Students' Nutrition Literacy and the Existence of Health Care Providers in Iranian Schools

Background: The objective of this study was to investigate the relationship between Students' nutrition literacy and the existence of health care providers in Iranian schools. Study design: A cross-sectional study. Methods: This study was conducted on 504 students in Ardebil City, northwestern Iran from Oct 2017 to Jan 2018. The FLINT questionnaire was used to assessment the food and nutrition literacy. Socio-demographic characteristics and the existence of health care providers were collected using demographic questionnaire. Results: Nearly 75% of students had not a health care provider. Most students had a low FNLIT (62% males and 58.1% females). The probability of low FNLIT was lower in students with health care providers than those without them (OR=0.46, CI 95%; 0.10, 0.91). Conclusion: One of the reasons for the low nutritional literacy of students may be due to the lack of health care providers in schools. Health educational administrators employ specialized health care providers in Iranian schools.


Introduction
he UNESCO has set one of its goals in planning elementary education, improving the growth and development of potential talents, and establishing proper health behaviors in children 1,2 . These behaviors can provide the foundation for a healthy lifestyle 3 . In Iran, some factors may endanger the health of students. The prevalence of obesity and metabolic syndrome is high in Iranian adolescents 4 , and students' knowledge of different aspects of nutrition is also inadequate 5 . Besides, the prevalence of overweight in the world is 5.6% and in Iran is between 5% and 10% 6,7 , which may increase in the future and threaten future adolescent health. Moreover, 73% of adolescents aged 14-18 yr were consuming fruits and vegetables below the recommended guideline amounts and consumed high amounts of fatty foods. On the other hand, more than 50% of them had fewer than 1.5 servings of fruit and vegetables daily, and 41% consume less than one serving/d 8 .
One of the essential aspects of literacy that affects student's health is food and nutrition literacy (FNLT). FNLT is a degree of ability for individuals to acquire, process, understand information and skills necessary to make appropriate nutrition decisions 9 . Studies suggested a positive association between food literacy and adolescents' dietary intake 10,11 and adolescents with better food knowledge, and frequent food preparation behaviors were shown to have healthier dietary practices 12 .
The existence of health care providers in schools can affect students' nutritional literacy and health 13 . A school health nurse performs school health activities in many countries that this role was first started by Lilian Wald in the US and gradually expanded 14 . The health care provider in schools is tasked with educating and providing health, nutrition, and psychological counseling to enhance literacy, enhance selfcare, and improve health behaviors 15,16 . The existence of health care providers in schools has a significant positive impact on health-related behaviors, especially on elementary school students [17][18][19] . For example, for dental and oral hygiene, studies claimed that the existence of health care providers in T JRHS 2020; 20(2): e00476| doi: 10.34172/jrhs.2020.11 schools causes health behaviors improvement [20][21][22] . Iranian Parliament's laws have required the Ministry of Education to apply health care in all schools 23 . According to the Ministry of Education's job classification, graduates with hygiene, nutrition, nursing, and midwifery degrees can work in schools as health care providers 14 . Despite legal requirements, many schools in Iran still lack health care providers with academic health sciences degree. On the other hand, students in schools that have health care providers are subject to specialized health monitoring and evaluation, and in schools without specialized health care, students may not be considered for health concepts such as nutrition and health literacy 24 .
However, based on our knowledge, there is no study of the relationship between student nutrition literacy and the existence of health care providers to produce the necessary scientific document for health and education policymakers in Iran. We aimed to assess the relationship between nutrition literacy and the existence of school health care in Iranian schools.

Study Design and Participants
This cross-sectional study was conducted from Oct 2017 to Jan 2018 and included 504, 13-15 yr students in Ardebil, a city placed in the northwest of Iran. The General Office of Education in Ardebil groups educational districts into two groups based on socioeconomic status; District One (north of Ardebil) and District two (south of Ardebil). The recruited students were selected from each of these two groups. A weighted sampling was conducted from six clusters (three from every two educational districts), according to their student's population density. Then a probability proportional to the size of the target population method was used to select governmental and non-governmental schools from these six districts. Afterward, an equal number of students from 13, 14, and 15 yr were randomly selected from each school.
These selected students and their parents were invited to participate in the study by a written invitation and information card. However, at the beginning of the study, verbal informed consent was obtained from students and their parents.

Food and nutrition literacy assessment
The FLINT questionnaire was used for food and nutrition literacy assessments. This tool contains 46 items assessing FLINT in two specific cognition and skills domains. The cognition domain consists of two subscales, including understanding food and nutrition information, and nutritional health knowledge. The skills domain consists of seven subscales and evaluates examining functional FNLIT, interactive FNLIT, food choice literacy, critical FNLIT, and food label literacy (Table 1 lists some questions from each subscale). This self-administrated questionnaire was completed by students on their own and approved by their parents. Parental confirmation was that for some demographic questions, which might not be sufficient information for students. It would then be completed and approved by the parents. Parents were not involved in completing the nutrition literacy questions. If the student did not understand each question, it was explained by the interviewer. The whole process of completing the questionnaire was under the supervision of the interviewer. Studies evaluating the validity and reliability of this tool indicated that the scale items were generally easy to read and comprehend for students 25 . The scores of questions in each domain were summed to calculate the score of each domain and subscales. Students nutrition literacy were classified into three categories: low FNLIT (≤51), moderate FNLIT (>51-<74) and high FNLIT (≥74) 26 . Food label literacy  Is the red color on the nutrition information of any food packaging above the limit?  If the amount of salt in the food information in the food packaging is green, what is the limit?

Statistical analysis methods
At each school, the health care providers do not cover all students. Some school classes have a health care provider, and some do not. For this reason, a comparison of student literacy between students with and without health care provider was performed at the individual level. Mean, and the standard deviation were reported for describing quantitative variables with normal distribution and counts and percentages for categorical variables. A Chi-square test was used to analyze the differences in baseline characteristics and FNLT between girls and boys. A logistic regression model was fit to measure the effect size of the independent variables on FLINT (dependent variable) prediction. All analyses were performed by Stata ver. 14.0.

Ethical considerations
The Ethics Committee of Ardebil University of Medical Sciences approved this study with the ethics code of IR.ARUMS.VCR.REC.1398.012. Verbal consent was obtained from students to participate in the study. Parents also verbally consented their child to participate in the study. The confidentiality of the obtained data was also guaranteed.

Demographic and socioeconomic characteristics of the study participants
The baseline characteristics of the sample are summarized in Table 2. Overall, 504 students (253 boys and 251 girls) participated in the study. The mean age was 13.77 ±0.71 years. Nearly two-thirds of students have not health care provider (75%). The girls and boys significantly differ in some demographic and parental related factors, including mother age (P=0.021), family size (P=0.038), father's education (P=0.043), and existing health care provider (P=0.001). About 69% of schools in boys and 76.5% of schools in girls were governmental.

Total food and nutrition literacy (FNLIT) and its subscales characteristics:
Total FNLIT in two domains (cognitive and skills) and nine subscales are reported in Table 3. Most students had a low FNLIT (62% in boys and 58.1% in girls). In terms of the FNLIT cognitive domain, the high proportion of students also had moderate status (61% in boys and 65.3% in girls). Moreover, most students were at a low level in Nutritional health knowledge (87.7% in boys and 86.1% in girls), and JRHS 2020; 20(2): e00476| doi: 10.34172/jrhs.2020.11 only 1.6% of all students had a high level of FNLIT skill. Most students had a high level in Food Choice Literacy (75.4%), but a high proportion of students had a low level in Food label literacy (66.4% in boys and 59.8% in girls). Gender differences were significant in Understanding food and nutrition info, Functional FNLIT, and Interactive FNLIT subscales (P<0.05).

FNLIT and existence health care provider:
In Table 4, multiple logistic regression was used to assess the relationship between the low FNLIT and its domains and subscales and existence health care provider adjusted to other demographic variables. Moderate and high levels were considered as a group. Overall, the probability of low FNLIT was lower in students with health care provider than those without health care provider (OR=0.46, CI 95%= 0.1 to 0.91). In addition, odds of low FNLIT adjust for other variables was lower in student with Health care provider than without health care provider in nutritional health knowledge (OR=0.61, CI 95%= 0.29 to 0.83), functional literacy (OR=0.32, CI 95%= 0.11 to 0.79), food choice literacy (OR=0.89, CI 95%= 0.13 to 0.98) and critical literacy subscales (OR=0.24, CI 95% =0.09 to 0.63). There was no relationship between the existence of health care providers and food labeling literacy, interactive literacy, and understanding food and nutrition info subscales.

Discussion
We aimed to investigate the relationship between students' nutritional literacy and the existence of health care providers in Iranian schools. Our results showed that six out of every ten students had low FNLIT, and about quarter students had moderate FNLIT. In our study, the difference in FNLIT between cognitive and skill domains was also examined, and as the results showed, third of the students had low FNLIT in the cognitive domain, and in the skill domain, this index increased to 50%. Similar to our results, in students of Tehran (capital of Iran), skill FNLIT was lower than cognitive FNLIT 26 . These results appear to be one of the crucial problems in the content of education in Iranian schools that focus more on theoretical content rather than practical skillbased topics.  A study by analyzing the educational content available in Iranian schools, 27 have also shown that more focus was on theoretical content rather than practical skill-based topics. Although FNLIT alone is not enough factor in improving health and nutritional behaviors in students, practical education and increasing FNLIT should be considered.
Our results showed that students with health care provider had better nutritional literacy than students without health care provider. This difference was also observed in nutritional health knowledge, functional literacy, food choice literacy and critical literacy subscales. There are limited studies of the relationship between the existence of health care providers and nutritional literacy. The existence of a school health nurse as a school health provider was important for enhancing health literacy and nutrition interventions 28 . Another study 29 has shown the need for specialized health care providers to implement programs that promote proper nutritional behaviors and oral health. Other similar studies have also shown a relationship between the existence of specialized health care providers in schools and rising in students' health and nutrition aspects 30-33 . Increasing the health literacy of school health care provider had a positive impact on students' health literacy 34 . Since student nutrition is a proxy for health, it can affect their nutrition literacy. Although our study only examined students' nutritional literacy, a study of 300 students in Tehran showed that students with better health behaviors had better health behaviors regarding physical activity and oral health 24 . The existence of health care providers in Iranian schools can play an essential role in improving the student's health and nutritional literacy. 10 In terms of the limitations of this study, the information was measured as a self-report. It can lead to under-reporting or over-reporting. Although there are many social, cultural, and economic factors affecting students' nutrition literacy, only some of these factors were investigated in this study, which requires further studies to investigate other factors.

Conclusion
Although the relationship between the existence of health care providers in schools and the improvement of various aspects of health in students has been partially confirmed, the existence of this specialized force has not been addressed in iranian schools yet. Overall, 75% of students in Ardebil city did not have health care. One of the reasons for the low nutritional literacy of students, especially in the skill domain, maybe due to the lack of health care providers in schools. Health policymakers and educational administrators employ specialized health care providers in schools to improve student health and implement specialized health care and self-care education interventions.