Adolescents form a socially important segment of the population. Apart from physical health, a positive social health constitutes a holistic health of the adolescents. The World Health Organization (WHO) defines adolescents as those people between 10 and 19 years of age.(1) Worldwide more than 1.2 billion population consists of adolescents which indicate that one out of every six people is an adolescent.(2) In context to India, roughly 21% of population is adolescents i.e. 243 million and every 5th person is between 10 to 19 years. They are the country's future, constituting a significant demographic and economic power.(3) As per WHO, the definition of health is not restricted to merely absence of a disease but is a state of complete physical, mental and social well-being.(4) Adolescent health is dynamic, involving social, demographic, and environmental influences. According to a recent national study, adolescents are generally affected by both under and over-nutrition, prevalent mental illnesses, drug use, and abuse.(5) They are the most vulnerable and heterogeneous group and it is necessary that the adolescents should be made aware of the benefits of being healthy, impact of keeping the environment clean, risk factors associated with lifestyle diseases and importance of mental health as well.(6)
The 2030 Agenda for Sustainable Development and the Global Strategy for Women's, Children's, and Adolescent Health provide the formerly opportunity to take immediate action on adolescent health.(7) Adolescents may have less interaction with the health care system and lower health care costs, but they are increasingly involved with their health care.(8) They are frequent users of mass media and other technology to access health information and are a target group for many health related education interventions.(9-11) They are also at a critical stage of development, learning skills they will carry with them into adulthood.(12) Teaching skills, new health attitudes, it is believed that early educational intervention will help strengthen one's ability to interpret health knowledge and enhance experiences with health care services, resulting in positive health outcomes.(13)
Health advocacy engaging ambassadors or renowned public figures may have superlative effect. Considering this, Indian Council of Medical Research, New Delhi in collaboration with Directorate of Education, Govt. of Delhi & National Gandhi Museum, New Delhi developed and rolled out Mission SHAKTTI (School based Health Awareness, Knowledge Test and Training Initiative) programme in Delhi region with an objective of re-introducing Gandhi as health ambassador as a part of the celebration of 150th birth anniversary of Mahatma Gandhi under the theme “Gandhi & Health @150”. Mahatma Gandhi led a disciplined life and gave ample importance to health and following healthy ways of life. His idea of health majorly revolved around four pillars: cleanliness, physical fitness, diet & mental health. School children read regularly about Mahatma Gandhi and his virtues during curricular & extra-curricular activities. During this programme, a pre-assessment activity was performed to identify the gaps in school children’ understanding about the concept of Gandhi & Health and devise ways to address those gaps. This paper brings out the findings of the pre-assessment activity during which the health literacy and knowledge about various domains of health was assessed and explored among adolescent in context of Gandhian philosophy of health.
Materials and Methods
The present study was a part of Mission SHAKTTI program launched by ICMR, to commemorate 150th birth anniversary of Mahatma Gandhi, in collaboration with National Gandhi Museum, Delhi and Directorate of Education, Govt. of NCT of Delhi. It was formative-qualitative study using grounded approach to understand health literacy including knowledge and perception about health related issues among school going children of Delhi.(14-15) It was done following the Gandhian philosophy of health. Gandhiji always stressed on a healthy living with self restrain and self reliance, physical activity for physical wellbeing and maun-vrat (silence fasting) for mental wellbeing. Keeping that on priority, knowledge based interactive session was held in continuation of a qualitative open ended questionnaire. A total of 36 schools from Govt. of NCT of Delhi were selected for the study. The selection of the schools was done considering the demographic, socio-economic aspects; distance and nature of school i.e. Govt. funded, Govt. aided and Private school.
Before initiating the programme, several meetings were held with the higher authority of Directorate of Education, Govt. of NCT of Delhi and School Principals/Head of School. Aim and objective of the programme were discussed and a final consensus decision was made and schedule of programme with date and time was shared with each participated school. An informed consent was taken from Principal/ Head of School before collecting the data.
Study Design and Setting
Participants were selected by purposive sampling from different zone/area of city. In purposive sampling, researchers choose study sites or informants to represent the range of variation on those characteristics that seem to be meaningful for the topic under study. A total 12 zones were identified, those were North, North-East, North-West-A, North-West-B, West-A, West-B, South, South-East, South-West-A, South West-B, Central/New Delhi, and East (Figure 1). Schools were categorized as Govt. funded, Govt. aided and Private in each zone (12*3=36 schools) and contacted with prior information from the authorities. The open ended questionnaire was prepared based on the pre-study informal meeting with subject experts. Initially, the questionnaire guide was prepared in English and translated to Hindi. Bilingual questionnaire were used to collect the data.
Figure 1: Map of Delhi showing the location of schools that participated in Mission SHAKTTI (Source of Map: Maps of India)
The school children of class 8th to 12th std participated in the study which was part of Mission SHAKTTI program. A total number of 1875 students of age between 11 to 19 participated but 79 students couldn’t complete the questionnaire. Therefore, 1796 students completed the questionnaire and data analysis was done on the basis of completed questionnaire (n=1796). These students were called in a lecture hall with sufficient and comfortable seating and detailed instructions were given to them to fill the questionnaire. During the selection of the students, it was ensured that sufficient representation from each class (8th to 12th) can be placed and they knew each other so that ambiguity of the responses can be subsided and care was taken to maintain homogeneity of the group (Figure 2).
Figure 2: Frequency Distribution of Age of Students participated in the study
Data management and analysis
The purpose of the study was explained to the Principal/ Head of School. As they were already aware about the programme, a brief explanation was done. After obtaining their permission, the details of the study were also explained to the students in general and questionnaire was distributed among them. Students were asked to write answers/their perspective on different questions. Filled questionnaire was collected from them. The questionnaire included questions pertaining to the concept of balanced diet, practices that harm ones’ well-being, substance abuse and importance of cleanliness and measures to keep one fit. The questions were kept open-ended deliberately as to allow children to consider their own ideas, thought and perception regarding the study theme. Subsequently, activities of Mission SHAKTTI programme were conducted which included a short animation film, an interaction talk by eminent experts and an exciting quiz. The theme of the activity was healthy diet, healthy habits, and healthy environment through Gandhian philosophy and ideology of health.
All the questionnaires were collected and data cleaning was done to exclude incomplete questionnaires. Standard guidelines of transcription of translation of qualitative data were followed.(16-17) The deductive approach of data coding was adopted. For this, thematic content analysis was done, which includes assigning codes to text in the transcripts. The data was read several times thoroughly and grouped under several heads of pre-decided themes. Under each theme, several codes (issues) were identified and inferences were drawn through thorough reading and discussion among the researchers.
The results are presented under 4 themes, namely Knowledge, Balanced Diet, Physical Exercise/Disease, and Cleanliness. Further, the results are presented under various sub-themes under each main theme (Table-1). The findings of the study are presented herewith under different themes.
|Table 1: Theme-specific findings
- The message of Gandhiji for staying healthy
- Ghutkha chewing is harmful and its causes
- Clean environment, plant trees, prefer vegetarian and eat green veg.
- Causes cancer and other unspecified diseases
- Understand by balanced diet
- Understanding by energy rich food
- Incorporation in one’s balanced diet
- Eating healthy/nutritious food and adequate amount of food
- Merely provide energy to body. Very few expressed that food contains carbohydrates, fats, minerals and vitamins
- Vegetables, fruits, cereals, dairy products
- Physical Exercise/ Disease
- Specific physical exercise recommended to adolescents
- Balanced diet and physical exercise can help to avoid lifestyle diseases
- Yoga, meditation, exercise included jogging and walking
- Most of agreed that balanced diet and physical exercise. Hypertension, obesity, diabetes and depression were major lifestyle diseases.
- Suggestions to keep surrounding clean
- Unhygienic atmosphere and types of diseases
- Using dustbin, stop littering and plant tress
- Dengue, malaria, chikungunya, asthma and diarrhoea
Under this theme, students were asked about the key messaging of Gandhi’s teachings to lead a healthy life (physical exercise, balanced diet, cleanliness/sanitation and mental health) along with abstinence from addictive substances like tobacco and alcohol.
The message of Gandhi Ji for staying healthy
Nearly half of the students (49.5%; CI: 46.72-51.39) stated Gandhi Ji’s counsel to be healthy was to keep the environment clean, and plant more trees. Subsequently, 41.3% (CI: 38.75-43.35) stated that eating green vegetables or following vegetarian diet was Gandhi’s mantra for staying healthy. Total 32.85% (CI: 30.68-35.08) participants expressed that Gandhiji emphasised the significance of physical exercise and meditation to stay healthy. Figure 3 represents the percentage of students who penned down Gandhiji’s message for staying healthy.
Figure 3: Student’s response on Gandhian Virtues of Staying Fit
Effects of consuming Gutka
When enquired about the harmful effects of Gutka, most of the students (71.93%; CI: 69.80-74.01) were in consensus that it can lead to cancer; however they couldn't specify which type of cancer. A total of 25.72% (CI: 23.72-27.81) said Gutka intake can cause asthma, brain damage, diarrhoea, tooth decay, and throat infection, in addition to cancer. A very few of them (12.86 %; CI: 11.35-14.50) echoed that Gutka can lead to addiction.
For adolescents, a healthy rich diet can contribute to overall physiological growth and development. Students were asked about balanced diet, energy rich food and incorporation in balanced diet.
Understanding of balanced diet
An attempt was made to check students understanding of the term ‘balanced diet”. Most of students (61.24%; CI: 58.95-63.51) said that consuming healthy, nutritious, or nutrient- rich foods is called ‘balanced diet’. Some students (36.46%; CI: 34.24-38.74) stated that a ‘balanced diet’ is food that maintains the body healthy and is and good for our health. A very few of them believed that merely eating adequate or taking proper amount of food is called balanced diet. The majority had only a smattering of or muddled information regarding balanced diet, which should be addressed through various educational programs.
Understanding of energy rich food
Students were asked to share their notions about energy rich food. Most of the student 64.24% (CI: 61.88-66.36) participants stated that energy rich food merely provides energy to body. A very few of them (13.47%) expressed that food containing carbohydrates, fats, minerals and vitamins are energy rich food.
What would you incorporate in your balanced diet?
Students were asked to formulate the components of balanced diet for them. A sizeable number of students (45.1%; CI: 42.78-47.44) preferred to add vegetables and fruits in their balanced diet. Total 28.6% (CI: 26.54-30.77) of total students opined that they would like to add cereals/pulses and 21.6% (CI: 19.72-23.58) wanted to add dairy products to make balanced diet. Few of them (19.7%; CI: 17.89-21.63) indexed nutritious food as a part of balanced diet. However, they could not specify the items in nutritious food.
Under this thematic assessment, school children were asked about recommended physical activities. The findings are;
Specific physical activity recommended to adolescents
Students were asked to specify physical activity that they would recommend to an adolescent. About half of the participants (52.67%; CI: 50.33-55.00) agreed that yoga may be advised to adolescents as kind of physical activity. Some students (34.18%; CI: 31.99-36.43) stated that running, jogging and walking may be part of adolescents’ physical activity. A few of them (19.37%; CI: 17.57-21.28) suggested outdoor games can be recommended as a physical activity to adolescents. Outdoor games were emphasised by a small number of students, which might be interpreted as more vigorous physical activity, although mostly of students expressed interest towards less participation into physical activity.
Balanced diet and physical exercise can help to avoid lifestyle diseases
The level of awareness regarding whether balanced diet and physical exercise can aid in preventing lifestyle disease was evaluated. The majority of students (69.54%; CI: 67.36-71.67) agreed that balanced diet and physical exercise can help avoid lifestyle related issues. Though, just 1.11% of students think that balanced diet and physical exercise can help avoid lifestyle related issues. A total of 29.32% (CI: 27.24-31.51) of students could not say if a healthy diet and regular exercise would help prevent lifestyle diseases. Figure 4 represents awareness trend about balanced diet and physical exercise help to avoid lifestyle related issues.
Figure 4: Trend of the students’ response on asking whether balanced diet and physical exercise can help to avoid lifestyle diseases.
Suggestions to keep surrounding clean
Gandhiji remarked that cleanliness is second only to godliness and that cleanliness and good health are inextricably linked. He emphasized that the habits cultivated at a young age become a part of one’s personality. In this context, students were asked about ways to keep their surroundings clean, it was found that a large number of them (69.1%; CI: 66.90-71.23) stressed the importance of using dustbin and not littering. Similarly, several students (25.44%; CI: 23.44-27.53) emphasized the need of creating awareness about cleanliness. Few of them (19.5%; CI: 17.25-20.94) highlighted the necessity of planting trees to keep environment clean.
The present study conveyed conscious and cognizance of numerous health-related concerns pertaining to ideology and philosophy of Mahatma Gandhi among schoolchildren of Delhi. Knowledge of a balanced diet, Gandhiji’s health mantra, the importance of physical exercise, and cleanliness in ones’ life were among the primary domains explored via a Gandhian perspective of health. Gandhiji constantly emphasized the importance of health as a real wealth and a cornerstone for long-term, sustainable growth. Gandhiji’s teaching insisted on one having knowledge and acceptance of one’s self and body to lead a healthy life. He suggested different ways to improve health, such as breathing exercise, walking, cleaning nostrils, sleeping under the sky and even hydrotherapy.(18) In present study, adolescents were asked to specify Gandhiji’s view of staying healthy. The majority of the respondents were aware that clean and green environment and adhering vegetarian diet can lead to a healthy lifestyle. However, gap of knowledge about basic principles of Gandhian ideology of health among adolescent’s perception was observed. To the best of our knowledge, there is no such study has been undertaken to date to explore Gandhian health philosophy. Despite writing a book titled ‘Key to Health’, in which he elaborated the many aspects of health, such as the human body, air, water, nutrition, tobacco, and so on, Gandhiji has always been portrayed as a ‘freedom fighter, crusader of non-violence’, rather as a ‘messenger of health’. As a result, this study was a novel concept in terms of exploring the applicability and relevance of Gandhiji’s health ideology, and it’s significance in everyday life.
Obesity is not only an issue for adults; it is also affecting children and adolescents, with data pointing to an increase in childhood and adolescent obesity over the last several decades.(19) According to the latest estimate from the International Obesity Task Force, about 155 million school-age children between 5 and 17 years of age, worldwide are overweight and 30-45 million within that are classified as obese.(20) In India, 2.2% to 25% children population is under category of overweight.(21-22) The knowledge and awareness related to balanced diet or nutrition is very poor in children. According to the current study, schoolchildren are not fully aware of the concept of a balanced diet and define it is as ‘just consuming healthy/ nutritious foods only’. Healthy food may be defined in a variety of ways by individuals and groups. Some of the children indicated that eating an adequate amount of food leads to a healthy diet, which is followed by personal and societal measurements of a sufficient food portion. In his book ‘Key to Health’, Gandhiji emphasized the need of consuming a sufficient amount of food, which is extremely important to the risk factors for non-communicable diseases (NCDs). Lack of knowledge regarding proper diet constituents may also encourage unhealthy eating behaviour. Only 13.47% of the children in this study could name carbohydrate, minerals, and vitamins as dietary components. In addition, cereals/pulses and dairy products were listed as healthy diet items in our study, although only a small fraction of participants used them. Gandhiji valued dairy products and secondary cereals in particular. He felt that healthy diets would strengthen India and Indians, and he ranked cereals (wheat, jowar, rice, bajra, etc.) second among the different dietary categories after milk.(23) In this regard, the view of Gandhiji “As a searcher for truth, I deem it necessary to find the perfect food for a man to keep body, mind and soul in a sound condition… I therefore still seek information and guidance from kindred spirits.” (Young India, 22.8.1929), advises us to have a balanced diet to keep our bodies and minds healthy.(24)
Modern industrialization and globalization have reduced physical activity levels and leading to a sedentary, inactive lifestyle. The physical inactive adult population was found to be 54.4%.(25) Keeping the importance of physical activity as one of major agenda, it was found in study that participants indicated an interest in physical activities, with the majority agreeing that yoga and physical exercise are two activities that adolescents should engage in. Subsequently, average number of students prioritized running, jogging, and walking as the most important forms of physical activity to engage in. Gandhiji was a highly active man who took lengthy marches and early walks on a regular basis. Gandhiji’s teachings inspire everyone to stay active throughout the day. Participants in our study also agreed that a proper balance diet and physical activity may lead to a disease-free life.
“We can no more gain God’s blessing with an unclean body than with an unclean mind. A clean body cannot reside in an unclean city.” – these words expressed by Gandhiji reiterating the importance of cleanliness.(18) He realized that the poor state of sanitation, cleanliness, and lack of proper toilets functioning required immediate attention, and he compared cleanliness to achieving Swaraj.(26) He observed that people are unaware of the benefits of hygienic activities, and as a result, they suffer from a variety of diseases. He felt that people needed to be educated about health and hygiene. Present study also reported importance of keeping surroundings clean, and majority of students stressed the importance of utilizing dustbins and refraining from littering/public spitting. Some of the students also stressed on creating awareness about cleanliness.
Globally, an estimated 24% of the disease burden (healthy life years lost) and an estimated 23% of all deaths (premature mortality) was attributed to environmental factors. Among children 0-14 years of age, the proportion of deaths attributed to the environment was as high as 36%. Diarrhoea has an estimation of 94% of burden diseases which is attributable to environment and also associated with risk factors such as unsafe drinking water, poor sanitation and hygiene.(27) Participants in present study also echoed that cleanliness and sanitation is an integral part of one’s life and that should be given priority.
As a result, the outcomes of this study underline the need of raising public knowledge about many aspects of health. The highlighted areas that were explored were a balanced diet, physical activity, cleanliness, and sanitation, all of which can help one live a disease-free life beginning in youth. Adolescents are foundation stones of any society. Teaching healthy practices and developing a new perspective on health can assist to enhance interactions with health-care systems, resulting in positive health outcomes. Gandhiji always showed a path to manage different issue in one’s life. He was an ardent believer in excellent health and always focused on physical fitness, mental wellbeing, balanced diet and vegetarianism in order to keep himself healthy. These basic principles were to keep him in a sound health despite his numerous social commitments and growing age. Through the glance of Gandhian ideology of health, one can lead a healthy life and avoid the risk factors for different NCD issues, which are more prominent in current modernization. Children from early age can be believed as a pillar of any educational intervention that focuses on a healthy lifestyle including balanced diet, physical activity, and cleanliness etc.
Limitations of the study: Since the data adequately represents the multiple demographic areas of a given state, having students from a single state cannot be universalized. Thus representativeness of the sample also limits the results applicability. The teaching method and school curriculum content does not follow a common pattern which may have an effect on the learning process and recitation of the same.
The study focused to understand the health literacy in school-going children. Based on the information collected on various parameters as relevant to Gandhian ideology and philosophy focuses such as cleanliness, balanced diet, physical fitness, the study indicated that though the school children are aware of Gandhian values of good health to some extent, but there are still gaps and need to educate students properly on various aspects. The information given by the participants appears to show a lack of understanding of health principles such as dietary habits, nutrition, and the development of NCDs. Mahatma Gandhi’s ideology of health was the medium to reinforce and inculcate healthy practices. The lack of factual information/knowledge regarding a healthy diet, physical activity, and proper sanitation has emerged as a variable that needs to be discussed in broad sample studies or multicentric studies. Via Gandhian principles of staying healthy, educational setup and curriculum activity should concentrate on these variables to develop the proper healthy practices including nutrition among children.
Funding statement: This work was supported by intramural fund (grant 7/8/119/2019-RMPPC) of the Indian Council of Medical Research (ICMR), New Delhi, India.
Acknowledgments: We are grateful to Mr. A. Annamalai, Director & Mr. Ansar Ali, Curator National Gandhi Museum and Mrs. Rumi Johri, Assistant Director, Sports (Education), Govt. of Delhi for coordinating and contributing immensely to the project Mission SHAKTTI. We are thankful to Ms Pooja Suri, Mr Vikul Narwal and Mr Manjeet Singh for providing the logistic help for successful completion of the project.
Competing interests: None declared.
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