Perceived barriers and facilitators of healthy eating and physical activity: focus groups with children, parents and teachers in Mumbai, India

INTRODUCTION

A staggering rise in obesity rates and an escalating burden of non- communicable diseases among children pose glaring public health challenges for epidemiologists and policy makers in low middle income countries, including India.^1-7 Several studies have reported that an unfavorable nutrition transition, the phenomenon hypothesized to encompass shifts in dietary patterns accompanying globalization and urbanization and resulting in an increased consumption of foods that are high in fat, sugar and salt is underway in India.^8-12 Furthermore, a decline in physical activity levels and an increase in sedentary behaviors seem to have contributed to an earlier onset and increasing prevalence of metabolic health problems such as overweight and obesity, diabetes and hypertension among children in India.^4,7,13-18

Factors that influence diet and activity related behaviors in children can vary considerably across communities, cultures, school and familial environments.^19-22 Thus, designing feasible interventions that aim at steering children towards better dietary and activity related practices can be challenging unless the perceived ecological and psycho social factors are recognized. Understanding the attitudes and perceptions of children regarding healthy eating and activity levels may help as formative research to tailor interventions according to the priorities of the specific group and support improvements in health related risk factors. Behavior theories and models can provide guidance for investigating health related behaviors in a population.^23,24 The Health Belief Model (HBM) is one of the most widely used frameworks developed to understand health and diet related behaviors and constitutes perceived susceptibility, severity, benefits and barriers, cues to action and self-efficacy as key constructs.²⁵ Parents and teachers impart key influences on lifestyle behaviors of children, thus understanding their knowledge and perceptions related to bringing a change in child’s eating habits and activity levels is crucial.

A qualitative study that is based on a behavior change framework and investigates the determinants of eating habits and activity levels among children, their parents and teachers, can make a significant contribution towards implementing age appropriate health promoting interventions among children in urban India. However, relatively little research has evaluated the attitude and perceptions to healthy eating and activity levels among school going children in India using qualitative methods. This study employed the tenets of the HBM to assess the knowledge, attitude and perceptions towards healthy eating and physical activity levels and focus group discussions with children, parents and teachers to identify the barriers and facilitators of improving diet and activity related practices in children in Mumbai, western India.²⁵

METHODS

Study design and participants

Overall, fourteen focus group discussions, six with children, five with parents and three with teachers were conducted from January to April 2019. The eligible participants for discussions with children were 10-12 years, old boys and girls, attending grade 6 or grade 7 of either a private school or an aided school in Mumbai. Considering that eating behaviors and activity patterns begin to change significantly during the period of transition from childhood to adolescence and that attitudes and behaviors learnt during this stage can set in practices that last for rest of their lives and can impact the present and future health, the researchers selected children, ages 10 to 12 years as focus groups.^26,27

Three private schools and three aided schools were selected using a purposive sampling method. From each of these schools, a class from either grade 6 or grade 7 was randomly selected as the participating class. An information sheet outlining the objectives of conducting focus group discussions was sent home for receiving parental consent. The first five girls and first five boys whose parents provided consent from each of the selected classes (n=60) were invited to participate in the discussions. Written and informed assent forms were collected from participants before starting the discussions. Each discussion included around 7-8 participants, took approximately 45 minutes to an hour to administer and was conducted in vacant school classrooms during school hours.

For conducting discussions with teachers, the homeroom or science teachers of the participating grade at each school were invited. A total of 9 teachers (5 from two private schools and 4 from an aided school) provided consent and participated in the discussions. For inviting parents’ participation, the parent’s association was contacted at each selected study site and details were shared with them. From six study sites, an aided school did not have an active parents’ association and a private school did not provide permission to conduct the parent discussions. A total of 28 parents provided consent to participate in the discussions; however six parents were not available on the day of the discussion, so finally there were 22 parents who participated in the discussions from two private schools and two aided schools. The average number of participants in each parent and teacher group was 3-5, a focus group size that is considered adequate to yield diversity in thoughts, when the participants hold knowledge and/or experiences to share during discussions.³² Ethics approval was obtained prior to starting the focus group discussions.

Focus group themes and topics

Focus group discussion is an effective method of data collection in qualitative research that allows for an interactive and facilitated discussion in relation to a particular issue and provides in-depth understanding of attitudes and perceptions of a specific group.^21,28-30 In this study, two semi-structured open ended focus group discussion (FGD) guides (one for children and one for parents and teachers) under the key themes of knowledge regarding healthy eating habits and recommended activity levels, perceived susceptibility and severity of adverse health consequences, perceived benefits and barriers, perceived readiness of change and self-efficacy and suggestions to improve practices were developed based on prior experience, extensive literature review and diligent discussions. As a pre testing exercise for the clarity and relevance of the FGD schedules, two discussions were conducted with children (n=11) and one with parents (n=5) at an aided school and a private school. The themes and examples of the questions included in the final FGD guides for children and parents and teachers are provided in Table 1.

Data analysis

All discussions were facilitated by the principal researcher (PM) assisted by two research assistants who took notes and observed non- verbal communications. The discussions were audio recorded and transcribed verbatim; the observational data was entered as remarks in the guide. The transcripts were systematically demarcated as per the responses received from each focus group (children, parents and teachers) and type of schools attended (aided or private) and the answers related to specific protocol questions were rearranged. The transcripts were then reviewed, coded and analyzed using the scissor and sort or cut-paste method to derive common themes based on the constructs of HBM and key research questions.^23,31 A posteriori inductive approach of data analysis ensured that the codes and interpretations were generated from the actual data. The findings were iteratively evaluated by a panel of experts with prior experience of conducting and interpreting focus group discussions and recurrent emergent themes and key quotes under each theme were identified. The summarized results are presented in a narrative format supported with few excerpts of the study participants

RESULTS

The total number of participants across discussions was 73 (42 children; 22 parents and 9 teachers in 14 FGDs). Eight focus group discussions were conducted with parent (5 FGDs; n=22) and teacher focus groups (3 FGDs; n=9).

The mean age of children who participated in the discussions was 11.3 (1.1) years, more than three fourth (81%) of the parent participants were mothers and all teacher participants were graduates with a degree or diploma in education. The number of participants across focus group discussions is given in Table 2.

The main themes and insights that emerged from the discussions are described below-

Knowledge and perceptions about healthy and unhealthy eating habits

Eating habits were frequently considered synonymous to consuming specific food items and rarely to eating habits such as breakfast consumption, meal skipping or frequency of eating outs. Teachers shared that “healthy eating implies eating to get a healthy weight”, “having home cooked foods” and that “eating food items that are cheap and cost Rs 5/- or Rs 10/- are the unhealthiest eating habits”. Parents mentioned that “if children don’t bring their tiffin, then they will have to eat from school canteen and because canteen usually has only unhealthy food options, eating more at canteen can be considered as an unhealthy eating habit”.

a: Number of focus group discussions=14; number of participants across discussions=73; b children, were recruited from aided schools (n=18) and private schools (n=24); mean age of children in focus group discussions=11.3 (1.1) years; #data is presented as number and percentages in parentheses

Knowledge about non communicable diseases and healthy eating and physical activity recommendations

Majority of the children understood the importance of eating healthily and being active, though their knowledge regarding recommended daily servings of fruits and vegetables and risk factors and preventive strategies for non-communicable diseases was inadequate. They were also unable to list out activities that may be categorized as sedentary, moderate and vigorous physical activities. More than three fourth of parent and teacher participants showed lack of knowledge about daily allowed screen time and the recommended duration of moderate to vigorous activity for children and adolescents.

Perceived susceptibility and severity of the consequences of unhealthy eating habits and physical inactivity

Children, in general did not perceive themselves to be susceptible to the adverse consequences of unhealthy eating habits and physical inactivity and were ‘only little worried’ about getting overweight, diabetes or heart diseases in future. The severity of the consequences were perceived in the short term (“get indigestion”, “cannot focus in class”, “feel tired and sleepy” and “pain in muscles”) by children and as “become weak”, “not able to study properly” and “food poisoning” by parents.

Perceived benefits and barriers to healthy eating and regular physical activity

The participants listed “staying fit and strong”, “having enough energy to carry out day’s work”’, “keeping bones strong”, “body stays flexible”, and “helps to lose unwanted weight” as perceived benefits of healthy eating and regular activity levels. A few direct quotes of what children mentioned as key barriers are given below:

“Fruits don’t smell and look as good as a pizza or burger, so I don’t like eating them”

“I don’t get time to eat breakfast so my mother gives me money to buy from canteen”

“I like mangoes and strawberries so when they are not in season, I don’t eat fruits at all”

“I think children don’t eat vegetables because vegetables don’t taste good”

“Drinking soft drinks can make your teeth bad but they will not make you sick”

“Sometimes you are so bored that you want to eat junk food. I eat chocolates when am bored” “Everybody eats samosa during recess, so it’s okay”; “they sell the same food daily in canteen”

“If I don’t like the menu at home, I just don’t eat anything”

“I don’t care whether my health is good or bad”

The comments showed that taste, appearance and flavor associated with specific foods and sometimes moods dictate the choice of foods; seasonal availability of favorite fruits and what peers are eating constitute other factors that may also influence the decision. The consequences of eating unhealthy foods are not totally understood, thus immediate pleasure of eating foods were much more important determinants than future risks involved with practicing unhealthy dietary habits. The biggest challenges, as mentioned by the parents were that “children just don’t listen” to them and that “children have become so stubborn nowadays that it becomes difficult to convince them”. Focus groups of teachers pointed out that “the major barrier is time- children are always busy so they want quick snacks but parents do not get time to try different recipes”. The teachers were also worried about the “easy access to unhealthy foods in school canteens, from street vendors adjacent to school premises and unrestricted use of food delivery apps”; the parents added that “there are always some or other discount offers or ‘special discount days in the weeks” that tempt the children to order takeaways. Parents pointed out that the “biggest menace” was gadgets and electronic devices that have “just made kids lazy” and that “children are so attached and pre- occupied with their screens, for academic and non- academic purposes, that they don’t feel the need to meet friends and play outside”. Children mentioned that, “everyone is busy with tuitions and assignments” and “I am so tired that I don't have energy to play any sport in the evening”.

Lack of adequate facilities (limited play areas, recreation centers and sports arenas at/near places where the participants stayed), limited knowledge about the right way to play a sport (“there isn’t any structured sports related instructions and guidance provided to them in schools”), lack of will power and enjoyment from physical play (“I would rather play video games than go out in my free time”) and parent role modeling ((“if children do not see their parents engaging in regular exercises or playing a sport, then they start assuming that it’s okay to not go outside to play”) were discussed as further barriers.

Perceived readiness to change and self- efficacy

The discussions revealed that children were quite open to trying new foods and were ready to add fruits or vegetables in their diet or even indulge in physica-activities if these foods and activities were introduced to them in a fun, interesting manner and if majority of their peers were also indulging into these habits, thus indicating that fun element and peer support are crucial to bring any change in dietary or activity related practices among children. Parents mentioned that they sometimes try to add healthy foods in their child’s diets by either trying new recipes or sneaking them in as sandwiches, wraps and cutlets but often end up giving up after a while due to time constraints or lack of support from children.

Facilitators to improve knowledge and practices

Children suggested showing videos, playing informative games related to healthy diet and activity behaviors in classrooms and organizing skits at school events as interesting ways to learn. According to them, posters, charts and talks may have limited reach as “nobody cares enough to read posters in canteens” or “listen to lectures”. Parents mentioned that better availability and variety of healthy foods like “rajmah chawal” (beans and rice), “bhelpuri” (puffed rice), “sandwiches and wraps”, “fruit salads and fruit juices” in school canteens can improve dietary practices. Teachers suggested that “parents should not give packaged foods high in fat and sugar like wafers and chocolates as snacks”, “parents should be strict about children having breakfast before leaving for school” and “a discipline in terms of allowed daily screen time must be maintained at home”. Other suggested strategies included reducing the frequency of takeaways, ensuring that proper meal time discipline is followed and not allowing children to eat their meals while watching television. Increasing parent and family involvement, and conducting skill based workshops for children as after school co-curricular activities were also suggested.

The key findings of the focus group discussions are summarized in Figure 1.

DISCUSSION

The series of focus group discussions that were conducted with key stakeholders-children, parents and teachers provided information regarding their perceptions on the importance of good health in general and healthy eating and physical activity in particular. The knowledge about risk factors, consequences of non-communicable diseases (NCDs), recommendations for allowed screen time and activity guidelines were observed to be inadequate. Few studies that had evaluated the NCDs related knowledge and health perceptions of urban children and adolescents had also reported poor knowledge and large gaps in knowledge-practice related behaviors.^33-37

This study observed that perceived susceptibility to and perceived severity of non-communicable diseases such as obesity, diabetes and heart diseases were low among children, highlighting the critical role that attitudes and perceptions may play in shaping practices. According to the HBM, individuals can be motivated to take health related actions such as increased consumption of fruits and vegetables or reduced sedentary behaviors if they understand the negative consequences of their present practices (perceived severity), feel that the recommended action can prevent/reduce the risk to negative health conditions (perceived benefits), believe that the efforts taken to engage in health related action is lower than the resulting harm related to their present action (perceived barriers) and are confident that the practice can be adopted comfortably and successfully by them (self-efficacy). Improving knowledge, especially with regards to perceived susceptibility to and perceived severity of non-communicable diseases and adopting measures that overcome perceived barriers are warranted. Targeting behavior change and promoting positive attitudes towards perceived benefits and self-efficacy can help to bring desired improvements in eating habits and activity related practices of school going children in India. Using interactive audio visual aids, conducting regular health assessment sessions and peer led health promoting activities may help improve knowledge among children while conducting training and awareness building sessions for parents will reinforce the messages learnt in schools.

Additionally, the discussions identified important barriers and facilitators to healthy eating and activity levels among children. Taste, personal likes and dislikes, peer influences and lack of motivation emerged as significant determinants of food choice. Parent groups perceived time, limited facilities for sports and ‘screen addiction’ as barriers to improve physical activity levels. Similar findings have been observed in previous studies. While a few studies had reported the lack of time and the high cost of healthy foods as barriers to being active and eating healthily in children, a qualitative study that evaluated the perceptions of Indian adolescents observed academic stress, lack of time and limited parental supervision as important perceived barriers.^34,38,39 Prior qualitative studies conducted in different parts of the world have suggested branding healthy foods as tasty foods, reinforcing messages such as ‘exercises can be fun’ and establishing positive food related experiences early in life as ways to foster motivation and promote healthy eating behaviors in children.^22,40,41

Similar to earlier studies, school canteen foods were considered to be ‘unhealthy’ and the canteen menus as ‘monotonous’ by participants of this study. Availability and easy access to unhealthy foods in and near schools and children’s preference for unhealthy foods were perceived as barriers to healthy eating in the school environment.^42,43 Several studies have deliberated on the demand and cost effectiveness of unhealthy foods and their availability in school canteens as factors that work in tandem to adversely impact the consumption patterns of children.^41-44 Therefore, it is important that clear and strict school food policies that ensure better availability of healthier food options and reduced accessibility to unhealthy foods be enforced in schools. The statutory food safety and regulation body in India, the Food Safety and Standards Authority of India has recently taken a step towards improving the school food environment by releasing draft regulations related to the sale and promotion of unhealthy food items in school canteens and around school premises. The enforcement of the regulations and the adherence by the schools will determine the impact of such initiatives in future. Besides the school food environment, modifications in other built environments such as the home food environment are also needed. Studies have established that home food environment factors such as a family’s purchasing behaviors, parents’ perception and practices towards diet and the availability and accessibility of foods at home may influence the consumption patterns of children.^21,45,46 Parents’ activity levels and role modeling can also motivate children to engage in physical play.^14,34 Future research should target the evaluation of the influences of these factors and identify strategies to improve the home environment and parental practices.

This qualitative study is the first to explore the barriers and facilitators to healthy eating and activity levels among children in Mumbai, a major urban city in India that has recently witnessed a remarkable economic growth as well as a subsequent transition in the nutritional landscape. The discussions with children, teachers and parents helped to delineate information about psycho-social influences on eating habits and physical activity among children. Several facilitators such as stricter school food policies especially with regards to the sale and promotion of unhealthy foods in and near school premises, active parental involvement in meal preparations, positive mealtime routines at home, exposure to different flavors and sport activities early in life and behaviorally focused education programs for children and parents were identified. These influences may provide potential targets for future interventions that are aimed at improving the eating and activity related practices of children in India. This study was also unique in using the constructs of the HBM as a theoretical framework to understand the perceived benefits, barriers and the readiness to change behavior and adopt healthier practices among the participants. A further strength was that the discussions were conducted at aided and private schools, which provided an opportunity to understand the perceptions of stakeholders from different socioeconomic status.

However, this study has few limitations, too. Although the focus groups of children were mixed gender, almost all parent and teacher groups were females. Furthermore, the modest sample size and selection of urban population as participants may limit the generalizability of the reported perceptions. Future research should include male participants and stakeholders in rural areas to assess the attitudes and perceptions related to healthy eating and activity levels in children in India.

CONCLUSION

The discussions revealed four main themes i.e. knowledge about healthy eating habits, physical activity and sedentary behavior recommendations, perceived susceptibility and the severity of consequences of unhealthy eating behaviors and physical inactivity, environmental determinants such as the availability and accessibility of foods at school and home, facilities and training for sports, and peer support and influence, and individual factors that shape food and activity related choices such as time, personal preferences, convenience and will power.

The results reiterated that providing children with tailored nutrition education and structured physical activity routines may shape their present and future eating habits as well as their activity patterns in a healthy manner. The interplay of interactions between individual factors such as personal preferences, perceptions and motivations with physical environment factors such as home food and the school food environment must be explored in depth to improve health promoting lifestyle behaviors and reduce the risk to early onset of non-communicable diseases among children in India.

ACKNOWLEDGEMENTS

The authors would like to acknowledge the efforts of field staff, the Heads of the Institutes who provided permission to conduct the study and appreciate the valuable inputs and cooperation provided by the children, parents and teachers of the participating schools during the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Intersystem Biomedica Ethics Committee, Mumbai, India

REFERENCES

1. 1. Gaiha R, Jha R, Kulkarni VS. Obesity, affluence and urbanisation in India. Available at https://ideas.repec.org/p/pas/asarcc/2010-10.html. Accessed on 12 February 2020.
2. 2. Kumar S, Kelly AS. Review of childhood obesity: from epidemiology, etiology and comorbidities to clinical assessment and treatment. Mayo Clin Proc. 2017;92(2):251-65.
3. 3. Gupta DK, Shah P, Misra A, et al. Secular trends in prevalence of overweight and obesity from 2006 to 2009 in Urban Asian Indian adolescents aged 14-17 years. PLoS One. 2011;6(2):e17221.
4. 4. Ranjani H, Mehreen TS, Pradeepa R. Epidemiology of childhood overweight and obesity in India: A systematic review. Indian J Med Res. 2016;143(2):160-74.
5. 5. Choudhary K, Mathur P, Garg M, Gupta PP. Prevalence of overweight and obesity amongst adolescents and identification of risk factors. Int J Contemp Pediatr. 2015;4(4):1153-9.
6. 6. Pawar SV, Choksey AS, Jain SS, Surude RG, Rathi PM. Prevalence of overweight and obesity in 4 schools of south Mumbai. J Clin Diagnostic Res. 2016;10(3):1-2.
7. 7. Singh AK, Maheshwari A, Sharma N, Anand K. Lifestyle associated risk factors in adolescents. Indian J Pediatr. 2006;73(10):901-6.
8. 8. Bailey C, Garg V, Kapoor D, Wasser H, Prabhakaran D, Jaacks LM. Food choice drivers in the context of the nutrition transition in Delhi, India. J Nutr Educ Behav. 2018;50(7):675-86.
9. 9. Popkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic of obesity in developing countries. Nutr Rev. 2012;70(1):3-21.
10. 10. Griffiths PL, Bentley ME. The nutrition transition is underway in India. J Nutr. 2001;131(10):2692-700.
11. 11. Mehta K, Mazumdar V, Patel SV. Dietary pattern of schoolgoing adolescents in urban Baroda, India. J Heal Popul Nutr. 2013;31(4):490-6.
12. 12. Jayawardena R, Ranasinghe P, Wijayabandara M, Hills AP, Misra A. Nutrition transition and obesity among teenagers and young adults in South Asia. Curr Diabetes Rev. 2016;11(2):342-6.
13. 13. Craggs C, Corder K, Sluijs EMF, Griffin SJ. Determinants of change in physical activity in children and adolescents: a systematic review. Am J Prev Med. 2011;40(6):645-658.
14. 14. Must A, Tybor DJ. Physical activity and sedentary behavior: A review of longitudinal studies of weight and adiposity in youth. Int J Obes. 2005;29:84-96.
15. 15. Esht V, Midha D, Chatterjee S, Sharma S. A preliminary report on physical activity patterns among children aged 8-14 years to predict risk of cardiovascular diseases in Malwa region of Punjab. Indian Heart J. 2018;70(6):777-82.
16. 16. Vaz M, Yusuf S, Bharathi AV, Kurpad AV, Swaminathan S. The nutrition transition in India. South African J Clin Nutr. 2016;10(8):173-5.
17. 17. Jagadesan S, Harish R, Miranda P. Prevalence of Overweight and Obesity Among School Children and Adolescents in Chennai. Indian Pedia. 2014;51:544-9.
18. 18. Kehoe SH, Krishnaveni GV, Veena SR. Diet patterns are associated with demographic factors and nutritional status in South Indian children. Matern Child Nutr. 2014;46:127-32.
19. 19. Story M, Kaphingst KM, Brien R, Glanz K. Creating healthy food and eating environments: policy and environmental approaches. Annu Rev Public Health. 2008;29(1):253-72.
20. 20. Silva DC, Frazão IS, Osório MM, Vasconcelos MGL. Perception of adolescents on healthy eating. Cienc Saude Coletiva. 2015;20(11):3299-308.
21. 21. Seguin R, Connor L, Nelson M, Lacroix A, Eldridge G. Understanding barriers and facilitators to healthy eating and active living in rural communities. J Nutr Metab. 2014;4:146-50.
22. 22. Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-Barron V, Chisholm D. Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness. Lancet. 2010;36(10):615-20.
23. 23. Glanz K, Bishop DB. The role of behavioral science theory in development and implementation of public health interventions. Annu Rev Public Health. 2010;31(1):399-418.
24. 24. Office of Behavioral and social sciences research. Available at https://obssr.od.nih.gov/wp-content/uploads/2016/09/OBSSR-SP-2017-2021.pdf. Accessed on 12 February 2020.
25. 25. Janz NK, Becker MH. The health belief model: a decade later. Heal Educ Behav. 1984;11(1):1-47.
26. 26. Koehn S, Gillison F, Standage M, Bailey J. Life transitions and relevance of healthy living in late adolescence. J Health Psychol. 2016;21(6):1085-95.
27. 27. WHO. Adolescent Nutrition. WHO. 2018.
28. 28. Sztainer ND, Story M, Perry C, Casey MA. Factors influencing food choices of adolescents: Findings from focus- group discussions with adolescents. J Am Diet Assoc. 1999;99(8):99-102.
29. 29. Nyumba OT, Wilson K, Derrick CJ, Mukherjee N. The use of focus group discussion methodology: Insights from two decades of application in conservation. Methods Ecol Evol. 2018;9(1):20-32.
30. 30. Leung FH, Savithiri R. Spotlight on focus groups. Can Fam Physician. 2009;55(2):218-9.
31. 31. Stewart DW, Shamdasani DWR. Focus groups: theory and practice. Available at https://books.google.co.in/books?id=Rb9KlLtpGe8C&pg=PA116&lpg=PA116&dq=scissor+and+sort+method+focus+group+discussion&source=bl&ots=m24RmnqVvO&sig=ACfU3U1yUib5iRVLrba3O_Cxv4TaXvqRqg&hl=en&sa=X&ved=2ahUKEwjYuClhtboAhXhzzgGHaMNBTsQ6AEwCnoECAwQKQ#v=onepage&. Accessed on 7 April 2020.
32. 32. Onwuegbuzie AJ, Dickinson WB, Leech NL, Zoran AG. A qualitative framework for collecting and analyzing data in focus group research. Int J Qual Methods. 2009;8(3):1-21.
33. 33. Shepherd J, Harden A, Rees R. Young people and healthy eating: a systematic review of research on barriers and facilitators. Health Educ Res. 2006;21(2):239-57.
34. 34. Kumar S, Ray S, Roy D. Exercise and eating habits among urban adolescents: a cross-sectional study in Kolkata, India. BMC Public Health. 2017;17(1):468.
35. 35. Worsley A. Nutrition knowledge and food consumption: can nutrition knowledge change food behaviour? Asia Pac J Clin Nutr. 2002;11(3):44-9.
36. 36. Mamba NPS, Napoles L, Mwaka NM. Nutrition knowledge, attitudes and practices of primary school children in Tshwane Metropole, South Africa. African J Prim Heal Care Fam Med. 2019;11(1):46-9.
37. 37. Cown MH, Grossman BM, Giraudo SQ. Nutrition education intervention to improve nutrition-related knowledge, attitudes, and behaviors for hispanic children. Ecol Food Nutr. 2017;56(6):493-513.
38. 38. Najarkolaei RF, Tavafan SS, Fesharaki MG, Jafari MR. Factors predicting nutrition and physical activity behaviors due to cardiovascular disease in Tehran university students: application of health belief model. Iran Red Crescent Med J. 2015;17(3):1-6.
39. 39. Correa N, Rajaraman D, Swaminathan S. Perceptions of healthy eating amongst Indian adolescents in India and Canada. Appetite. 2017;10.101-6.
40. 40. Scaglioni S, Cosmi V, Ciappolino V, Parazzini F, Brambilla P, Agostoni C. Factors influencing children’s eating behaviours. Nutrients. 2018;10(6):706-10.
41. 41. Swaminathan S, Thomas T, Kurpad A V., Vaz M. Perceptions of healthy eating: a qualitative study of school-going children in south India. Health Educ J. 2009;68(2):94-110.
42. 42. McKinley MC, Lowis C, Robson PJ. It’s good to talk: children’s views on food and nutrition. Eur J Clin Nutr. 2005;59(4):542-51.
43. 43. Rathi N, Riddell L, Worsley A. Parents’ and teachers’ views of food environments and policies in Indian private secondary schools. Int J Environ Res Public Health. 2018;15(7):32-8.
44. 44. Savige G, Macfarlane A, Ball K, Worsley A, Crawford D. Snacking behaviours of adolescents and their association with skipping meals. Int J Behav Nutr Phys Act. 2007;4:34-38.
45. 45. Pearson N, Griffiths P, Biddle SJH, Johnston JP, Haycraft E. Individual, behavioural and home environmental factors associated with eating behaviours in young adolescents. Appetite. 2017;112:35-43.
46. 46. Rathi N, Riddell L, Worsley A. Indian adolescents’ perceptions of the home food environment. BMC Public Health. 2018;18(1):169.