance of the study
1.6. Research questions
1.7. Assumptions
1.8. Limitations
1.9. Operational Definitions

Chapter Two:
LITRATURE REVIEW
2.1. Legal considerations
2.2. Nutrition communication
2.3. School based health and nutrition programs
2.4. School Nutrition Clubs
2.5. Media role for nutrition behavior change
2.6. School mini-media roles for behavior change
2.7. Theoretical Backgrounds: CIPP and KAPs Models

Chapter Three:
METHODOLOGY
3.1. Sampling Procedure and Participants
3.2. Development and dissemination of audio nutrition messages
3.3. Procedure
3.4. Instrumentation
3.5. Data Collection and Analysis
3.6. Validity and Reliability
3.7. Ethical Considerations
3.8. Dissemination of the Research Findings

Chapter Four:
RESULTS and DISCUSSIONS
4.1. Results
4.2. Discussion

Chapter Five:
CONCLUSIONS and RECOMMENDATIONS
5.1. Conclusions
5.2. Recommendations

References

APPENDICES

Chapter One

INTRODUCTION

This chapter deals with a brief introduction about essence and values of nutrition education in school. The chapter explains concept definitions, brief history of the topic as well as related researches. It also describes the problem that is going to be solved, assumptions and limitations of the research.

1.1. Introduction

Nutrition Social Behaviour Change Communication (Nutrition-SBCC) and studying its impacts in schools has received much attention in recent years because it influence students as well as their families nutrition related practices by affecting change in behaviour in general and changes in knowledge, attitudes, beliefs and norms in particular. The Nutrition Social Behavior Change Communication stress that in addition to information, individuals also need access to resources, decision making power, motivation, encouragement, confidence, support, and a shift in gender and social norms that requires promotion through several approaches and many channels, for various influencers at multiple levels (SC-GtN-SBCC, 2016).To be effective according to Pe´rez-Rodrigo and Aranceta (2003), nutrition-promotion strategies must be creative, engaging, and inexpensive and widely disseminated. Making opportunities for nutrition education in schools is important because children learn best when they receive information through multiple communication channels. Knowing this in many interventions nutrition promotion using audio message through radio, school mini-media, print materials, games, club activities, teachers other actors support as well as participating in school garden activities are employed. However, the impacts of such interventions on students’ knowledge, attitude and behaviour change are rarely evaluated. Effective communication comprise four steps: 1) preliminary research – appropriate key messages with targets, 2) planning– decision making, 3) communication – listen the message with change in action, and 4) evaluation. The final step is crucial since the evaluation will act as a guideline for the organization to determine whether or not its entire communication effort has met its objective(s) and the information retrieved from the evaluation can be beneficial for both current and future communication projects (Smith & Benjamaporn, 2013).

One way to look the effects of media on nutrition behaviour change in school is using Context, Input, Process and Product (CIPP) model which is integrated with Knowledge, Attitude and Practice (KAP’s) evaluation component. CIPP according to Patton (1997), is the “systematic collection of information about the activities, characteristics, and outcomes of programs to make judgments about the program, improve program effectiveness, and/or inform decisions about future programming.”

The present research plans to identify and evaluate the effectiveness of the nutrition audio messages disseminated through school mini-media and its integration with other SBCC activities performance to provide recommendations to improve its communication activities.

1.2. Background of the study

Children are among the most vulnerable sections of the society where their mental and physical maturity preventing them from protecting their own rights and interests (Tesfaye, 2017). Hence, human rights instruments and domestic legislations impose obligations on the part of the government to provide special protection to children. Such protection according to Tesfaye (2017),is premised on the realization that ensuring the rights of children is imperative for every country since it can advance a more equitable society; foster a healthier, more literate and, in due course, a more productive population. Endorsing the UN child Right Convention FDRE’s Constitution preserves the right of every child to the highest attainable standard of physical and mental health development. The government of Ethiopia designed and implemented several laws, policies and strategies to make sure and provide the basic necessities of the child including nutrition, clothing and housing by mobilizing resources and working in collaboration with government and non government organizations.

Nutrition is a fundamental pillar of human life, health and development across the entire life span. In explaining the vital importance of nutrition for human development WHO (2000) states;

From the earliest stages of embryonic development, at birth, through infancy, childhood, adolescence, and into adulthood and old age, proper food and good nutrition are essential for survival, physical growth, mental development, performance and productivity, health and well-being. It is an essential foundation of human and national development (WHO, 2000).

People learn what and how to eat from their families and community. In human life development the family plays a key role in the process not only as responsible for feeding he child, but also by setting norms within the family, acting as role models, encouraging certain behaviors and rewarding or limiting other (Birch & Fisher, 1998).There is a complex interrelationship between nutrition, social and economic factors and health and education (Sorhaindo and Feinstein, 2009).

Malnutrition issues are greatly related with children growth and their school performance. Stunting (low height for age) is a physical indicator of chronic or long-term malnutrition, whereas underweight (low weight for age) is an indicator of both chronic and acute malnutrition. Both are common in school-age children (Partnership for Child Development, 1998). Girls who are better nourished are more attentive and more involved during class, and boys have improved classroom behavior and increased activity levels. Hunger, which reduces ability to perform school tasks, is readily reversed by feeding. Missing breakfast impairs performance to a greater extent for children of poor nutritional status.

A balanced diet that contains a diversity of foods from all food groups in minimal quantities. According to WHO (2007), “food products from cattle, sheep, goats, chickens can be beneficial as well as harmful to our health. In appropriate amounts, animal source foods are valuable sources of good quality digestible protein, micro nutrients such as iron, calcium, vitamin A and vitamin B12”. In addition to this nutrition provides the fuel that drives a child’s early development. That is according to Georgoeff, Rao & Fuglestand (1999), during the first 1,000-days, the brain grows more quickly than at any other time in a person’s life and a child needs the right nutrients at the right time to feed the mother animal source foods so that the baby brain rapidly develop. But the overconsumption of certain foods, particularly those highly saturated fat and cholesterol, salt and total energy, has been linked to overweight, obesity and subsequent diseases (WHO, 2007). Poor nutrition may also result in decreased immunity and greater susceptibility to infectious disease that has the potential to lead to increased levels of absence from school through ill health (Sorhaindo and Feinstein, 2009). Micronutrient deficiencies may take several different forms, each with negative impacts on children’s ability to perform well in school. School-age children in low-income countries are estimated to suffer from iron deficiency anemia are poor in their educational tests and are less likely to attend school (Partnership for Child Development, 2001). Iodine deficiency is related to lower general cognitive abilities and tests scores(Huda, Grantham- McGregor, and Tomkins, 2001). The vitamin A deficiency, which causes impaired immune function and increases risk of mortality from infectious disease, is an important cause of blindness. Obesity is associated with underperformance in education. In low-income countries obesity is still rare, but the prevalence in the children of many middle-income countries is high. Practically all the causes of malnutrition are behavioral – which are influenced by the behaviors of individuals and their household members as well by the behaviors of other actors, including health professionals, teachers, religious and community leaders, and policy makers. Behavioral interventions can influence nutrition-related practices by affecting changes in behavior.

Nutrition education is “any combination of educational strategies designed to facilitate voluntary adoption of food choices and other food- and nutrition-related behaviors conducive to health and well-being…it is delivered through multiple venues and involves activities at the individual, community, and policy levels” (Contento, 2007). Many books and authorities give different definitions for nutrition education the one that best describes the relationships of nutrition, education and communication is the following:

Nutrition education may be defined as a group of communication activities aimed to bring about voluntary changes in practices, which have an effect on nutritional status of a population. The ultimate goal of nutrition education is to improve nutritional status. The term "nutrition education" applies to any communication system that teaches people to make better use of available food resources with the ultimate goal of improving nutritional status. Sometimes it is customary to use the term Nutrition Education Communication (NEC)in place of nutrition education (IGNOU MFN-06, 2019).

Health education can be defined as education that consists of any combination of planned learning experiences that provide the opportunity to acquire information and the skills students need to make quality health decisions (CDC, 2015). Well-designed nutrition education can help children and youth select and consume healthy foods through enhanced awareness, skills, and motivation (USDA, 2010).The media has an extremely powerful and challenging role to play when it comes to disseminating nutrition information to the underprivileged and susceptible group of peoples with lower levels of education and higher levels of under-nutrition amongst children and women. The media can make a positive difference by:

- Advocating the importance of good nutrition and its benefits.
- Reaching out and empowering families to prevent causes of under nutrition, like diarrhea, malaria, poor infant feeding practices and poor hygiene practices.
- Advocating correct health and nutrition behavior, such as promotion of breastfeeding, hand washing practices, use of toilets and consumption of safe drinking water.
- Influencing families and communities to dismiss myths, taboos related to nutrition and changing behavior by adopting positive practices.
- Promoting nutrition, health care and family support during pregnancy. All of which helps in ensuring the health of the mother and the new born baby and reduces the risk of low birth weight.
- Laying emphasis on the care of children, adolescent girls and pregnant women.
- Disseminating information about government programs to enable better utilization of services.
- Disseminating updated scientific information on nutrition and health related issues to the public (MoWCDoI, no date).

Nutrition education is a vital part of a comprehensive health education program and empowers children with knowledge and skills to make healthy food and beverage choices. To get best result at a minimum, we should have to promote nutrition in the classroom, playground and at home. Nutrition education should be progressively part of the school curriculum for all ages, from the very early stages through secondary school. To be effective, nutrition-promotion strategies must be creative, engaging, inexpensive and widely disseminated (Pe´rez-Rodrigo and Aranceta, 2003). Participation in co-curricular activities benefits students in many ways such as gain knowledge, change attitude as well as practice new skills on several health issues, developing self-esteem, enhancing commitment, improving social relationships, learning in terms of time management and improve individual interest.

There are many reasons and characteristics of clubs that children and adolescents identify as important and that motivate them to want to participate. One reason that clubs succeed is that they are familial–participants feel that they belong and are cared for at the club. Another reason that young people participate is that the available activities are rewarding–participants learn through participating and performing in the activities. Participants also have a sense of ownership, as they are expected to contribute to the planning, maintenance, and success of the organization. Teachers at the clubs empower, support, and set high expectations for the participants, and the clubs are responsive to the needs and circumstances of their members. Many of the adolescents felt cared for at the club and reported receiving both support and advice. Adolescents mentioned psychosocial benefits far more often than physical characteristics of the clubs.

Save the Children Growth through Nutrition Project (SC-GtN) in 2016 initiated the nutrition clubs in project covered 52 schools conduct a weekly peer discussion, play nutrition games, and listen audio messages on good nutrition and what it means to their community and the students themselves. Their discussion is guided by a module designed for this purpose. The 10 members of each clubs, focal teachers, principals and woreda education office focal persons received training on nutrition including how to prepare in school and homestead gardens; how to play several nutrition games and how to deliver nutrition messages to their fellow students, to their family members and the surrounding community at large. The training gave them the necessary skills to facilitate educational sessions to their peers, the main purpose of which is for the students to take the messages to the community and raise awareness. A trained teacher assigned to be a nutrition focal person is always on board to guide and support the sessions. Increasing knowledge and understanding of the students and the community at large on adolescent girl’s nutrition appropriate feeding practice and other related issues are among the key missions of the club.

Save the children Growth through Nutrition (SC-GtNu) a six years Project (October 2016-August 2022) aiming to improve the nutritional status of women and children with focus on the first 1000 days and objective to reduce stunting by 20% in the project operational area: Amhara, Oromiya, Tigray, and SNNP regions. To do this effectively, cooperation from various entities is required, for example, the media, public health, agriculture and education institutions. This cooperation depends on many factors, including reliability, trust, and realization of possible benefits gained through cooperation, and effective nutrition promotion communication platform. In this regard one of the five strategies of the Growth through Nutrition Project is Social and Behavioral Change Communication (SBCC) on nutrition for adopting new Optimal Nutrition, WASH, and Agriculture Behavior. This new behavior expected to be achieved using Evidence-based SBCC approaches to improve nutrition, WASH, and agriculture-related behaviors.

Particularly in Amhara region the project activities were implemented in 7 zones (i.e., East Gojam, West Gojam, North Gondar, South Gondar, Awi, North Shewa, and North Wollo). The implementation approaches are innovative and intensive SBCC to promote maternal, adolescent, and child nutrition by increasing the adoption of optimal gender sensitive nutrition, WASH, and Agriculture behavioral changes with a focus on the first 1000 days. Several strategies are utilized to achieve the project objectives’ by delivering nutrition sensitive livelihoods and agriculture activities; Social and Behavioral Change Communication (SBCC) on nutrition; Water Sanitation and Hygiene (WASH); agriculture related behaviors; utilization of nutrition sensitive services; and multi-sector coordination and capacity to implement the National Nutrition Program and one WASH National Program; and other cross cutting issues.

As a part of Growth through Nutrition project since the year 2019 SBCC activities are implemented in 7 woredas (i.e., Wogera, Kobo, Mersa, JabiTehenane, BasoLiben, Guangua and Debre Sina) selected 52 schools of Amhara region. In these 52 schools nutrition clubs are established; trainings about nutrition are given to focal teachers and selected students to be cascaded for other club members; schools are encouraged and material supported to establish nutrition garden so that students can practically exercise; every week nutrition day assigned to do nutrition focused activities in schools; students are encouraged to play nutrition games supported by the project; and schools are supplied with 28 nutrition audio messages to broadcast them through mini-media.

1.3. Identification of the problem

Save the Children Growth through Nutrition Project has a Social and Behavioral Change Communication (SBCC) component on nutrition for adopting new Optimal Nutrition, WASH, and Agriculture Behavior project implemented in 52 Amhara region schools from 2016 to 2021. The nutrition audio message is stated in the year 2019. Starting from the inception year of the project some indicators of changes are observed from monitoring reports. However, the performance, total reach, changes, and problem that affect the desired goals and lessons learned are not evaluated and documented in organized manner. Evaluation of project activities is very essential to look how far the project goals are attained and get input for further planning. In this evaluative study, we will investigate the extent to which the contextual conditions, media strategies and input activities do impacted students knowledge, attitudes and practice of students on their nutrition related behaviour. In addition the study will identify ideas on future improvement of nutrition behaviour change communication strategy.

1.4. Purpose statement

The aim of this study is to assess how nutrition radio/audio messages and participation in school nutrition clubs influences the student’s knowledge, attitude and practice(KAPs) towards their health development. In the research by assessing the context and participation level on audio messages contents, inputs on learning contents and environment, the process in listening activities and product level of improvements on students KAPs. The study also aims to evaluate the satisfaction on the helpfulness of the messages as well as identify ideas to improve the overall activities based on modified CIPP evaluation model.

1.5. Significance of the study

This study provides a clear assessment of nutrition media messages and participation in school nutrition clubs influence students’ knowledge, attitude and practice. Moreover, this research also elucidates what factors facilitate and hampers the students’ performance in nutrition activities in school as well as at home.

Through this research, stakeholders and nutrition project implementers will further realize the identified ideas to improve the overall activities. The result of this research also provides valuable information for advocates to further school nutrition promotion. Through this research academic institutions and administrators may promote school nutrition programs.

Furthermore, a detailed presentation on the school level nutrition activities, strategies and factors affecting it may serve as a tool for further studies.

1.6. Research questions

Four main research questions guided the study:

1. To what extent contextual conditions, strategies and activities does have impact on nutrition audio messages delivery in schools?
2. To what extent does students’ knowledge, attitude and practice improved after listening nutrition audio messages?
3. How should the nutrition audio messages development and delivery be redesigned to better meet the needs of students?

1.7. Assumptions

The following assumptions are made regarding this study:

- Schools are best and ideal place for nutrition awareness creation on children.
- Children get maximum or at least good support from stakeholders in schools.
- Education media centers produced and disseminated quality nutrition audio messages.
- Schools create conducive conditions for nutrition activities.
- The instrument to be used will elicit reliable and honest response from respondents with full understanding of the questions they are asked.

1.8. Limitations

This research is a subject to several limitations.

- Constraints to get participants: unable to get high school and grade 8 students for questionnaire due to class end and examination time; due to conflict situation in some areas; and due to heavy rain in some areas road accessibility were difficult and lack of willingness to participate. These forced repeated discussion and appearance of data collectors until data collection is successful.
- Language barrier is another problem; for some students particularly in Guangua woreda language is problem. The data collectors used local teachers to translate the questioner into local language Awi. But we believe that the language problem were somehow affected both the media delivery and evaluation processes.
- Religion as a factor is not taken in to consideration.
- Lack of previous studies on school nutrition media interventions in Ethiopia.

1.9. Operational Definitions

Attitude:- Attitude of the students’ focuses on believe on importance of nutrition messages and demand for some support. By importance of nutrition messages which means belief of students’ on importance of the messages, needs for participation in nutrition club and their belief on the contribution of nutrition messages for their knowledge improvement. Another point is students’ attitude on the needs for some guidance from adults, continues broadcast of nutrition messages via mini-medias and necessity of group discussion after broadcast.

Knowledge:- Students understanding of information’s about nutrition issues like knowledge on star foods, as defined by the project; knowledge on adolescent girls feeding, avoid misconceptions about nutrition

Mental interaction: - The mind’s casual interaction with the world, and in influence on behaviour- is central to our concentration of ourselves as agents. Mind-world interaction is taken for grant in everyday experience. Compared to text messages voice-based communication tend to create a stronger bond (Kumar & Epley, 2021)

Mini-media:- Mini-medias in schools guided by teachers produce and disseminate messages via megaphone, amplifiers and microphones during break times. Students participate, entertain and learn from mini-medias. According to Yidnekachew (2018), school mini-media are useful instruments to facilitate the activities of individual co-curricular clubs and similar arrangements besides their use in their own to raise students’ communication and speaking and writing skills and their support in promoting co-curricular programs to the schools’ community.

Nutrition Audio Messages:- The 28 nutrition focused short audio messages broadcasted through education radio stations and school mini-medias.

Practice:- is students’ practice of hand washing; growing vegetables and raising animals, their knowledge sharing practice, whether they advise adolescent girls not buy and drink soft drink.

School Nutrition Clubs:- School nutrition clubs are venues of getting nutrition information and participation that should consider the needs and interests of students, teachers and the school all the groups meeting in the school setting should be invited to become relevant actors in the nutrition activities.

Understanding:- knowing something new about nutrition issues and improvement in knowledge on star foods are essential for girls brain and body development; improvement in knowledge on adolescent girls feeding, avoid soft drinks and avoid misconceptions about nutrition

Chapter Two:

LITRATURE REVIEW

This chapter deals with discussions about school based nutrition education using affordable media benefits, principles and trends. The first part discusses the legal considerations concept of nutrition education for children which includes the conventions our country accepted as part of the laws dealing on children. In the second part describes the school based health and nutrition programs. The third part discusses about the school nutrition clubs roles. The fourth part presents media role for nutrition behavior change and media message total reach measurement. The fifth part deals about school mini-media role for behavior change. The last part contains mainly theoretical framework which is central concept for conducting the study. The literatures also include points that are hoped to shade some light to the discussion.

2.1. Legal considerations

The Government of Ethiopia ratified the UN CRC in 1992 (FDRE, 1992). The State of Ethiopia adopted a new Constitution in December 1995, which improved in many ways the legal protection of children. Article 36 of the Constitution pertains specifically to the rights of children, and was drafted taking the provisions of the CRC into account (Haggstrom, 2003).Article 41(4) of the FDRE Constitution obligates States Parties to allocate ever increasing resources to provide to the public health, education and other social services. As Geremachew&Yonas (20120), stated Article 27 is closely linked with Article 6 of the CRC which lays down the right to life and maximum survival and development. These provisions imply the need to fulfill the basic necessities of the child including nutrition, clothing and housing. Apart from these, it also points to the need for the fulfillment of clean drinking water, health education, good hygiene and sanitation and breastfeeding.

In addition to endorsing UN-CRC the government of Ethiopia ratified African Charter on the Rights & Welfare of Children and also in 2017 developed and implemented a National Child Policy. The Ethiopian National Child Policy Article 3.3 C and D say measures should be taken to ensure nutritional adequacy (FDRE, 2017). The African Charter on the Rights & Welfare of Children Article 14:2d & 14:2h as EDREMJ (2003), stated every country shall take measures:-

- to combat disease and malnutrition within the framework of primary health care through the application of appropriate technology.
- to ensure that all sectors of the society, in particular parents, children, country leaders and workers are informed and supported in the issue of basic knowledge of child health and nutrition, the advantage of breastfeeding and sanitation and domestic accidents (EDREMJ, 2003).

The government of Ethiopia in addition to the efforts by the agricultural and rural development sector, which plays a role in availing adequate nutrition to the population, the health sector also initiated the National Nutrition Strategy (NNS) in 2008 with the objective of ensuring that all Ethiopians secure adequate nutritional status in a sustainable manner, which is an essential requirement for a healthy and productive life(Committee on the Rights of the Child, 2012).The same document Committee on the Rights of the Child (2012), added that the health sector initiated enhancement of good nutritional practice through (1) health education and treatment of severely malnourished children, and (2) prevention of nutritional health problems through provision of micronutrients to vulnerable groups of the population (mothers and children).

The Ethiopia constitution and CRC contain articles about the role of media for children wellbeing’s and their health. As Haggstrom (2003), stated the right of the child to freedom of expression, freedom of thought, conscience and religion and freedom of association and of peaceful assembly is ensured by the Constitution of the FDRE in articles 27-31. Civil rights and freedoms (Art. 7, 8, 13-16 and 37) is especially manifested in the participation of children in drawing, poem and essay competitions at the national and international levels and in their participation in the regular weekly radio programs for children (Haggstrom, 2003).CRC Article 24 indicates the right to health care service and appropriate information’s about health care issues. Article 24(2) (e) of the CRC which stipulates that Member States must make sure that children as well as parents are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding, hygiene and environmental sanitation and the prevention of accidents (FDRE, 1992). Article 17 of CRC assures the right of the child to access appropriate information (FDRE, 1992). The focus of Article 17 is on the role of the media in regard to the rights to rights of children. The provision also specifies the child’s access to information and material from various sources, in particular those meant to promote well-being and physical and mental health. Moreover, Article 17 implies that children should have access to the media to exercise their participatory rights. Article 12 and 13 of CRC declared the right to express their views, seek, receive and impart information through all means that includes media.

The National Child Policy of Ethiopia has Articles which stress the use of media and communication channels to make children participate in and aware that can be used in nutrition and health issues. Article 2.34 says children’s meaningful participation on matters that affects them is essential so that it is important to enhance and encourage them appropriately to their age and level of maturity (FDRE, 2017). In the same document Article 3.3.J says creating an enabling environment for children to have awareness, access to information, and counseling. Similarly Article 3.5.G says ensuring and encouraging print and electronic media to incorporate children issues; Article 4.2 & 4.4 says awareness creation and increasing the role of media and ensuring that the contents of media programs give attention to children’s wellbeing; enhance children access to information and participation in dissemination of information are some of the policy implementation strategies.

2.2. Nutrition communication

Nutrition communication can be defined as a process by which nutrition knowledge is converted into dietary changes (Rayner, 2003). According to Andrien (1994), nutrition communication is an art and technique of informing, influencing, and motivating individual, institutional and public audiences about the importance of nutritional issues. The benefits of communication according to Gavaravarapu (2019), includes providing the public with sound and accurate nutrition information, influencing health and nutrition policy and gaining grate visibility of nutrition activities. Some of the objectives of any kind of nutrition communication project includes improve the nutritional status of a specific community; restrict misconception about nutrition; implement healthy diet; encourage on home production practice; ensure better use of food resources; and eliminate wrong concepts and ideas about nutrition (Rahman, 2017).

2.3. School based health and nutrition programs

School based health and nutrition programs which focus on promoting health and improving the educational outcomes of children, as well as being socially progressive and specifically targeting the poor, girls, and other disadvantaged children. This evolution according to Bundy D, Shaeffer S, Jukes M, et al. (2006), reflects five key changes in our understanding of the role of these programs in child development.

- First, ensuring good health at school age requires a life cycle approach to intervention, starting in uterus and continuing throughout child development. In programmatic terms this requirement implies a sequence of programs to promote maternal and reproductive health, management of childhood illness, and early childhood care and development. Promoting good health and nutrition before and during school age is essential to effective growth and development.
- Second, operations research shows that the pre existing infrastructure of the educational system can often offer a more cost-effective route for delivery of simple health interventions and health promotion than can the health system. Low-income countries typically have more teachers’ than nurses and more schools than clinics, often by an order of magnitude.
- Third, empirical evidence shows that good health and nutrition are prerequisites for effective learning.
- Fourth, the provision of quality schools, textbooks, and teachers can result in effective education only if the child is present, ready, and able to learn.
- Finally, education, including education that promotes positive health behaviors, contributes to the prevention of several diseases which are the greatest challenge for generations to come. School health and nutrition programs that help children complete their education and develop knowledge, practices, and behaviors that protect them from HIV infection as they mature have been described as a “social vaccine” against the disease. (Bundy D, Shaeffer S, Jukes M, et al., 2006).

2.4. School Nutrition Clubs

Human beings are social animals forming various bonds with other people helping each other and live social life. The meaning and quality of someone’s social life is influences on their mental and physical health. A social action view emphasizes social interdependence and interaction in personal control of health-endangering behavior (Ewart, 1991). Many people take their cue for appropriate action from peers, and significant individuals in one's environment are often influential in alerting people about risk, suggesting ways to reduce risk, and in modeling specific methods for changing behavior (Coates, Stall, & Catania, 1988). There are a number of reasons that both scholars and parents expect young people to benefit from participation in clubs and youth organizations. These reasons have to do with the activities, roles, and relationships available to children and adolescents when they participate in clubs. According to Norland and Bennet (1993), club activities are important for students in several ways.

1. Participation in a supervised constructive activity limits the time that is available for less constructive activity, such as television watching, or for getting involved in risky behaviors.
2. Activities offered by clubs or youth organizations enable members to learn valuable skills. Many of the activities offered by clubs help students to extend and elaborate on the more formal knowledge learned in school.
3. Provides an opportunity to participate in new roles like leadership, helper, singer, artist etc.
4. Relationships formed with adult leaders and with peers at the clubs are important. Adults and peers at these organizations can serve as models and as sources of social support, friendship, and caring (Norland & Bennet,1993 and Steven, 1991).

Schools are critical links to homes and communities, besides being natural conduits for learning and generating knowledge. As schools can influence parents, teachers and the larger community, cascading benefits can be realized with well-designed school-level initiatives (IIRR, 2018). Pe´rez-Rodrigo and Aranceta (2003), said in school-based nutrition education should consider the needs and interests of students, teachers and the school all the groups meeting in the school setting should be invited to become relevant actors in the activities. Children who have been involved in their school nutrition activities can influence their families and siblings, potentially decreasing the number of children entering schools already malnourished. Involving families in their children’s nutrition education and engendering community participation through activities such as school gardens and school feeding can spread the message and benefits to a wider range of people(UNSSCoN, 2017).

As Keith, (1996) and Daniel, Earl, and Satish, (2000), indicated there are several reasons that clubs succeed: 1) that they are familial–participants feel that they belong and are cared for at the club; 2) that young people participate is that the available activities are rewarding–participants learn through participating and performing in the activities; 3) have a sense of ownership, as they are expected to contribute to the planning, maintenance, and success of the organization; 4) Adults at the clubs empower, support, and set high expectations for the participants, and the clubs are responsive to the needs and circumstances of their members (Keith, 1996, and Daniel, Earl, and Satish, 2000).

Researches indicated nutrition clubs are effective in attaining the goals they are organized. Long time ago school-based interventions like club activities have been identified as one of the “most efficient means the nations might employ to reduce four main chronic disease risks: tobacco use, unhealthy eating patterns, inadequate physical activity, and obesity” Kolbe, Kann, Patterson et al., (2004). The research conducted by Vogin, Rooks and Finkbeiner (2014), on nutrition clubs achievements in USA. During the 2012-2013 school years, 7 after school Nutrition Clubs in Maryland USA were created to deliver nutrition education and help students develop cooking skills, provide opportunities to experience new foods, and become accepting of a wider variety of foods. A total of 104 youth were reached through 7 after-school Nutrition Clubs. Club length ranged from 7-16 sessions, with students receiving an average of 13.6 hours of nutrition education. Students reported that on the day prior to survey administration, they doubled the number of fruits eaten from 1fruit at the beginning, to 2 fruits at the conclusion of the program. Preference increased significantly for 8 of 25 food items assessed: squash, peaches, pears, oranges, bananas, brown breads, brown rice, and oatmeal. When grouped, preference increased significantly for fruits, vegetables, and whole grains, from ‘‘like a little’’ to ‘‘like a lot.’’ Students reported a significant increase in their ability to prepare their favorite fruits and vegetables at home. In another study where Santa Maria High School Community Health Center, in Santa Maria California organized Nutrition Club ; with the objective of promoting healthy foods on campus, the Nutrition Club was instrumental and effective in removing soft drinks from the 3,000-student campus and replacing it with water (CSHC, 2008).

In Africa a study was conducted by Kipchumba, (2018), on nutrition clubs which were set-up in Somali/Somaliland 10 schools of Baidoa district where each treatment schools and each club consisted of 10 students (five male and five female) who received training in schools by SCI nutrition team. The clubs provided interactive peer-to-peer nutrition education platforms, actively delivering messages on balanced diet for prevention of malnutrition. A baseline survey conducted in Feb of 2017, which was followed by 6-months of intervention period. An end line survey was conducted in Oct, 2017. Nutrition clubs in treatment schools were successful in increasing nutrition knowledge and dietary diversity among the general students. The study found out that nutrition clubs had significant effects on students’ knowledge on responsive feeding (i.e. when and how much to eat). The result shows that lack of nutritional awareness is a constraint to improving nutrition status even if the households have access to nutritious food. Children from poorer households have limited options when it comes to food items consumed at household level; hence even if they are aware of the need to diversify diets; they have to content with what is available at home. In general this research result shows a clear process of change, whereby the nutrition promotion through nutrition clubs increased students’ dietary knowledge, improved dietary diversity and resulted in better health status. This study shows high prevalence of underweight students at baseline where eight in every 10 students were underweight based on body mass index (BMI≤18.5kg/m2). Due to the nutrition clubs’ intervention the rate of underweight has reduced by 15 percentage points for these students. In conclusion, nutrition clubs in schools prove to be an effective tool in addressing under-nutrition among schoolchildren (Kipchumba, 2018). Its effectiveness is constrained by access to food at household level. This shows the need to not only address knowledge constraints but also availability of diverse food at household level.

The crucial factor in implementation of school level nutrition intervention is context like environment and policy support from government bodies. Stokols, (1992), says the environment can be viewed as an enabler of health behavior exemplified by exposure to interpersonal modeling or cultural practices that foster positive health behavior. Environmental settings and social systems affect personal behavior by channeling a person's interpretations of events (Ewart, 1991). Stokols (1992), stated that opportunities for designing health supportive environments at local levels will be more and more influenced by the regulatory and economic policies implemented in municipal, regional, and international contexts. For instance, according to ATONU (2018), report Tanzanian school nutrition clubs have not been active because many wait to have clearance from the national government.

In Ethiopia one research conducted in Amhara region by Kenaw Gebreselassie and Sosina Melese (2016), evaluated the achievements Qerere 1st Cycle and Junior school located in the East Gojam zone of Machekel woreda, at Qererkebele. Qerere primary school is one of the schools; with support from DeutcheStiftungweltbevoerkerung (DSW), it established health and nutrition club and carry out different nutrition related activities. Kenaw and Sosina found out that the Qerere School nutrition club members received training on nutrition including homestead garden patch preparation and how to deliver nutrition messages to their fellow students and the surrounding community at large. The training gave them the necessary skills to facilitate educational sessions to their peers, the main purpose of which is for the students to take the messages to the community and raise awareness.

One club member said; as members of the Health and Nutrition Club of our school, we prepare and deliver key nutrition messages to our fellow students through drama, poem, songs and cooking demonstration. In a bid to reach many students and through them the wider community, we use the school mini media. We also organize community conversations in the villages and inject nutrition messages through drama we show amid the conversation. These ways, we create awareness about the importance that nutrition has to a healthy physical and metal growth of children as well as adults (Kenaw & Sosina, 2016) .

One nutrition focal teacher said; as part of the nutrition initiative we are involved in, our school has prepared a garden patch, which we mainly use as a learning center for students to learn gardening and vegetable growing skills. We encourage them to do the same in their home-yard and also create awareness in their community. The school as change agent has achieved a lot regarding awareness creation among the community. Inspired by the school nutrition club, many households began to have backyard garden of their own (Kenaw&Sosina, 2016) .

In general according to Kenaw &Sosina, (2016),the schools’ involved in similar project activities efforts to tackle malnutrition and boost good nutrition reach the community through the nutrition club members and other students who take the messages home every day. In this regard, Qerere school’s contribution has been notable to whatever change is seen on nutrition in the community. According to Kenaw & Sosina, after the implementation of the project in Qerere school nutrition issues become the agenda of the school and the surrounding wider community.

In another report on average, 25 pupils belong to a nutrition club in a school and mostly are between grades 4 and 7 have been well received in SNNPR Ethiopia, where all schools in the 20 villages are actively participating in activities which include school gardens, sports, card games, debates, drama, story writing, quiz and related activities, all to teach the students about nutrition and how they can achieve better nutrition through agriculture (ATONU, 2018).

2.5. Media role for nutrition behavior change

Communications that explicitly (instill in people the belief that they have the capability to alter their health habits and instruct them on how to do it) increase people's determination to modify habits detrimental to their health (Bandura, 1990). Bandura added that to strengthen the staying power of self-beliefs health communications should emphasize that success requires perseverant effort. According to Lau, et al., (1980), the media cannot, of course, directly affect behavior; it must work indirectly through beliefs and attitudes. The truthfulness and believability of media messages is very essential to create positive impact. For this highly credible sources are more likely to produce attitude change than low credibility sources (O'Keeffe, Nesselhof-Kendall, & Baum, 1990).

The impact of the media on children’s health has traditionally been a topic for intense discussion and debate. Some aggressive media campaigns linking food with entertainment directed towards children are designed to encourage children to influence their parents’ shopping decisions (Sorhaindo and Feinstein, 2009). However, there is an argument in defense of the media that suggests that it is the responsibility of parents, teachers and guardians to protect children from media influence. In research by Hindin, Contento and Gussow (2004), with 35 mothers of 3 to 6 year olds taking part in the in New York, results of an intervention program showed that mothers critically understand the persuasive techniques used by the media to influence their children’s requests for food was successful at increasing parents’ self confidence and the extent to which they value good nutrition. One developmental psychology research suggests that advertising stimulates materialism in children and may instigate parent child conflict and unhappiness (Buijzen and Valkenburg, 2003). But positively influencing students through school media enable them to argue their portents. We can think of innovative idea like parents at home can learn from students on what they learn from school mini-media if good influential nutrition programs are produced and delivered to schools.

For any communication message to create impact first it has to reach to audience and to know how many people’s got the message we have to measure total reach. Many authorities give different name and definitions for media reach. A gross impression (anothername for total reach) is the total number of exposures to a media schedule or the total number of times a message is heard (Radio Connector’s Connection, 2021). Reach further explained by Radio Connector’s Connection as:-

This is the reach audience expressed as a percentage of the population of a geographically defined area(s).Reach is the estimated number of different people who listened to a station or to Radio for at least one-quarter hour within a specified time block. Each person is counted only once. It is an unduplicated or cumulative audience (Radio Connector’s Connection, 2021).

According to Wikipedia (2013), reach refers to the total number of different people or households exposed, at least once, to a medium during a given period; which should not be confused with the number of people who will actually be exposed to and consume the message, though. For example, in the UK, BARB defines the reach of a television channel as the percentage of the population in private households who view a channel for more than 3 minutes in a given day or week (BARB, 2006).Similarly, for radio, RAJAR defines the weekly reach of a radio station as the number of people who tune into a radio station for at least 5 minutes (within at least one 15 min period) in a given week (RAJAR, 2006). It is just the number of people who are exposed to the medium and therefore have an opportunity to see or hear the message. Therefore; reach may be stated either as an absolute number, or as a fraction of a given population. Based on expert judgment for actual total reach calculation we can use the estimation that every radio listening group members/ club members who listen at list 7 nutrition messages re-disseminate it for 5 to 10 other people.

2.6. School mini-media roles for behavior change

Education media centers according to Anis (2008), in Ethiopia are 11 government owned radio stations part of Ministry of Education airing educational and community-oriented programming i.e., Monday to Friday they transmit subject focused educational topics for Children grade 1-8; on the weekend, they air programs on topics like harmful traditional practice, HIV/AIDS, gender, WASH, health, migration, education etc. The function of mini-media is very closely related in fact part and parcel of educational media which often proved useful in supplementing direct teaching, and on a lower level of cost and complexity (Gebeyehu, 2001).

Mini-media originated around 1967 together with the establishment of Education media centers in schools. Then later on mini-media is cultivated in kebeles to use them for political propaganda dissemination (FDREOGCA, 2007Ec). Gebeyehu (2001) says every successful club needs a club leader, who is willing togive sufficient time to help and advise the members of the club; give them specialinstruction and patiently discuss their problems with them. A mini-media club leader must be interested in young people and enjoy working with them (Saville, 1978). The schooldirector and mini-media club leader plan to fulfill their objectives to facilitate the performance of the club. Mini-media clubs in schools guided by teachers produce and disseminate messages via megaphone, amplifiers and microphones during break times. Students participate, entertain and learn from mini-medias. According to Yidnekachew (2018), school mini-media are useful instruments to facilitate the activities of individual co-curricular clubs and similar arrangements besides their use in their own to raise students’ communication and speaking and writing skills and their support in promoting co-curricular programs to the schools’ community. Some of the media used in school mini-media according to Gebeyehu (2001), are print, audio, and audio-visual can be also more effective by providing more realistic experiences and filling the gap that are missed by the formal curriculum.

Looking their advantages according to FDREOGCA (2007Ec), besides schools mini-medias are formed in other government and non government organizations like in bus stations to disseminate road traffic accident prevention education; Anti-AIDS clubs disseminated HIV/AIDS prevention messages; in the past 10 years government communication offices in woredas use mini-medias to educate and mobilize the community. That is why Samuel & Desalegn (2014), concluding remark says encouraging mini media programs and establishing reproductive health clubs should be promoted by school officials. Similarly as Gebeyehu (2001), suggested the school mini-media should be well equipped to be able to produce and disseminate programs, particularly HIV / AIDS education programs, which would bring behavioral change and alleviate the problem of HIV/AIDS.

Mini-media is one-to-many communication which a message (audio, picture, print or combined) and disseminated to small group of closed audience which do similar activities. Mini-media a message delivery system that can’t go away from the surrounding area of one compound; the audio message can be recorded or live broadcast through megaphone, microphone and amplifier or montarbo without any broadcast license. Mini-media audio messages don’t need a receiver gadget you can hear it simply by your ears. The principles of mini-media implementation are secularism, participation, consensus, rule of law, efficiency & effectiveness, voluntarism, transparency & responsibility(FDREOGCA, 2007Ec). Although mini-medias are very strong mechanism to engage and aware children in school environment they have many constraints in their functionality like:-

- Voluntary people participating in mini-media consider it as additional job creating burden on them;
- Voluntary participation has impact on content selection, where most of the time issues covered in mini-medias are about sport and music;limited time given to cover health, social and national issues and it lacks continuity.
- Lack of budget, lack materials for mini-media, lack of maintenance for the materials is some of the problems and they stop their function because of malfunctioning.
- Problem of training for mini-media club members when the trained ones are living the club.
- There is limited monitoring and follow-up on mini-media activities (FDREOGCA, 2007Ec).

Mini-media centers have not existed; though some equipment like tape recorders and loud speakers, many of them have not been working properly were available (Yidnekachew, 2018).These constraints also stressed in Gebeyehu (2001) research. The major problems of unsuccessful mini-media clubs as Gebeyehu, indicated are inadequacy of technical facilities (hardware equipment), inability to identify basic problems to be solved, inability to indicate an alternative of feasible size, inadequate financial resources, lack of interest to participate in the mini-media club, lack of training and poor mini-media management. Therefore, for better utilization of the school mini-media system one has to solve the above mentioned constraints. Mini-media clubs should have the support of the community as a whole including government and non-governmental organizations (Gebeyehu, 2001).

There are several best practices of mini-media clubs in different projects and issues. Some involved in training; others in HIV/AIDS and Harmful traditional practices; migration and WASH, health and gender; nutrition issues are some of the areas where mini-media are looked as a means to achieve behavioral change. The following are some of the examples:-

One:- capacity building material provision and Training: - The DAGU Youth Media Program according to Biniyam (nd), is managed by the Johns Hopkins Center for Communication Programs/AIDS Resource Center (CCP/ARC) and funded by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S in 15 Addis Ababa high schools, in abstinence, faithfulness and youth programming and those that work with school mini media. Mini-media training in schools helps to develop students’ capacity. In these trainings, children develop basic journalism and broadcast skills, including news and commentary writing, on-air announcing and music programming. The DAGU training also strengthens verbal expression, writing, and use of technology, critical thinking, and conflict resolution skills among mini-media members. Another organization that strengthens mini-medias is ANNAPCAN-Ethiopia. Association for National Planned Program for Vulnerable Children and in Need (ANPPCAN) –Ethiopia in the year 2015 Gondar Zuria, Chilga and Lay Armachiho Woredas North Gondar Zone 26 schools mini media clubs were strengthened through provision of mini media materials /tape recorders/(ANNAPCAN Ethiopia, 2015). This was to enhance aware raising activities in the school community regarding empowerment of girls and young women and also reach as many girls and boys as possible.

Two:- raising-awareness to change irregular migration of children:-At Ras Desta Agaro School found in Jima City south-western Ethiopia, the Mini Media broadcasting between class breaks raises-awareness on the dangers associated with irregular crossings by smugglers (IOM- UN Migration, 2020). Ras Desta Agaro School’s children social club determined to change migration of children by irregular means to the Middle East for work, by raising-awareness on the dangers associated with irregular crossings through mini-media club. The club was launched when IOM hosted an awareness-raising campaign with the teachers and a Mini Media program, which runs informative radio programs during school breaks for the students. The role of the Mini Media centers in schools is important in raising awareness among the children, through a relatable approach using drama, poetry and other art forms. They encourage the students to pursue their education and complete their studies. If they choose to migrate when they finish school, they encourage them to do so through regular means such as attending the vocational and technical schooling required and signing work agreement with countries which have signed bilateral agreement with Ethiopia. Mini-medias are essential in providing alternative information which will not be easily accessible otherwise in that area. It discusses the issue of irregular migration as well as local employment and livelihood alternatives or opportunities. They have a much-improved level of consciousness and understanding.

Three:- change hygiene and sanitation behavior:-Sheshicho town, the capital of Kacha Bira District use of mini-media improved hygiene and sanitation behavior (World Vision International, 2021). World Vision helped the trained students to establish WASH clubs in their respective schools so as to transfer the sanitation and hygiene skills that they acquired through the training to their schoolmate through school mini media. “We teach about WASH elements through our mini media in play, drama, poem and question and answer. Since we started the teaching, students have begun practicing hygiene and sanitation both at personal and environmental level. You cannot see any student defecating in the open field as before. Everyone is curious of sanitation and hygienic practice. The Kacha Bira Health Office is very much pleased with World Vision’s massive awareness creation training and the behavioral changes observed. Mr. Tadele Temesgen, Head for Kacha Bira Health Office explains as stated in World Vision International (2021), “World Vision’s massive WASH awareness creation works have brought about encouraging behavioral changes in the entire community. People have begun practicing the WASH elements in their everyday life.”

Four:- Girls’ engagement in Chagni high school Mini-media clubs improves confidence:-Meron, aged 17, is a student at Chagni Secondary School in Ethiopia. During school breaks, she reads works of literature to her peers via the mini-media club to foster understanding about gender equality at school and in society. Eden Muket, also aged 17, has been involved in the club with her friend. Both Meron and Eden took part in a life skills training as part of a project in Ethiopia, which provides girls with the tools to succeed in their studies and in their life goals. Meron and Eden decided to take on an active role in raising awareness on gender equality among their peers, through the mini-media club at their school. Leading the mini-media club, Gizachew Mebrate is a mathematics teacher at Meron and Eden’s school. He encouraged Meron and Eden to join the mini-media club and to write their own messages about gender equality. Chagni Secondary School is one of the participating schools under the project and it is showing promising results. Girls’ engagement in school clubs has also had a beneficial effect on their confidence and academic achievement(UNESCO Liaison Office in Ethiopia,2019). The number of adolescent girls sitting their secondary education national examination at the school doubled within a year. Both Meron and Eden aspire to become journalists when they grow up. By becoming a journalist, Meron aims to make a greater impact in her country by addressing issues related to gender discrimination in Ethiopia (UNESCO Liaison Office in Ethiopia, 2019).

Five:- create awareness about disabilities in schools:- As Schiemer (2017), described in her research that the disability clubs in the Addis Ababa schools, including teachers and students are the ones to regularly on daily basis from Monday to Friday raise awareness through mini-media raise awareness during the morning ceremonies. Through poems and through drama they really teach the whole school community, teachers and students on daily basis. The children they are really the means and the tools that are now talking and teaching to their parents, to their neighbors, to their family members, to the relatives, who are really changing the awareness level and the attitudes of the people at this moment.

2.7. Theoretical Backgrounds: CIPP and KAPs Models

The three terms measurement, assessment and evaluation are interrelated. According to Griffin and Peter (1991), measurement is the determination of the object observed numbers/data retrieval. The assessment is the interpretation of the results of observation and description of the results of the overall measurement. Assessment according to Marchese (1987), is the systematic collection, review, and use of information about educational programs undertaken for the purpose of improving student learning and development. While evaluation is an activity use the assessment results as consideration for decision making. So, from both the above opinion can be concluded that measurement, assessment and evaluation have understanding and different functions, but between the one and the other interrelated. Evaluation is conducted to determine the value of certain information by comparing it to given criteria (Smith & Benjamaporn, 2013). Gruning (1983) suggested five levels measurement of the effects of any communication intervention: communication activities, retention of message sent, acceptance of cognition, formation or change of attitude, and behavioral change.

The evaluation approach used in the present research CIPP was developed by the Phi Delta Kappa Committee on Evaluation in 1971 (Smith, 1980); and further described as CIPP evaluation model by Daniel Stufflebeam’s (Fitzpatrick, Sanders &Worthen, 2011; Mertens &Wilson, 2012; Stufflebeam, 2003; Zhang, Zeller, Griffith, Metcalf, Williams, Shea & Misulis, 2011). In this decision-oriented approach, according to Patton (1997, p. 23), program evaluation is defined as the “systematic collection of information about the activities, characteristics, and outcomes of programs to make judgments about the program, improve program effectiveness, and/or inform decisions about future programming.” Stufflebeam (1971a,p.267) describes evaluation according to the CIPP model as a “process of delineating, obtaining and providing useful information for judging decision alternatives”. In other words, CIPP is based on providing information for decisions (Stufflebeam, 1971b). Moreover, Boulmetis and Dutwin (2005) named the CIPP model as the best decision-making model. The CIPP evaluation model (presented in figure 1) is a framework for guiding evaluations of programs, projects, personnel, products, institutions, and evaluation systems (Stufflebeam, 2003).

Figure 1: Components of Stufflebeam’s (2003) CIPP Model.

Abbildung in dieser Leseprobe nicht enthalten

Educational evaluators have always used the CIPP method, and derived benefits (Tseng, et al, 2010).Its core concepts are context, input, process, and product evaluation, with the intention of not to prove, but rather improve, the program itself (Stufflebeam, 2003). An evaluation following the CIPP model may include a context, input, process, or product evaluation, or a combination of these elements (Stufflebeam, 2003).The context evaluation stage of the CIPP Model assists in decision-making related to planning, and enables the evaluator to identify the needs, assets, resources, identifies the climate that could influence the success of the program (Mertens& Wilson, 2012). To achieve this, the evaluator should compile and assesses background information, and interviews program leaders and stakeholders. In the present research the key stakeholders are the donor, media officers, school directors, teachers, and students. In input evaluation stage, information is collected regarding the mission, goals, and plan of the program. Its purpose is to assess the program’s strategy, merit and work plan against research, the responsiveness of the program to client needs, and alternative strategies offered in similar programs (Mertens& Wilson, 2012). Process evaluation investigates the quality of the program’s implementation. In this stage, program activities are monitored, documented and assessed by the evaluator (Fitzpatrick et al., 2011; Mertens & Wilson, 2012). Primary objectives of this stage are to provide feedback regarding the extent to which planned activities are carried out, guide staff on how to modify and improve the program plan, and assess the degree to which participants can carry out their roles (Sufflebeam, 2003).The final component to CIPP, product evaluation, assesses the positive and negative effects the program had on its target audience (Mertens & Wilson, 2012), assessing both the intended and unintended outcomes (Stufflebeam, 2003). During this stage, judgments of stakeholders and relevant experts are analyzed, viewing outcomes that impact the group, subgroups, and individual.

Applying a combination of methodological techniques assure all outcomes are noted and assist in verifying evaluation findings (Mertens& Wilson, 2012; Stufflebeam, 2003).In the present research product evaluation stage KAPs study tool is utilized in together with CIPP model to assess the attained knowledge, attitudinal change and practical behavior changes due to the intervention. Several scholars stressed about the interrelationships of knowledge, attitude and practice to attain KAPs. Let’s refer some of these statements:

Knowledge

"The preconditions for change are created by increasing people's awareness and knowledge of the profound threat of (illness)." (Bandura, 1990)

"Education that provides accurate and specific instructions on the health utility of (safe) behaviors and suggests ways to increase the enjoyment of low risk activities is expected to facilitate people's commitment to seek change and take action." (Catania, Kegeles, & Coates 1990)

"Information is necessary, but is not sufficient to effect and sustain behavioral change in large segments of the population." (Coates, Stall, Catania, &Kegeles,1988)

"Increasing knowledge does not necessarily overcome attitudinal barriers to preventive behavior."(Darrow, & Siegel, 1989)

"Relying on education alone overlooks some significant aspects of helping adolescents prevent negative health outcomes: knowledge alone does not change behavior." (Howard, 1988)

Attitude

"It is not information, but attitudes which need to be targeted in future intervention studies." (Becker,1988)

"Success.., requires not only skills, but also strong self-belief in one's capabilities to exercise personal control." (Bandura, 1990)

"People's belief that they can motivate themselves and regulate their own behavior plays a crucial role in whether they even consider altering habits detrimental to health." (Bandura, 1990)

"Knowledge regarding (the disease), and the perceived value of behavioral change in reducing one's risk of (infection), were both consistently related to various measures of risk reduction." (Becker,1988)

"Belief in one's capabilities for executing a behavior predict intentions to change unhealthy behavior and performance of health actions." (Catania, Kegeles, & Coates, 1990)

"To be motivated to take preventive action, a person must perceive a disease as having serious consequences." (Darrow, 1989)

Practice

"Appropriate knowledge and attitudes are prerequisites for alteration of behavior." (Becker, 1988)

“Practice refers to the ways in which they people demonstrate their knowledge and attitudes.” (Kaliyaperumal, K. (2004)

"Existing social, religious, recreational, occupational, and educational organizations can serve as highly effective disseminators of preventive health guidelines." (Bandura, 1990)

"Each individual in (a close social relationship) has the ability to facilitate or impede the other's sequences and thus affect their ability to attain valued goals related to love, work, self-care, or other desired ends." (Ewart, 1991)

"Seeking help from formal and informal sources may help to reduce risk." (Coates, Stall, & Catania 1988)

"Decisions to adopt health-protective behaviors are influenced by expectations that are commended action will protect or enhance valued resources or outcomes." (Ewart, 1991)

According to Vandame (2009), KAPs studies are highly focused evaluations that insure changes in human knowledge, attitude/believes and practice done in response to a specific intervention, usually outreach, demonstrations or education; and most frequently used study tool in health-seeking behavior research (WHO, 2008). Knowledge is usually assessed in order to see how far people knowledge corresponds to what is expected; or it refers to their understanding of any given topic. Attitude is a learned predisposition to think, feel and act in a particular way towards a given object or subject i.e., it is a product of complex interaction of beliefs, feelings, and values. Practice refers to the ways peoples demonstrate their knowledge and attitude through their actions; which can be the use of preventive measures or different health care options.KAP surveys can identify information knowledge gaps, cultural beliefs, or behavioral patterns that may facilitate understanding and action, as well as create problem on health prevention. KAPs study is essential to help plan, implement and evaluate certain activities. Therefore Vandame (2009), said that KAPs survey should be perceived more as a conceptual framework to study human behavior instead of becoming a specific methodology.

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