Aplikasi Teori Piaget

O R I G I N A L A R T I C L E

Outcomes of nutrition knowledge and healthy food choices in 5-to 6-year-old children who received a nutrition interventionbased on Piaget’s theoryjspn_300 263..279

Hatice Baskale and Zuhal Bahar

Hatice Baskale, PhD, RN, is a Research Assistant; and Zuhal Bahar, PhD, RN, is a Professor, Dokuz Eylul University, School of Nursing, Inciralti, Izmir, Turkey

Search termsChildren, experimental, nursing, nutrition

education, Piaget’s cognitive development

theory.

Author [email protected], with a copy to the Editor:

[email protected]

AcknowledgementNo external or intramural funding was received.

Authorship: (a) conception and design, or

analysis and interpretation of data; Hatice

Baskale, Zuhal Bahar, (b) drafting the article or

revising it critically for important intellectual

content; Hatice Baskale, Zuhal Bahar, (c) final

approval of the version to be published; Hatice

Baskale, Zuhal Bahar.

Disclosure: The authors report no actual or

potential conflicts of interest.

First Received August 31, 2010; Revision

received April 21, 2011; Accepted for

publication May 20, 2011.

doi: 10.1111/j.1744-6155.2011.00300.x

Abstract

Purpose. To develop nutrition education for preschool children based onPiaget’s theory and to examine the effects of this education on children’snutritional knowledge, nutritional behaviors, and anthropometric mea-surements.Design and Methods. Pre- and postexperimental design. In experimentalschools nutrition education was given. Children’s nutritional knowledge,food consumption frequencies, and anthropometric measurements wereevaluated.Results. The experimental group’s nutritional knowledge scores increasedand the group’s food preferences positively changed. No significant differ-ence was observed between the experimental and control groups’ anthro-pometric measurements.Practice Implications. The nutrition education program used in thisstudy may guide nurses in preparing education for preschoolers. The par-ticipation of families is recommended in their children’s nutrition program.

Inadequate and unbalanced nutrition in childhoodyears hinders children’s development (Wang,Patterson, & Oldenburg, 2000) and leads to disorderssuch as obesity (Wake et al., 2009), cardiovasculardisorders, diabetes, hypertension, and cancer(Branca, Nikogosian, & Lobstein, 2007; Gaglianoneet al., 2006). According to a report by the UnitedNations Children’s Fund (UNICEF), 26% of childrenworldwide under 5 years of age are underweight,11% are wasted, and 30% are stunted (UNICEF,2009). In Turkey, 10% of children under the age of 5are short for their age (Turkey Demographic andHealth Survey, 2008).

There are three reasons why children’s diets maybe inadequate and unbalanced. These can be cited asthe low level of education of mothers, the low socio-economic status of the family, and thirdly, the insuf-ficient knowledge of the family about theirchildren’s nutritional needs (Salehi, Kimiagar,Shahbazi, Mehrabi, & Kolahi, 2004; Turkey Demo-graphic and Health Survey, 2008; Wang et al.,2000). Consequently, children may be insufficientlynourished in terms of energy, protein, calcium, zinc,iron, and vitamins (Wang et al., 2000). All of thesefactors hinder children’s growth and development.Many countries have adopted national nutrition

Journal for Specialists in Pediatric Nursing

263Journal for Specialists in Pediatric Nursing 16 (2011) 263–279 © 2011, Wiley Periodicals, Inc.

mailto:[email protected]

mailto:[email protected]

programs such as Healthy Start; the Women, Infants,and Children Nutrition Program (WIC); the Supple-mental Nutrition Assistance Program (SNAP); andFive-a-Day, which are geared to achieve propernutrition in children and their families. There is nolong-term nutrition program in Turkey for preschoolchildren.

Studies of instances where nutrition educationhas been given to children along with their mothersindicate that the level of nutritional knowledgeincreased in these cases in both mothers andchildren. In addition, children preferred healthierfoods (Cason, 2001; Powers, Struempler, Guarino,& Parmer, 2005; Salehi et al., 2004; Wang et al.,2000) and their anthropometric measurementswere within the recommended limits for theirages (Ghoneim, Hassan, & Amine, 2004; Walsh,Dannhauser, & Joubert, 2002).

Studies on food consumption have found thatfoods least eaten by children are vegetables and themost consumed foods are fruit juices, carbonateddrinks, pizza, chips, and fried potatoes (Magarey,Daniels, & Smith, 2001; Skinner, Carruth, & Moran,1998; Skinner et al., 1999). After nutrition educa-tion, children are able to make the right food choicesand there are increases in their consumption ofhealthier snacks (Bannon & Schwartz, 2006). Withnutrition education, children eat more fruits, veg-etables, milk products, and bread, and they eat lessbutter, vegetable oils, and sweets (Cason, 2001;Powers et al., 2005).

In a study carried out in India, it was found thatwhen preschool children’s eating frequencieswere monitored, a significant correlation was seenbetween this and body mass index values (Noel,2003). Walsh et al. (2002) conducted a community-based nutritional program that included food assis-tance. The study showed that at the end of 2 years,there was an improvement in the weight-for-ageand height-for-age measurements of children ages2–5 years old. Children participating in the “GoldMedal Schools” program, in a study group ofschools, were reported to have experienced lessincrease in body mass index values following theprogram as compared with the control group(Jordan et al., 2008). Other studies also notedimprovements in body mass index values (Joosse,Stearns, Anderson, Hartlaub, & Euclide, 2008). Theliterature has demonstrated effectiveness in promot-ing preschoolers’ appropriate dietary behaviors,nutrition knowledge, and anthropometric measure-ments by nutrition education. At the end of nutri-tion education that is age appropriate and based on

Piaget’s theory, it was seen that there were improve-ments in children’s nutritional knowledge, in theirchoice of foods, and in their actual consumption(Auld, Romaniello, Heimendinger, Hambidge, &Hambidge, 1998; Gaglianone et al., 2006; Gorelick &Clark, 1985).

Auld et al. (1998) conducted a project onnutrition where they made use of Piaget’stheory and created a school program of nutritioneducation. The study was of quasi-experimentaldesign and encompassed the implementation ofclass activities. Interviews were held with theteachers and amounts of leftovers were noted. Atthe end of the program, it was found that thestudents in the study group exhibited increasedknowledge.

Gaglianone et al. (2006) also conducted aprogram of education based on Piaget’s theory inorder to increase the nutritional knowledge of chil-dren and teachers and improve their attitudestoward nutrition. Another aim of the program wasto develop and execute the RRIDA Nutrition educa-tion program. The sessions included role-playing,classifying foods, and games focused on healthyeating, carrying the message that all foods should beeaten. The nutritional knowledge of the children inthe study group increased at the end of the study(Gaglianone et al., 2006).

Gorelick and Clark (1985) studied experimentaland control groups of 187 children ages 3–5 years byimplementing a program of nutrition education thatincluded training in preparing food, developing cog-nitive skills, and encouraging creativity. Theresearchers divided the classes into two experimen-tal and two control groups with 47 (46 in one) chil-dren in each group. The expectations of the programwere to have children learn to identify foods, classifyfoods (fruits–vegetables), pair food images, andunderstand what is to be done before and aftereating (showing a picture of soap before eating,showing a picture of a toothbrush afterwards). Theyreported that the 3- to 5-year olds were able to easilyidentify the foods. The children’s nutritional knowl-edge scores increased in the category of identifyingfoods following the program of education. Theresearchers concluded that their results were consis-tent with Piaget’s theory. The study suggests that tofacilitate the development of the concepts of foodand nutrition in children and to render the educa-tion successful, developmentally appropriate andactivity-based teaching should be used.

The use of theories that are focused on the child’scognitive development is of importance in making

Nutrition Education Based on Piaget’s Theory H. Baskale and Z. Bahar

264 Journal for Specialists in Pediatric Nursing 16 (2011) 263–279 © 2011, Wiley Periodicals, Inc.

the education provided to children more effective.One of the most well-known of these theories isPiaget’s cognitive development theory, which ishelpful in preparing a program of nutrition educa-tion from the child’s perspective (Contento, 1981).The present study focused on Piaget’s CognitiveDevelopment Theory, since it clearly defines thecognitive development of a child, emphasizes achild-centered approach, attaches importance toself-discovery, and provides guidance to children asto how they can build positive behaviors.

Preschool children need support in establishinglong-term health habits and in understanding thedifference between good and bad choices. It isimportant that nurses, who play an important role inchildren’s health, create health messages that willinstigate thinking and learning. In order to achievethis, nurses should be knowledgeable about cog-nitive development in children. A nurse who iswell-versed in the topic of children’s cognitivedevelopment will also be aware of changes in thechild’s thoughts in the various stages of growth. Thenurse will thus be able to integrate this knowledgeinto the education program, using it to develop acontinuous and positive interaction between childand nurse. No study in nursing that has imple-mented Piaget’s theory has been conducted inTurkey. In this context, it is expected that the find-ings of this study, based on Piaget’s theory on nutri-tion in preschool children, will act as a guide forthe training of all nurses working as primary-,secondary-, or tertiary-level care providers and willalso be of use to educators in the planning ofin-house educational programs and research. Forthis reason, the purpose of this study was to developand implement a program of nutrition education forpreschool children based on Piaget’s theory. It alsoaimed to determine whether the average levels ofknowledge children would have about nutrition fol-lowing the program would be different in terms ofgroup, time, and group * time, whether there wouldbe any differences in food consumption frequenciesbetween the study and the control groups, andwhether there would be changes in the anthropo-metric measurements of the children following theeducation (body mass index, mid-upper arm cir-cumference [MUAC]).

METHOD

This study was designed as a pre- and postexperi-mental study. The dependent variables in the studyare the nutritional knowledge level, food consump-

tion frequency, and anthropometric measurements(height, weight, MUAC), whereas the independentvariable is the status of receiving nutrition educationguided by Piaget’s theory.

Setting and sample

There are 12 nursery schools connected to the IzmirProvincial Directorate of National Education. Theseschools were layered into the three socioeconomiclevels they represent: low-, middle-, and upper-income bracket. Two schools from each bracket weredrawn from a bag, then randomized to interventionand control. Children included in the study were5 years of age. The children in the control grouphad not received nutrition education but theyhad received a general program of education (thenutrition education prescribed by the Ministry ofNational Education preschool). The yearly syllabusof the Ministry includes subjects on nutrition every 2months. This time frame, however, may be insuffi-cient for nutrition education. The research plan ispresented in Figure 1.

Data collection instruments

A demographic data form, a nutritional knowledgeform for children, a form on food consumption fre-quency, and a form to record anthropometric mea-surements were used as data collection tools.

Demographic data form. This form comprisednine questions encompassing variables related to thechild’s gender, the ages of the parents, parents’ edu-cation, occupations, the number of siblings, and thefamily’s socioeconomic status.

Nutritional knowledge form for children. Thenutritional knowledge form entitled “Eat Smartwith My Pyramid for Kids” within the syllabus of“My Pyramid For Kids” prepared by the U.S. Depart-ment of Agriculture (USDA) was used to assess chil-dren’s nutritional knowledge (MyPyramid for kids,2005). In this form, there are 30 images of foods infive food groups. The information form comprisesconcrete images of food. The form was implementedprior to the education (pretest), following the educa-tion (post-test 1), and 1 year after the education(post-test 2). In the application stage, questions wereasked face to face. The researcher read all the ques-tions one by one and the child was asked to point tothe right answer. Each right answer was awarded 1point while each wrong answer was awarded 0

H. Baskale and Z. Bahar Nutrition Education Based on Piaget’s Theory


points. The minimum-maximum values of the formrange between 0 and 20 points. Rising scores indicatethat the child’s nutritional knowledge is increasing.

Food frequency form. The food frequency formcontained questions about food groups (milk anddairy products, meat and related products, veg-etables, fruits, cereals, fats/desserts, and beverages)and aimed to determine the child’s food consump-tion status (Baysal, 2002). Those who ate a particu-lar food every day were awarded 5 points, thoseeating it three to five times a week were awarded 4points, those who ate it one to two times a weekwere awarded 3 points, those who ate it every 15days were awarded 2 points, those who ate the foodonce a month were awarded 1 point, while thosewho never ate it were awarded 0 points. Risingscores indicated that the child’s food consumptionwas increasing. Parents completed the form prior tothe education, following the education, and 1 yearafter the education.

Anthropometric measurements (weight,height, MUAC) record form. A digital scale sensi-tive to 0.1 kg was used for measuring weight. An

inflexible tape was used for measuring height, and aflexible tape was used to encircle the MUAC(Centers for Disease Control and Prevention [CDC],2009; Cogill, 2003).

The anthropometric measurements were recordedprior to and 1 year after the education. Children atand under the 5th percentile were assessed as under-weight, those between the 5th and 85th percentileswere assessed as normal weight, and those over the85th percentile as overweight and obese.

Intervention

Preparation of the children’s nutritioneducation program. Piaget’s cognitive develop-ment theory formed the theoretical basis for theeducation. The theory facilitated the design of aframework for drawing up a program of nutritioneducation from the perspective of the child (Con-tento, 1981). Faculty members from pediatrics andpublic health nursing, a child development expert,and a dietician provided their opinions and supportfor the educational content and materials used.

The educational content was prepared by takinginto account the child’s characteristics and learning

Demographic data formNutritional Knowledge Form for Children

Food Frequency QuestionnaireAnthropometric Measurements

N = 238

Pretest-February 2007

Experimental group Control group

Nutrition education based on Piaget’s Theory (six sessions)

Nutritional Knowledge Form for Children Food Frequency Questionnaire

n = 227

Education-March-April

2007

Nutrition education for mothersNutrition education for children

(reminder-three sessions)

Nutrition education for mothers

Nutritional Knowledge Form for ChildrenFood Frequency QuestionnaireAnthropometric Measurements

n = 115

Posttest2-May-June

2008

Posttest1-June 2007

Experimental groupn = 141

Control groupn = 97

Controln = 88Experiment

n = 139

Experimentaln = 67

Controln = 48

Education-February-April

2008

National nutrition education

Figure 1 Research Plan.



patterns in the preoperational stage as stated inPiaget’s theory. Messages were simple, positive,and behavior-oriented, and abstract concepts wereavoided. During the game-based education, activestudent participation was maintained and activitiessuch as playing, painting, coloring, and interactivestories were included. By using the food pyramid,the focus was turned on a single aspect such as aparticular food group. Thus, the child was aided indeveloping classification abilities (Contento, 1981).The educational content was planned accordingto Piaget’s schema, assimilation, accommodation,and equilibration stages (Piaget, 1999). Taking thetheory’s factors of maturation, experience, andsocial transmission into account, culture-specificcolorful food photographs were used. In thegame-based education, the educator guided thechildren, allowing them the opportunity to expressthemselves.

Knowledge of changes in a child’s cognitive devel-opment is crucial for the preparation of age-appropriate educational materials in the planning ofnutrition education (Contento, 1981). In his cogni-tive development theory, Piaget stated that eachchild possesses different cognitive abilities in eachperiod. The theory shows us how we can teach moreeffectively and guides us in our teaching plan. Theuse of the schema, adaptation, and accommodationstages enables us to make connections between syl-labus topics. An active, learning-oriented programthat encourages creativity and self-learning is morehelpful than classical teaching patterns in preparingteaching plans. The children recruited into the studywere in Piaget’s preoperational period, which is thetime children learn basic concepts. A child in thepreoperational stage learns by imitating the envi-ronment, exploring, asking questions, and classify-ing. Piaget argues that children learn conceptsmore easily and rapidly on the basis of activities theyhave participated in (Piaget, 1999; Piaget & Inhelder,1969). These children cannot understand abstractconcepts (e.g., vitamins, minerals, proteins; Con-tento, 1981) and are not capable of advanced classi-fication but can concentrate on only one aspect ofthe stimulus, such as the color, shape, or content ofan object (Piaget & Inhelder, 1969). The ideas of thepreoperational child are irreversible; his concept ofconservation has not yet developed. The child is nota passive receiver and has an active role in acquiringknowledge (Piaget, 1999). In light of this, Piaget’stheory has been selected here because of its clearlydefined description of a child’s cognitive develop-ment, its emphasis on game-based education and

self-discovery, and its guidance in the preparation ofage-appropriate educational content.

Piaget’s theory is based on children’s use ofschemas. Piaget defined the term “schema” asfollows: “The structure or organization of actionsas they are transferred or generalized by repetitionin similar or analogous circumstances” (Piaget &Inhelder, 1969, p. 4). When a child is asked what heate for breakfast, a schema comes to his mind. If thequestion is about breakfast, the child thinks of abreakfast schema, believing, for example, that hemust have cheese and olives for breakfast if he is aTurkish child. The child’s understanding and recallof foods depend upon the schema related to thevarious foods. If nutrition education includes, forexample, fruits such as mangos and avocados, whichare not part of Turkish culture, the child cannot con-serve this information because these fruits are notamong the child’s previous schemas.

To Piaget, development is a balancing process ofbalance-imbalance-new balance. The continuousprogression of this period depends on “adaptation,”which includes “assimilation” and “accommoda-tion” (Piaget, 1999). Assimilation is the classificationor use of a single object within mental groups oroperations. When the child comes across an objectand begins to use it, he assimilates the object. If thechild has learned the schemas of rattling an objectand throwing it, then he will apply the sameschemas to any new object, rattling and throwing itin the same way. This is how he will assimilate it.Accommodation is to show a new and differentbehavior as a result of assimilation. As a result of theinteraction between assimilation and accommoda-tion processes, equilibration takes place. The newbalance is not static, but dynamic. Since the environ-ment changes continuously and there are things tolearn, learning and development take place with thecontinuous disequilibrium and retrieval of equilib-rium (Piaget & Inhelder, 1969).

Piaget argued that maturation, experience, socialtransmission, and equilibration are the factors thataffect cognitive development. The nurse who knowsthat a child learns by experience and interactionwith the environment should increase the child’sinteractions with the environment. The nurseshould shape the child’s education by taking intoconsideration the child’s learned knowledgethrough social transmission and by assessing the cul-tural eating habits of the family and the child’s ownknowledge of nutrition.

The content of the education guided by Piaget’stheory included play and visual materials. Thus,



healthy food choices were created by means ofplay/games (Gaglianone et al., 2006). Followingage-appropriate education carried out using Piaget’stheory, improvements are observed in food selectionand consumption (Auld et al., 1998; Gaglianoneet al., 2006; Gorelick & Clark, 1985).

Timeline of events. Data were collected over theperiod February 2007 to June 2008. The children inthe study were queried a total of three times for nutri-tion knowledge and food consumption frequencyand their anthropometric measurements were takentwice. Initial data (nutrition knowledge, food con-sumption frequency, and anthropometric measure-ments) were collected in February 2007 prior to theeducation, when the children were 5 years old. Later,the children in the experimental group were given a6-week nutrition education program based on Piag-et’s theory. Following the education, the second setof data (nutrition knowledge, food consumptionfrequency) was collected in June 2007. In February2008 the children’s mothers were given nutritioneducation,and fromMarchtoApril2008thechildrenwere subjected to a 3-week refresher course on nutri-tion. The third set of data (nutrition knowledge, foodconsumption frequency, and anthropometric mea-surements) was collected over the period May–June2008 when the children were 6 years old.

Setting and educational sessions. Theresearcher (H.B.), who is a nurse educator, was theinterventionist for all sessions. Each interventionsession was carried out by the researcher once aweek for 6 weeks; the length of each session was20–30 min. The sessions were held in the children’sown classrooms at the nursery school. The schoolshad a minimum of 13, a maximum of 25 students ineach classroom. For more effective teaching, theclasses were divided into groups and each sessionwas held with 8–15 children. The content of educa-tion (Aby-Valestrino, 2002; Merdol, 1999; NationalFood Service Management Institute, 2004; MyPyra-mid for kids, 2005; Randall, Sprague, Connell, &Golay, 2001) based on Piaget’s theory is presented inFigure 2.

Preparation of mothers’ nutrition educationprogram. The child’s nutrition is not isolated fromthat of the family. For this reason, parents in boththe experimental and control groups were givennutrition education for 1.5–2 hr in accordance withthe principles of adult education. No evaluation wasmade of the mothers’ knowledge; the sessions were

provided to the mothers only to present them withinformation on children’s nutritional needs. Thetopics discussed in the program of education were asfollows:

• The importance of effective and sufficient nutri-tion for children in the 3- to 6-year age group.

• Nutritional problems that might be encounteredin the 3- to 6-year age group.

• The daily required food amounts of food groupsfor the 3- to 6-year age group.

• Menu samples.• Things to be done to develop good nutritional

habits, and suggestions (Burgess & Glasauer,2004; Merdol, 1999; Sanlıer & Ersoy, 2005).

After the program, an educational bookletprepared by the researcher was distributed to allmothers.

Ethical considerations

Ethical approval from the Ethics Review Committeeof Dokuz Eylul University School of Nursing and theconsent of Ministry of Education were obtainedprior to beginning the study. Verbal permission wasobtained from school management and class teach-ers. The children were orally informed about thetreatment to be applied. The children gave verbalassent and mothers gave signed consent to partici-pate in the study.

Data analysis

Data were analyzed by means of SPSS 15.0 (SPSSInc., Chicago, IL, USA). Significance value wasaccepted as alpha less than .05. The two-wayrepeated measures analysis of variance was usedto compare children’s nutrition knowledge in theexperimental and control groups in terms of group,time, and group * time interaction. In further analy-sis, paired sample t-tests with Bonferroni adjust-ments were used. Food consumption frequencieswere analyzed by means of the Friedman analysis ofvariance, and further analyses were performedusing the Wilcoxon signed ranks test. Anthropomet-ric measurements were analyzed by means of thechi-square test.

During the research, some sample losses wereexperienced, often due to illness, moving, and regis-tering for the primary schools’ preclasses childrenwould attend the next year. There were no differ-ences between the dropped-out children/parentsand the children/parents who remained in the



Visual Nutrition Knowledge Questionnaire

Learning about children’s available schemata and forming schemata about nutrition

• Meeting game• Drawing and coloring the favorite food• Fruit basket game • Reading stories about food • Asking about the foods in the story or seen on television

• Attaching the colored pictures to suitable places on the food pyramid

Learning the foods necessary for healthy nutrition, food pyramid, and food groups • Completing the food pyramid puzzle (cereal and milk groups) • Coloring the cereal and milk groups pictures

Asking about the consumption of previously mentioned cereal and milk products in the following lesson

Accomodation

Assimilation

Learning schemata, forming new schemata

Equilibrium

Learning the foods necessary for healthy nutrition, food pyramid, and food groups with the food pyramid (fruit and vegetable groups) • Completing the food pyramid puzzle • Coloring the pictures of fruits and vegetables • Attaching the colored pictures to suitable places on the food

pyramidAsking about the consumption of previously mentioned vegetables and fruits in the following lesson

Assimilation

Accomodation

Equilibrium

Schema

Learning the foods necessary for healthy nutrition and food groups with the food pyramid (meat/legume and sugar/fat group)• Completing the food pyramid puzzle • Coloring the pictures in this group • Attaching the colored pictures to suitable places onthe food pyramid• Greengrocer’s game (with foods from meat/legumeand sugar/fat group)

Asking about the consumption of previously mentioned foods in meat/legume, sugar/fat group in the following lesson.

Assimilation

Accomodation

Equilibrium

Schema

• Asking about the known fruit and vegetable names• Showing healthy-unhealthy and underweight-overweight children and

asking the causes • Emphasizing the importance of fruits and vegetables • Reading a story about fruits and vegetables

Preparation of the fruit−vegetable calendar

Observation of what children learned in their diaries and the drawing of fruits and vegetables eaten

Assimilation

Schema

Accomodation

Equilibrium

Learning stages based on Piaget’s theory

Education program based on Piaget’s theory

LESSON 1:Introduction to nutrition

LESSON 2: Discovering the food pyramid for children 1

LESSON 3: Discovering the food pyramid for chidren 2

LESSON 4: Discovering the food pyramid for chidren 3

LESSON 5: Eating various vegetables and focus on fruits

• Showing a picture of a beautiful child with rotten teeth and askingabout the reasons

• Asking about the foods that make bones and teeth stronger

• Showing and analyzing pictures that contain material to strengthen bones (calcium)

• Asking about the consumed foods that strengthen bones

• Putting the child’s picture on the wall• Putting the milk/dairy products pictures next to children• Putting the picture of the child showing the taller state • Making an experiment with egg

• Discussing the importance of milk and dairy products • Drawing and coloring favorite foods

Assimilation

Accomodation

Equilibrium

Schema LESSON 6: Foods that will make your bones healthier and stronger

Figure 2 Educational Content on the Basis of Piaget’s Theory.



study. There were 227 children completing post-test1 and 115 children completing post-test 2. One yearelapsed between post-test 1 and post-test 2. For thisreason, an “intention to treat (ITT) analysis” wasconducted. An ITT analysis is the comparison of indi-viduals in a sample group with the groups they arerandomly assigned to. This means that the individu-als in the sample are analyzed regardless of thechanges in their inclusion criteria, their compliancewith the intended treatment, or their withdrawalfrom the treatment protocol (Fergusson, Aaron,Guyatt, & Hebert, 2002). In this study, data werefilled in by repeating the resulting measurements ofthe last observed data (last observation carriedforward [LOCF]; Whittaker, Sutton, & Burton,2006).

Power analysis

The nutritional knowledge score was used as theprimary result variable. Before beginning the study,effect sizes of other research were used to determinethe size of the sample. In the review entitled, “EPPI-Centre, Children and healthy eating: A systematicreview of barriers and facilitators, Evidence forPolicy and Practice” (Information and CoordinatingCenter, October, 2003), the effect size of children’snutritional knowledge was determined as .67. Effectsize according to these data is between .60 and .70 inCohen’s table. When effect size is accepted as .60,power is 80%, sample size is 45; when effect size is.70, power is 80%, the sample size is 33 (Cohen,1988). Using the G*power program, the power ofthe study was found to be .98 at the significancelevel of .05, and the effect size was .79 (high).

FINDINGS

Sociodemographic characteristics

Some of the sociodemographic characteristics of thefamilies and children in the experimental andcontrol groups in this research were tested forhomogeneity to confirm that there were no differ-ences (Table 1). The analysis showed that the groupswere not statistically different (p > .05).

Nutritional knowledge. The repeated measurestwo-way analysis of variance revealed a significantdifference between mean scores in terms of group (F= 95.192, p < .001), time (F = 80.449, p < .001), andgroup * time (F = 59.997, p < .001) interaction(Table 2). The results of the independent groups

t-test to determine from where the differencestemmed showed a significant difference betweenthe mean scores of the experimental and controlgroups in post-test 1 (t = 10.676, p < .001) and post-test 2 (t = 10.398, p < .001).

A repeated measures one-way variance analysiswas conducted to determine whether there weredifferences in the mean nutritional knowledgescores within the groups themselves. The analysisshowed that there was a significant differencebetween mean scores in the study group (F =124.957, p < .001). To understand which measure-ment was responsible for the difference, pairedsample t-tests with Bonferroni adjustmentswere used. The results of this analysis establishedthat there was a significant difference in theexperimental group between pre-test and post-test 1(t = 14.395, p < .001) and pre-test and post-test 2(t = 14.080, p < .001). No significant difference wasfound between the post-test 1 and post-test 2 mea-surements of the experimental group and thecontrol group.

Food consumption frequency. Some foods wereslightly higher at pretest for the control group. Thesewere milk and dairy products, white/red meat,fish, some vegetables (green leaf, root vegetables,cabbage), and fruits.

Two-way comparisons showed increases in theexperimental group’s pretest and post-test 1 (p <.001 for milk, p = .001 for ayran/yoghurt), and post-test 1 and post-test 2 (p = .011 for milk, p = .006 forayran/yoghurt) measurements for the consumptionof milk and ayran (yoghurt drink), and in the pretestand post-test 1 (p = .004), post-test 1 and post-test2 (p = .016), and pretest and post-test 2 (p < .001)measurements for cheese consumption (p < .05),whereas no differences were found in the controlgroup (p > .05). The experimental group’s pretestand post-test 1 (p = .047) measurements exhibitedan increase in white meat consumption and anincrease was also observed in the post-test 1 andpost-test 2 (p = .026) and pretest and post-test 2(p = .007) measurements in fish consumption(p < .05). The children’s consumption of red meat,meat products, and egg was not significantlyincreased (p > .05).

Increases were observed in green leafy vegetableconsumption in the pretest and post-test 1 (p =.002), post-test 1 and post-test 2 (p < .001), andpretest and post-test 2 (p < .001) measurements andin the consumption of root vegetables in the pretestand post-test 2 (p = .017) measurements of the



Table 1. Sociodemographic Characteristics of Participants

Group n Mean t p

Mother age Experimental 141 33.45 .043 .965

Control 97 33.42

Father age Experimental 141 36.96 .200 .842

Control 97 36.84

Group Measure Gender n Mean � SD t p

Experimental Pre-BMI Female 40 15.94 � 2.149 .437 .664

Male 27 16.16 � 1.868

Pre-MUAC Female 40 17.38 � 1.675 .417 .678

Male 27 17.56 � 1.826

Post-BMI Female 40 16.37 � 2.056 .062 .950

Male 27 16.34 � 2.186

Post-MUAC Female 40 18.78 � 1.888 .385 .702

Male 27 18.59 � 1.927

Control Pre-BMI Female 23 15.81 � 1.575 .283 .778

Male 25 15.94 � 1.618

Pre-MUAC Female 23 17.48 � 1.410 .329 .744

Male 25 17.64 � 1.934

Post-BMI Female 23 16.54 � 1.967 .435 .665

Male 25 16.84 � 2.727

Post-MUAC Female 23 18.30 � 1.550 .701 .487

Male 25 18.68 � 2.096

Experimental Control Total

n % n % n %

Mother educationPrimary school 14 9.9 7 7.2 21 8.8

x2 = .649

p = .885

Secondary school 22 15.6 14 14.4 36 15.1

High school 53 37.6 38 39.2 91 38.2

Universiy 52 36.9 38 39.2 90 37.8

Father educationPrimary school 15 10.6 8 8.2 23 9.7

x 2 = 1.720

p = .632

Secondary school 20 14.2 13 13.4 33 13.9

High school 55 39.0 33 34.0 88 37.0

Universiy 51 36.2 43 44.3 94 39.5

Mother occupationOfficial 37 26.2 32 33.0 69 29.0

x2 = 6.159

p = .104

Worker 23 16.3 11 11.3 34 14.3

Self-employment 30 21.3 11 11.3 41 17.2

Housewife 51 36.2 43 44.3 94 39.5

Father occupationOfficial 33 23.4 31 32.0 64 26.9

x2 = 3.311

p = .191Worker 45 31.9 22 22.7 67 28.2

Self-employment 63 44.7 44 45.4 107 45.0

Number of childrenOne 72 51.1 52 53.6 124 52.1

x2 = .420

p = .810Two 62 44.0 39 40.2 101 42.4

Three 7 5.0 6 6.2 13 5.5

Socio-economic statusLow 25 17.7 13 13.4 38 16.0

x2 = 2.539

p = .281Medium 104 73.8 70 72.2 174 73.1

Upper 12 8.5 14 14.4 26 10.9



experimental group. No significant differences wereseen in the control group. The children’s consump-tion of other vegetables (tomatoes, cucumbers, pep-pers, zucchini, artichokes, eggplant, leek, okra, andstring beans), and cabbage (black cabbage, cauli-flower, broccoli) was not significantly increased(p > .05).

The post-test 1 and post-test 2 (p = .014) andpretest and post-test 2 (p = .002) measurements ofthe children in the experimental group displayedan increase in citrus fruit consumption; an increasewas also found in the pretest and post-test 2(p = .014) measurements for other fruits (apples,pears, bananas, strawberries, cherries, grapes, kiwi,watermelon). The children’s consumption of cerealproducts such as bread, pita bread, pizza, macaroni,rice, and bulghur was not significantly increased(p > .05).

In the pretest and post-test 2 (p = .042) measure-ments, there was a decrease in the children’s sugarconsumption (p < .05). The children’s consumptionof butter, honey, jam, molasses, mayonnaise,ketchup, doughy sweets, and dairy desserts was notincreased significantly (p > .05). The study group’sconsumption of ready-to-drink fruit juice was foundstatistically significant (p < .05) in their pretest andpost-test 2 (p = .040) measurements. The children’scola and fresh fruit juice consumption was not sig-nificantly increased (p > .05).

Anthropometric measurements. An evaluationof the experimental group’s body mass index valuesprior to the education and according to groups andgender (Table 3) did not reveal a significant differ-ence between experimental and control groupsfor girls (x2 = .776, p = .678) and for boys (x2 = 2.148,p = .342; p > .05).

In the evaluation of the children’s body mass indexvalues after the education in terms of groups andgender (Table 4), no significant difference was foundbetween the experimental and control groups forgirls (x2 = .210, p = .900) and for boys (x2 = .705,p = .401; p > .05).

When the arm circumferences of the children inthe experimental group were measured before theeducation and assessed in terms of groups andgender (Table 5), it was observed that there wasno significant difference prior to the educationbetween the experimental and control groups forgirls (x2 = .046, p = .977) and for boys (x2 = 2.148,p = .342; p > .05).

DISCUSSION

Nutritional knowledge

In this study, children’s knowledge scores andhealthy food consumption increased after nutrition

Table 2. Children’s Knowledge Scores Before

and After Education (n = 238)Groups

Pre-test Post-test 1 Post-test 2X � SS X � SS X � SS F p

Experimental 9.38 � 2.33 13.70 � 3.32 13.82 � 3.41

Control 9.26 � 2.27 9.49 � 2.42 9.70 � 2.26

Group 95.192 <.001

Time 80.449 <.001

Group*Time 59.997 <.001

Table 3. Experimental and Control Group’s Body Mass Index Percentiles Before the Education (n = 115)

Gender Group

BMI

� 5 > 5 to < 85 � 85

Totaln % n % n %

Girl Experimental 4 10.0 28 70.0 8 20.0 40 100.0 x2 = .776

p = .678Control 1 4.3 18 78.3 4 17.4 23 100.0

Total 5 7.9 46 73.0 12 19.0 63 100.0

Boy Experimental 0 0 25 92.6 2 7.4 27 100.0 x2 = 2.148

p = .342Control 1 4.0 20 80.0 4 16.0 25 100.0

Total 1 1.9 45 86.5 6 11.5 52 100.0



education based on Piaget’s theory. Similar resultshave been obtained in other studies using Piaget’stheory (Auld et al., 1998; Gaglianone et al., 2006;Gorelick & Clark, 1985). Auld et al. (1998) estab-lished in their study that at the end of a program ofeducation, students in the experimental group hadacquired self-efficacy with their knowledge of pre-paring foods as well as experiencing an increase intheir consumption of fruits and vegetables. In otherstudies based on Piaget’s theory, improvementsin students’ choice of foods as well as decreasesin their consumption of high-energy foods wasreported (Gaglianone et al., 2006). Gorelickand Clark (1985) asserted that 3- to 5-year-oldchildren were able to easily identify foods, increas-ing their points in food identification. The recom-mendation of the study is that in order to facilitatethe development of concepts of food and nutritionand render the education successful, developmen-tally effective activity-based materials should beused.

Other studies also reported an increase in chil-dren’s nutritional knowledge (Anderson et al.,2005; Cason, 2001; Hu et al., 2009; Powers et al.,2005; Warren, Henry, Lighttowler, Bradshaw, &Perwaiz, 2003). A 6-week nutrition education con-ducted with 6- to 8-year-olds by Powers et al. (2005)

showed that nutritional knowledge had increased asa result of the program. In other research, 164 chil-dren were taken into an experimental group and 54children were recruited as controls. The experimen-tal group was divided into three. The first group wasgiven nutrition education, the second group partici-pated in a program of physical education, and thethird group was subjected to both types of education.At the end of the intervention, nutritional knowl-edge increased in the first and third groups (Warrenet al., 2003). Cason’s study (2001), where 46 nutri-tion teachers provided preschoolers an educationalprogram that involved activities and active participa-tion, showed that the children’s nutrition knowl-edge had increased at the end of the education. In astudy conducted in the United Kingdom (Andersonet al., 2005) it was found that the nutrition scores ofthe children in the experimental group increasedmore than the children in the control group. In astudy in China with randomly selected preschools,four were assigned as experimental groups and threewere assigned to control groups. The children’snutritional knowledge scores rose from their level of10.5 before the education to 11.9 afterwards (Huet al., 2009).

In the 3-year Health and Nutrition EducationProgram organized in Greece, nutrition education

Table 4. Experimental and Control Group’s Body Mass Index Percentiles After the Educationa (n = 115)

Gender Group

BMI

� 5 > 5 to < 85 � 85

Totaln % n % n %


p = .900Control 1 4.3 18 78.3 4 17.4 23 100.0

Total 2 3.2 49 77.8 12 19.0 63 100.0

Boy Experimental 0 0 23 85.2 4 14.8 27 100.0 x2 = .705

p = .401Control 0 0 19 76.0 6 24.0 25 100.0

Total 0 0 42 80.8 10 19.2 52 100.0

a1-year measurement.

Table 5. Experimental and Control Group’s Mid-Upper Arm Circumference Percentiles Before Education (n = 115)

Gender Group

Mid-upper arm circumference

� 10 > 10–<85 � 85

Totaln % n % n %


p = .977Control 1 4.3 20 87.0 2 8.7 23 100.0

Total 3 4.8 54 85.7 6 9.5 63 100.0

Boy Experimental 2 7.4 23 85.2 2 7.4 27 100.0 x2 = 2.148

p = .342Control 0 0 22 88.0 3 12.0 25 100.0

Total 2 3.8 45 86.5 5 9.6 52 100.0



was given to teachers, parents, and children. Theprogram continued to provide children with 4–6 hrof nutrition education for 3 years while the parentswere furnished with brochures. The children’sknowledge of nutrition was assessed prior to theeducation and at the end of the 3-year period. Theresult was that a difference was seen in the level ofknowledge between the experimental and controlgroups (Manios, Moschandreas, Hatzis, & Kafatos,1999).

In this study, which was designed on the basis ofPiaget’s cognitive development theory, the increasein nutritional scores may have stemmed from theage-appropriate educational content, the use ofculture-specific and available foods that suited Piag-et’s theory about how learning is made possible onlythrough experience and social transmission, andfrom the inclusion in the program of many playactivities such as drawing that encouraged childrento learn about their environment by exploring andmaking their own discoveries. In effect, the chil-dren’s familiarization with the different food groupsand their adaptation to these foods through theactivities they engaged in facilitated appropriateclassifications and ultimately learning. Piaget hasstated that preschool children concentrate not onmany but only on one aspect of a stimulus (Piaget &Inhelder, 1969). Therefore, it can be said that educa-tion based on various food groups makes it easier forchildren to increase their nutritional knowledge.

It can also be hypothesized that the experimentalgroup’s knowledge of nutrition increased because ofthe experience they had gained in the environmentand from their families. This finding supports Piag-et’s theory of learning through experience and socialtransmission.

Food consumption frequency

Our data supported the hypothesis that nutritioneducation based on Piaget’s theory increases chil-dren’s consumption of healthy foods. Previousstudies have reported an increase in the consump-tion of milk and dairy products as a result of nutri-tion education (Bruening, Gilbride, Passannante, &McClowry, 1999; Cason, 2001; Hu et al., 2009). InTurkish culture, yoghurt is a much preferred fooddue to its health-improving aspects, its wide avail-ability, and the fact it is an economical staple.According to Piaget (1999), preschool children learnconcepts in response to their attractive features(color, shape, and appearance) and by simple classi-fication. Therefore, it might be argued that an intro-

duction of the food pyramid with its separation offoods into food groups facilitates the learning expe-rience. In the education, children were given pic-tures of dairy products and asked tocolor them, which enabled them to learn byhands-on activity; the foods were then visualizedwith pictures.

An increase in white meat and fish consumptionwas observed in the study. No significant differenceswere observed in the consumption of red meat,meat products, eggs, and legumes. Previous studiesreported an increase in meat and egg consumptionafter the program of nutrition education (Cason,2001; Salehi et al., 2004). White meat and fish con-sumption might have increased due to the fact thatwhite meat is less expensive compared to red meatand also because a rich variety of fish is more easilyavailable in Izmir.

Our results demonstrated a statistically significantdifference in green leafy vegetable and root veg-etable consumption. Although no difference wasdetected in four studies (Anderson et al., 2005; Auldet al., 1998; Vereecken et al., 2009; Wake et al.,2009), in others an increase was observed in veg-etable consumption (Bruening et al., 1999; Cason,2001; Powers et al., 2005; Salehi et al., 2004). In ameta-analysis, it was emphasized that school-basednutrition programs increase children’s vegetableconsumption (Howerton et al., 2007). Since theclimate and flora of the region where Izmir is locatedis suitable for growing vegetables, green leafyvegetable and root vegetable production and con-sumption are high. The lack of difference in the con-sumption of other vegetables might be because ofthe taste of these vegetables (Moura, 2007), whichalso change in color and appearance when they arecooked. To Piaget, the shapes and appearances ofobjects are important in children’s preferences. Theuse of the schema, assimilation, accommodation,and adaptation stages in education is important interms of facilitating children’s incremental learningand thus transforming this learning into behavior.

According to the results of this study, a statisticallysignificant increase was seen in the consumption ofcitrus fruits and other fruits. Apart from one study(Wake et al., 2009), in general, studies have foundincreases in fruit consumption (Anderson et al.,2005; Auld et al., 1998; Bruening et al., 1999;Cason, 2001; Müller, Asbeck, Mast, Langnase, &Grund, 2001; Powers et al., 2005; Salehi et al., 2004;Vereecken et al., 2009; Warren et al., 2003). In ameta-analysis, it was emphasized that school-basednutrition education increased children’s fruit con-



sumption (Howerton et al., 2007). In order toprovide education appropriate to the child’s cogni-tive development, it is important to make use ofperception-based food groups (Contento, 1981). Inthis study, an increase was observed in the consump-tion of oranges (citrus fruits) and yellow fruits(apples, pears, bananas, peaches). Production offresh fruit is at a high level in Turkey’s westernregions. Children’s consumption of fruit and citrusfruits is especially high in the winter since thesefruits are rich in vitamin C, easily available, andinexpensive. Because of the data obtained in winterand spring months, there was an increase in the con-sumption of winter fruits and especially citrus fruits.The educator guided the students during the activi-ties. When introducing food groups, abstract wordssuch as vitamin, nutrition, and diet were not used.Instead of the term “nutritional,” the expression“foods which help us grow and get stronger” wasused. For the above reasons, it could be thought thatthe consumption of these foods increased.

Our results showed no significant difference ineither the control or the experimental group interms of cereal consumption. In previous studies,children’s consumption of daily bread and cerealsincreased after the education (Cason, 2001; Huet al., 2009; Salehi et al., 2004). In Turkish culture,consumption of cereal, and especially of bread, ishigh due to socioeconomic conditions and the highrate of production and distribution (Gül, Isik, Bal, &Özer, 2003). In addition, bread, macaroni, rice, andbulghur are foods that are easily prepared andfavored by children. The fact that children men-tioned the names of cereal foods as their favoritesshowed that they had accommodated what theylearned recently; they could not, however, put thisknowledge into practice.

In the present study, a decrease was observed inchildren’s consumption of fats (butter, mayonnaise);yet, this was not found to be significant. Apart fromone study (Wake et al., 2009), in previous studies,decreases in fat consumption have been reported(Bruening et al., 1999; Cason, 2001; Dixon, Tersha-kovec, Mckenzie, & Shannon, 2000; Gaglianoneet al., 2006; Müller et al., 2001).

In this study, a decrease was observed in the chil-dren’s sugar consumption. Apart from one study(Dixon et al., 2000), in previous studies, children’sdessert preferences decreased (Gaglianone et al.,2006; Joosse et al., 2008). Piaget’s theory is effectivein that it provides children the opportunity toincrease their knowledge and to have healthy foodconsumption behaviors about nutrition and then

put this knowledge into practice. However, theinformation that children acquire from the environ-ment and from television (social transmission)cannot be ignored. Advertisements and fast-foodconsumption increase the intake of fats and desserts(Strasburger, 2004). It may be said, for this reason,that there was no significant change in the con-sumption of these foods. It might be suggested thatto effectively reduce the consumption of these foodcategories, there would need to be more perception-based, longer-term educational content that makesuse of cognitive skills and emphasizes the value oflimiting the consumption of such foods.

It was seen in the study that children’s consump-tion of processed fruit juice decreased. With educa-tion, processed fruit juice consumption may bedecreased (Jordan et al., 2008) while the consump-tion of fresh fruit may be promoted (Powers et al.,2005). In one school-based nutrition educationprogram, no significant difference was seen in theconsumption of either fresh or processed fruit juice(Vereecken et al., 2009). Although these resultsshowed that children put what they learned intopractice, there was no difference seen in cola drinkconsumption. This might be due to the negative effectof commercials on children (Strasburger, 2004).

The treatments in the study lasted more than1 year in order to show application, repetition, andlong-term effects. The results showed that theexperimental group consumed most of the requiredfood groups for daily consumption, and the effec-tiveness of education based on Piaget’s theory wasestablished. The remarkable “boost” was seen inalmost every food group for experimental childrenafter their mothers were given nutrition education.It is believed that the parents were easily able to findmost of the foods listed on the food frequency form.Additionally, the nutritional education given toparents as well as children encouraged the familiesto provide their children with a greater variety offoods. It is important for this reason that the educa-tion given to children is long-term and continuous.In short, the data obtained from the present studyconfirms the hypotheses about children’s nutri-tional behavior and that Piaget’s theory can beapplied effectively in nutrition education.

Anthropometric measurements

The difference between body mass indexes of thechildren after the education did not differ signifi-cantly between the experimental and control groups(Table 4). Walsh et al. (2002) stated that no signifi-



cant difference was observed in children’s height-for-age and that the rate of severe underweightdecreased from 45.5% to 23.9%. In the study bySalehi et al. (2004) improvements were seen in chil-dren’s height and weight measurements. In a studyconducted in three daily care centers in Egypt,extreme overweight increased whereas low weightand stunted growth decreased in boys (Ghoneimet al., 2004). In previous studies, increases in bodymass indexes in experimental groups after educationdecreased when compared with the control group(Joosse et al., 2008; Jordan et al., 2008). In somestudies, no difference was observed in anthropomet-ric measurements (Bruening et al., 1999; Hu et al.,2009; Wake et al., 2009; Warren et al., 2003). Addi-tionally, in this study four children moved out of theless than 5th percentile (underweight) to either thenormal weight or to the greater than 85th percen-tile. Health risk at this age is much greater for thosechildren who are underweight than those who areoverweight or obese because these children are atrisk either for severe infectious diseases such aspneumonia, diarrhea, malaria, and measles or defi-ciencies of micronutrients-zinc deficiency, andvitamin A deficiency (Caulfield, Onis, Blössner, &Black, 2004). In the present study, no significant dif-ference was observed between study and controlgroups in terms of MUAC measurements after theeducation (Table 6), whereas in previous studies, apositive change was reported in MUAC (Salehi et al.,2004; Yeudall, Gibson, Kayira, & Umar, 2002).

Children’s growth and development depend ontwo factors: genetics and environment. Nutritionhas a large effect on growth and development.Adequate nutrition positively affects children’sphysical development. On the other hand, the factthat no significant difference was observed betweenthe study and control groups might be attributed toenvironmental factors, the restricted time-frame,and/or what is expected as normal in terms of chil-dren’s growth curves.

Limitations

The limitations of this study may be outlined asfollows: Body mass index findings were assessed bymeans of the percentile table developed by Neyziet al. (2008) for Turkish girls and boys. Since a per-centile table specific to Turkish children could notbe found for MUAC measurements of 5-year-oldchildren, this was assessed by international refer-ence values (McDowell, Fryar, Ogden, & Flegal,2008). In addition, there was an undesirable dropin the sample size due to the fact that some chil-dren withdrew from the study for various reasonssuch as illness, moving, and registering for primaryschools’ preclasses for the next year. Anotherlimitation is that parents may have answered thequestionnaire “appropriately” due to social desir-ability. The lack of information on mother’snutritional knowledge pre- and post-nutritionaleducation and lack of validity and reliability for theinstruments utilized in the study are limitations ofthe study.

LOCF is the technique used in intention-to-treatanalyses. LOCF analysis would be preferred byresearchers through its simplicity and ease of appli-cation. But there are some limitations in utilizingthe LOCF. The method may introduce bias in theresults, according to circumstance or in eitherdirection (Molnar, Hutton, & Fergusson, 2008).LOCF leads to bias in the estimation of the clinicaleffectiveness, but the magnitude and direction ofthe bias can only be surmised (Whittaker et al.,2006).

IMPLICATIONS FOR PRACTICE

In Turkey, the number of children experiencingnutritional problems such as inadequate nutri-tion and obesity—the problems of developingcountries—is increasing. In addition, it is knownthat many nutrition education programs conducted

Table 6. Experimental and Control Group’s

Mid-Upper Arm Circumference Percentiles

After Educationa (n = 115)

Gender Group

Mid-upper arm circumference

� 10 > 10 to < 85 � 85

Totaln % n % n %


p = .676Control 2 8.7 19 82.6 2 8.7 23 100.0

Total 4 6.3 51 81.0 8 12.7 63 100.0

Boy Experimental 3 11.1 22 81.5 2 7.4 27 100.0 x2 = 1.687

p = .430Control 1 4.0 20 80.0 4 16.0 25 100.0

Total 4 7.7 42 80.8 6 11.5 52 100.0

a1-year measurement.



in nursing and other disciplines may produce a posi-tive effect on children. There are numerous pro-grams of nutrition education for preschool children.There are few studies, however, carried out usingPiaget’s cognitive development theory. In this study,the game-based educational and visual assessmenttools applied to children facilitated comprehension,helped their construction of schemas, and enabledthe transfer of the learned items to long-termmemory. The use of the schema, assimilation, andadaptation concepts equipped the children with ahigher-level cognitive experience and enabled themto use their cognitive skills. Thus, children’s knowl-edge and nutrition preferences changed positivelyon the basis of the newly acquired schemas. Thetheory provided guidance in the preparation of atheory-based education specific to children’s agegroups.

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How Do I Apply This Evidence to Nursing Practice?

Based on this research, we recommend that:

• Educational programs that enhance children’sknowledge, skills, and experiences, that facili-tate the development of a concept of food andnutrition, and that are developmentally sound,activity-based, creative, and concrete should beplanned for preschool-age children.

• Nurses working in primary-, secondary-, andtertiary-level health services should delivernutrition education based on Piaget’s theory.

• Parents, who play an important role in chil-dren’s nutrition, should be provided educationas well.

• Researchers should conduct studies for the dif-ferent age groups suggested by Piaget andcompare Piaget’s theory with others. It is essen-tial that these be long-term cohort studies,which should become more widespread in thecountry with support from the government.

• In order to accelerate this process and make itmore enduring, it is recommended that nurseryschool teachers be trained as educators.



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