Exploration of the nutrition knowledge among general population: multi—national study in Arab countries | BMC Public Health


To assess the NK among a convenient sample in four countries, namely Egypt, Syria, Saudi Arabia, and Jordan, to determine the association between different selected demographic factors and NK, and to explore the need for further interventions.

Study setting and design

A cross-sectional, multi-national survey was conducted among a sample of the general population from four countries. The selection of participating study countries was based on identifying potential survey partners interested in the study. Overall, four countries showed their willingness to participate: Egypt, Syria, Saudi Arabia, and Jordan. In addition, according to the Global Nutrition Report, Egypt and Syria were burdened by a triple burden of malnutrition (overweight, anemia, and stunting), and Saudi Arabia and Jordan by a double burden of malnutrition (overweight and anemia).A country was considered ‘burdened’ by a malnutrition indicator depending on whether the national prevalence was greater than a certain cut-off. Stunting was measured in children under age 5, and its burden limit was 20% or more. Anaemia among women of reproductive age (15–49 years) had the same 20% or more cutoff, and for overweight women (18 +), this was 35% or more [22].

Sample size and sampling technique

A convenient consecutive sample of 9,000 participants was reached and responded to on-street survey interview questionnaires. (Widely used in marketing research). In total 8267 agreed to participate (response rate 91.8%). Finally, 8191 (91.0%) forms were revised for completeness and logical consistency. The number of participants from each country was 2,483 (Egypt), 2,110 (Syria), 1,895 (Saudi Arabia), and 1,703 (Jordan). Data were collected between January 2019 and January 2020.

Participants aged > 18, apparently healthy (By asking participants about having any chronic conditions such as DM, HTN, CVD, which were considered as unhealthy participants in this study). Those who responded to the screening question at the start of the interview by yes about if they have a chronic disease, or were on diet, or whether they were health care providers, were excluded.

Participants were recruited in the four countries in crowded locations such as malls, around clubs. Particular streets were chosen based on the site of the high traffic enumeration via tossing in. Subjects were approached and informed of the study objectives.

Study questionnaire

A pre-tested street survey interview questionnaire included three sections:

  1. i)

    Section one included background characteristics: age in years, gender, education, country of residence, and living with parents or not.

  2. ii)

    Section two included 20 questions related to NK. NK was evaluated based on an adapted consumer NK scale version (CoNKS) by Dickson-Spillmann et al. [23]. The scale uses procedural as well as declarative nutritional knowledge questions to assess NK. The final item set entailed questions about declarative NK on nutrient calorie as well as contents (For instance, ‘‘The same amount of sugar and fat contains equally many calories’’) in addition to comparisons of food (For example, ‘‘A salad dressing made with mayonnaise is as healthy as the same dressing made with mustard’’); besides questions about procedural NK on the related contribution of various food groups to healthful nutrition (For example, ‘‘For healthy nutrition, dairy products should be consumed in the same amounts as fruit and vegetables’’), on the fat role (like ‘‘Fat is always bad for your health; you should therefore avoid it as much as possible’’), and finally on fruit benefit as well as consumption of vegetables (For instance, ‘‘To eat healthily, you should eat less fat. Whether you also eat more fruit and vegetables does not matter’’). The knowledge tool consists of three subscales: one scale for procedural NK (Seven items, thus Zero–Seven points), one scale for nutrient content declarative knowledge (Seven items, Zero-Seven points), and one scale for calorie content declarative knowledge (Six items, Zero-Six points) A 20 closed-ended format were employed with ‘Yes’, ‘No’, and ‘don’t know’ options. The correct response received a score of one, while the incorrect response received zero. The total score ranged from 0 to 20.

  3. iii)

    Section three had one question about the sources of NK and included multiple option formats that asked about educational courses, health care providers, the university, mass media, family, social media, and relatives.

Anthropometric measurements

Self-reported weights and heights of the participants were utilized to estimate body mass index (BMI). We classified subjects as healthy weight (BMI 18.5 to 24.9 kg/m2), overweight (BMI 25.0- to 29.9), obese (BMI > 30-), as well as underweight (BMI < 18.5) [24].

Data collection was performed by trained researchers after receiving standardized training on how to conduct the survey.

Pilot testing

In larger populations, surveys, CoNKS can be considered a quick and efficient tool for measuring NK [23]. We tested the questionnaire on 100 participants in the four countries to evaluate comprehension as well as clarity of questions. As a result, it was deemed appropriate for use in the current study. Nonetheless, certain scale changes were deemed essential. This entailed food terminology usage that is more widespread in the four nations (For example, cheddar cheese instead of Emmental and Swiss cheese).

Final questionnaire

The questionnaire consisted of 20 items with an estimated reliability coefficient of (Cronbach’s alpha = 0.797), in addition to inquiry about sources of knowledge that was evolved during the pilot. The researchers established face and content validity before conducting the study by reviewing the questionnaire items with faculty staff members. Three questions about the recommended dietary allowance of macronutrients were deleted due to non-specific responses.

English was the original language of the questionnaire items, and it was then translated into Arabic by two experts followed by a translation into English by other experts.

Statistical analysis

The pre-coded data were fed into the computer via the Statistical Package of Social Sciences (SPSS) version 24.0 (SPSS Inc. IBM, U.S.A.) to be statistically analyzed. We presented data as frequencies and percentages for categorical data; the Chi-square test was utilized for comparison when appropriate. For quantitative variables, mean, median, standard deviation, as well as interquartile range, were used for expression; an independent sample t-test was utilized for comparison. Total knowledge score was computed (a total of 21 questions), correct responses were assigned a score of 1, whereas incorrect or not sure responses were assigned zero.

NK scores can range from 0–20 points. The total knowledge of respondents was classified based on the modified Bloom’s cut-off point as follows: good for scores of 80–100% (16–20 points), moderate for scores of 50-79% (10–15 points), poor score of< 50% (< 10 points) then recategorized into satisfactory and unsatisfactory (<16 points) [25].

The researchers pooled the scores of all questions in each section in each respondent and then divided them by the overall participant number. All scores were then multiplied by 100 and presented as percentages.

A forward stepwise logistic regression model was performed to explore predictors of satisfactory knowledge, all background characteristics variables (age, sex, country, education, living with parents, BMI, and reading nutrition articles) were entered in the first step.

We considered all statistical tests to be statistically significant at P < 0.05.

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