Telenutrition health education program to increase nutritional awareness, attitude, and dietary diversity among secondary high school adolescent girls in rural area of Bangladesh: A quasi-experimental study protocol

Abstract

BACKGROUND:

Telenutrition, using telehealth technologies for remote nutritional care, has proven effective in primary care. Nutritional deficiencies constitute a global health burden, characterized by chronic undernutrition and micronutrient deficiencies, especially in adolescent girls in impoverished nations such as Bangladesh. Telenutrition, which uses digital technologies to provide remote nutritional treatment, is a promising strategy to decrease this burden. This study aims to determine the impact of telenutrition education on improving nutritional awareness, attitude, and dietary diversity among school going adolescent girls in rural Bangladesh.

MATERIALS AND METHODS:

A school-based quasi-experimental study was conducted among 190 adolescent girls (95 intervention, 95 control) from two higher secondary schools in Sakhipur, Bangladesh. Schools were allocated into intervention and control groups using a coin toss method to reduce selection bias and to mitigate the risk of contamination of health education information among students within the same school. Interviewers used structured questionnaires to gather baseline data on socio-demographic traits, nutrition-related knowledge, attitudes, and practices, dietary diversity, food hygiene, sanitation, and menstrual hygiene. The intervention group received six months of nutrition-focused education, covered video sessions, text messages, and follow-up phone calls, while the control group received no intervention. The primary outcome of this study is changes in nutritional awareness, attitudes, and practice scores among adolescents. Additionally, secondary outcomes include improvements in dietary diversity and changes in BMI, hip-waist circumference, and MUAC that will be compared across groups over time. The effects of the intervention will be evaluated over time using mixed-effects models in STATA 18.5.

RESULTS:

Data analysis will commence after implementation collection, with findings prepared for publication.

CONCLUSION:

Telenutrition education is expected to effectively enhance knowledge and promote healthy behaviors among adolescent girls. Digital health programs, policy-driven approaches, and school-based nutrition education are essential for improving nutritional awareness.

Introduction

Adolescence describes the age span of 10 to 19 years old, and it is a time of intense development and growth that starts during puberty and lasts through the initial stages of adulthood. Moreover, it is often referred to as the second decade of life, a crucial time of human growth, and an ideal period to lay the foundation for a successful and healthy adult life.[1] During this time, approximately 20% of adult height, 45% of bone mass growth, and 50% of adult weight are reached, and several of these transitions happen throughout early adolescence.[2] Globally, the population has grown by more than three times to 8.0 billion, with 1.3 billion adolescents.[3] Adolescents in underdeveloped nations continue to experience a high burden of nutritional deficiencies, which remain a major public health concern. Approximately 90% of adolescents reside in low- and middle-income countries, where anemia, malnutrition, undernutrition, and multiple micronutrient deficiencies constitute a significant health burden linked to socioeconomic challenges.[4] These nutritional challenges are often attributed to prolonged dietary inadequacies, limited access to healthcare, and broader socioeconomic inequalities. Adolescent girls are particularly vulnerable due to increased physiological demands during puberty, the onset of menstruation, and gender-based disparities that may limit their access to adequate nutrition. These factors collectively compromise long-term health outcomes, cognitive development, and physical growth, highlighting the necessity for targeted interventions during this critical developmental period.

According to the Bangladesh Demographic and Health Survey (BDHS), 31% of adolescent girls aged 15 to 19 years have a body mass index (BMI) of less than 18.5, which indicates them as undernourished. In Bangladesh, adolescent girls face a struggle to ensure proper nutrition due to multiple factors. Sedentary lifestyles, poor eating habits, diseases, a lack of food security, inadequate access to healthcare, and insufficient water, sanitation, and hygiene facilities are the primary causes of undernutrition.[5,6] Prior research indicates that newborns delivered to adolescent mothers are more likely to suffer from undernutrition, which can manifest as stunting, wasting, and underweight.[7] According to multiple studies, underweight mothers may experience reduced fertility and an increased risk of pregnancy complications like low birth weight, small for gestational age, preterm birth, and neonatal death.[8,9] To improve adolescent girls’ health, it is crucial to address their nutritional status by breaking the cycle of undernutrition and ensuring the well-being of mothers and their future generations.

Adolescent malnutrition is mostly caused by poor dietary diversity and nutrient deficiencies, as evidenced by data gathered from several nations.[10,11,12] Consuming a variety of foods increases the nutritional content of the diet and offers a broad range of macro and micronutrients.[13] On the other hand, monotonous diets consisting of starchy foods are lacking in essential nutrients and contribute to the prevalence of malnutrition.[10,14] In Bangladesh, the dietary diversity score (DDS) is particularly limited among adolescents and women. Rangpur district had the greatest percentage (72%) of inadequacy in diversified foods, including adolescents, and two-thirds (66%) of women ate a diet that was not sufficiently varied.[15] One study reported that adolescent girls are more likely than boys to skip meals, as are students in high school and those who reside in distant and socioeconomically underprivileged locations.[16] In Bangladesh, this scenario is more common; adolescent schoolgirls who ate lunch irregularly had a greater chance of developing anemia.[17]

According to the World Health Organization (WHO), increasing the consumption of diverse foods within households is one of the primary ways to enhance nutrition (WHO, 2006). Food diversity strengthens people’s well-being in several ways. For instance, it grabs the interest of individuals in food, lowers the harmful effects of food on health, permits healthy eating, and eventually decreases the chance of long-term diseases.[18]

Telenutrition is a specialized branch of telehealth that delivers nutritional care, instruction, and counseling remotely, which includes SMS (Short Message Service) and phone calls, and has emerged as a cutting-edge approach to healthcare. In recent years, mobile phones have become the primary device for global communication and information access.[19] Some studies have been carried out in Bangladesh to assess the efficacy of health education programs that use digital devices, such as text messaging and phone calls, to improve knowledge, awareness, and motivation about leading a healthy lifestyle for people with hypertension (HTN) and chronic kidney disease (CKD).[20,21] Telenutrition offers the capacity to improve health outcomes for adolescents, particularly for schoolgirls, as demonstrated by recent advancements in developing countries. A recent study from Indonesia examined the effectiveness of telenutrition interventions for obese adolescents through a comprehensive review protocol. The study reported that mobile app education and online counseling were linked with improved self-monitoring, more physical activity, and better eating habits. These results highlight how internet platforms can encourage adolescents to adopt more sustainable lifestyles.[22] A separate study from Italy suggests that digital health-based treatments targeting pediatric nutrition are beneficial for managing complex nutritional needs. In this study, children with neurological impairments who received dietary counseling remotely experienced fewer hospital visits and improved nutritional status.[23]

However, very limited research has been conducted in Bangladesh on the use of telenutrition through phone calls and SMS messages to increase awareness, promote behavior change, and improve dietary diversity among adolescent girls. This approach delivers information directly to adolescents and indirectly to their parents at home, aiming to achieve long-term benefits. This study aims to assess the impact of telenutrition education on improving nutritional awareness, attitudes, practices, and dietary diversity among school-aged adolescent girls in rural Bangladesh.

Methods and Materials

Study design and setting

This was a quasi-experimental study conducted in two secondary high schools in a rural area of Bangladesh. One school was assigned as the intervention group and the other as the control group. The allocation had been determined by a coin toss to minimize selection bias and reduce the risk of contamination of health education information among students within the same school. The participants were adolescent girls, and the study involved a 6-month telenutrition education intervention. The intervention group received nutrition-focused health education, while the control group received usual care without additional health education [Figure 1].

Figure 1.

Flowchart of the study

Study sites

The study was conducted in Tangail District, which is the largest district of the Dhaka division. It is located in the central region of Bangladesh and is 117 km away from the capital of Dhaka. The total population of the district was approximately 4 million, and its area was 3,414.28 square km² (1,318.26 sq mi), with a literacy rate of about 69.75%.[24] In the rural sub-district of Tangail, mobile phone accessibility had been high, with 90.3% of households reporting ownership. We selected two secondary schools in the Sakhipur sub-district of the Tangail District. The schools were selected purposively based on rural classification, defined as institutions located outside urban/city boundaries with limited infrastructure, lower population density, and agriculture-based livelihoods, which also ensured convenience for the data collection and easy access for the researcher.

Study participants and sampling

Participants were recruited from Boharatoil Gano High School and Gohailbari Abdul Gani High School in the Tangail district of Bangladesh. In this study, adolescent girls in classes 6–9, aged 10–19 years, participated.

Inclusion Criteria: The study inclusion criteria were as follows:

• Adolescent girls aged 10–19 years studying in the selected schools

• Adolescent girls who were the permanent residents of the Tangail district

• Adolescent girls who had cell phones in their family and whose guardian(s) provided written consent participated in this study.

Exclusion Criteria

• Adolescent girls who were not physically and mentally well

• Adolescent girls who were pregnant

Sample size calculation

We used the G*Power software (version 3.1.9.4) to calculate the sample size.[25] Since there was no prior research on telenutrition education interventions in Bangladesh with an established effect size, a standard medium effect size (Cohen’s d = 0.5) was employed. The sample size was calculated with a significance level (two-tailed) of 0.05 and a power of 90% with a confidence level (CI) of 0.95.[26] The required sample size was 172 participants from both schools. Depending on the socio-demographic context, lost-to-follow-up rate, unavailability, absence, and refusal to give consent for data collection and physical assessments, we considered a 10% proportion of lost-to-follow-up rate. The final sample size was 190, 95 in the intervention group (IG) and 95 in the control group (CG) in this study.

Sampling technique

Initially, one school was assigned as the intervention group and the other as the control group through a coin toss conducted by a statistician who was not involved in the study. Subsequently, the principal investigator, along with Bachelor of Science in Nursing (B.Sc) nurses and Community Health Workers (CHWs) acting as health educators, collected student data from the school register, including names, identification numbers (roll numbers), and classes, following approval from each school’s head teacher. Stratified random sampling was then performed to determine the number of study participants from each school. Participants were divided into four strata based on class level (classes 6 to 9), and a computer-generated random number series in Microsoft Excel was used to select students proportionally from each stratum. This probability-based sampling ensured that larger classes contributed more participants, thereby maintaining fair representation across all class levels.

Study procedure

Using telenutrition technology, the intervention group receives health education including video counselling, phone calls, and SMS texts to increase awareness, change attitudes and behaviors, and enhance dietary diversity [Figure 2]. In the initial phase, health educators obtained written assent from each participant and written consent from their guardians to conduct surveys. They used a researcher-developed pretested questionnaire, which was divided into two sections. The first section focused on socioeconomic data, including age, class, religion, family structure, parents’ education, occupation, and monthly income, as well as the lifestyle, food hygiene, sanitation, and menstrual hygiene knowledge of the adolescent schoolgirls.[17,27] In the second section, to evaluate nutritional awareness, attitude, and practice, the researcher utilized a validated questionnaire developed by the Food and Agriculture Organization (FAO)[28] and other publications.[29,30,31] A validated 24-hour dietary recall questionnaire was collected at baseline, and it will be administered at midline and endpoint,[32] along with anthropometric measurements (height, weight, waist-hip circumference, and MUAC) collected by B.Sc. nurses and CHWs. There were no more dietary recall evaluations scheduled outside of these specified periods of time.

Figure 2.

Study outline and outcome

Telenutrition group counselling session

For the Intervention Group: The intervention group received telenutrition education through a series of six sessions conducted via video presentations in the classroom. These sessions included a combination of video materials, PowerPoint presentations, and group discussions on relevant topics, supplemented by homework assignments. A central feature of the sessions was a dietary chart that represented a variety of foods, based on the Food and Agriculture Organization’s (FAO) guidelines and encompassing sixteen food groups.[33] Each session was delivered at the beginning of the month using portable devices such as laptops and projectors.

Telenutrition Education (Text Messaging and Phone Calls): Telenutrition education was delivered through weekly text messages and phone calls. The messages contained simple health education information to assist in the behavioral change of participants. In addition to receiving weekly updates of useful health education messages, each participant and their guardians engaged in a 5-minute phone call with the health educator. The study activities are outlined in [Table 1].

Table 1.

Activities of the study

Study activities
Schedule		Intervention group		Control group
First month		First week- Arranged a video session on Information about nutrition, balanced diet, undernutrition, its causes, and management. Food types and their general function in the body, and what can arise from the absence of those foods in daily consumption.		Usual care
Second month		First week- A video session explaining the benefits of eating different foods in meals such as cereals, roots and tubers, vitamins, and proteins.		Usual care
Third month		First week- Video session on the benefits of eating fish, meat, vegetables and fruits, milk and milk products, egg, and egg products, fats, and oils daily, their nutritive values and functions on our body.		Usual care
Fourth month		First week- Video session on healthy eating, the importance of homemade foods, such as choosing or preparing foods with low salt and sugar, and reasons for eating minimally processed foods instead of extra-processed foods.		Usual care
Fifth month		First week- Video session on food choices for infants and children, puberty, pregnancy, and lactating mothers. Health benefits for drinking an adequate amount of safe water, sanitation, and menstrual hygiene management, the benefits of regular exercise, and education on the disposal of waste and kitchen garbage, etc.,		Usual care
Sixth month		Explanations on food labelling, food storage, food poisoning, eating disorders in adolescents, the importance of making a budget plan for family food, and a grocery shopping-related video, and discussion will be provided for the first week.		Usual care

Participants received a weekly phone call and text SMS (once a week) reminder for follow-up during the second, third, and fourth weeks of each month throughout the duration of the intervention.

For the Control Group: The control group monitored throughout the study period without receiving telenutrition education and received usual care.

The Primary Endpoint: Effectiveness of telenutrition education to increase nutritional awareness, attitudes, practices, and dietary diversity among adolescent schoolgirls in rural areas of Bangladesh.

Primary outcome measures: A self-administered questionnaire was developed based on participants’ understanding of nutrition and diet. (1) Nutritional awareness covered 36 items according to FAO guidelines. The questions were multiple-choice, with a list of answers to complete once participants had submitted their responses. There was only one correct response for single-answer questions, marked either “Yes” or “No.” Additionally, there were multiple correct responses for some questions, where the options were coded as “Yes” (if the respondent provided one, some, or all the correct answers) and “No” (if the respondent provided none of the correct answers). Therefore, the “number of correct responses” indicated how many right answers were given. Every correct response (Yes) received one (1) point, while every incorrect response (No) or “Don’t know” received zero (0) points. The total score for awareness was 36. Scores ≥50% (18–28) were classified as high awareness, while scores <50% (<18) were classified as low awareness.[28] (2) For the nutritional attitudes section, there were 20 items with five response categories ranging from 1 (Strongly Disagree) to 5 (Strongly Agree). (3) For the nutritional practices section, there were seven items with five response categories ranging from 1 (Never) to 5 (Very Frequently), and participants provided feedback on their everyday practices. To represent both attitudes and practice statements, mean scores were categorized into two groups. Scores above the mean on the corresponding scales represented higher or positive attitudes and practices toward leading a healthy life, while scores below the mean represented lower or negative attitudes and practices.[28]

The Secondary Endpoint: This study has two different secondary endpoints, which are as follows:

1. Improvements in the personal level of dietary diversity among adolescent schoolgirls, and

2. Changes in body mass index (BMI), hip-waist circumference, and mid-upper arm circumference (MUAC).

Secondary Outcomes Measure: (1) Dietary Diversity (DD) data will be collected using the Food Frequency Questionnaire (FFQ). FFQ has been developed based on 16 questions, which were recommended by FAO.[33,34] Participants will be asked to remember everything they have eaten and drunk during the last 24 hours, both inside and outside the house. First, the numbers 0–16 will be added to get the total number of food categories. Subsequently, the DD will be separated into three groups: ranging from the highest, minimum, and lowest range, which refer to intake of ≥6 food groups, 4–5 food groups, and ≤3 food groups, respectively.

(2) Furthermore, the secondary outcome of this study will assess the changes in BMI of adolescent schoolgirls. The WHO formula was used to determine the BMI: BMI = weight (kg)/height² (m)². By comparing the z-scores to the 2007 WHO growth reference tables for children aged 5–19, the nutritional status and BMI-for-age of the children were determined.[35] The cut-off values for severe thinness and thinness were <- 3SD and <- 2SD, while the cut-off values for overweight and obesity were > +1 SD and > +2SD, respectively.

Definitions

Malnutrition: Malnutrition is defined as insufficiencies, excesses, or imbalances in a person’s energy and/or nutrient consumption.[29]

Undernutrition: The definition of undernutrition in adolescent girls was a MUAC of <18.5 cm for those aged 10–14 and ≤22 cm for those aged 15–19.[27]

Underweight: The WHO defines underweight for adolescent girls as having a body mass index (BMI) Z-score of less than -2SD.[35]

Dietary Diversity: The quantity of various foods or food groups ingested within a certain time is known as dietary diversity.[36]

Telenutrition Education: Delivering nutritional information and improving food quality through phone calls, video conferences, educational videos, and text messages using digital devices and virtual techniques is known as telenutrition education.[37]

Usual Care: It refers to the standard health services and routine school curriculum provided to students without any supplementary health education intervention from the research team. The control group schools maintain their regular school activities and any health-related programs, as organized by the school or local health authorities. All students enrolled in the control group receive this usual care, which serves as the comparison condition against the intervention group.[38]

Statistical analysis

The data will be analyzed using STATA statistical software, version 18.5 (released in 2024). Initially, data will be entered into Microsoft Excel 2019 (Microsoft Corporation, Redmond, Washington) and then transferred to STATA for analysis. WHO Anthro Plus version 10.4 will be used to convert anthropometric data, such as height and weight, into BMI-for-age z-scores (BMIZ). The normality of continuous variables, including nutritional awareness, attitudes, and practice scores, will be assessed using the Shapiro–Wilk test. Descriptive statistics will be presented as mean, standard deviation, and percentage. Baseline categorical variables will be compared using the Chi-square test. Comparisons between the intervention and control groups will be conducted using either an independent t-test or the Mann–Whitney test, depending on the normality test results. Paired t-tests will be used to compare continuous variables within groups between pre-test and post-test measurements. To assess the effects of health education while adjusting for relevant covariates, a mixed-effects model will be applied. A significance level of P < 0.05 and a 95% confidence interval will be used for all statistical analyses. Within groups at pre-test and post-test, independent t-tests will be used to find significant differences in pre-test and post-test scores between the intervention group and the control group.

Discussion

There are very few studies in Bangladesh to demonstrate that nutrition education intervention is a significant way to reduce the nutritional gap. Consequently, the utilization of tele-technology may serve as an efficacious approach to mitigating the nutritional knowledge gap among adolescent schoolgirls in Bangladesh. The study emphasizes how telenutrition might be used to fill in the gaps in adolescent schoolgirls’ understanding of nutrition in Bangladesh. Research across the globe shows that, particularly in rural areas that are underserved, mobile-based education interventions can greatly improve dietary behavior, knowledge, and cultural relevance.[39,40,41]

Limitation

One limitation of this study is that the 24-hour dietary recall captured only the types of foods consumed, without recording portion sizes or quantitative intake data. However, information on dietary supplement use was not collected. These gaps may limit the ability to fully assess nutrient adequacy and overall dietary intake patterns. Also, the short intervention time, financial constraints, and the study’s quasi-experimental design are important limitations. In addition, the rural environment limits the generalizability of the findings, as adolescents in urban or semi-urban settings may have different socioeconomic conditions, dietary diversity, and access to health and nutrition services. These elements might have an impact on the findings’ accuracy and wider application with regard to the nutrition of adolescent girls.

Conclusion

Telenutrition is a promising and easily accessible strategy to enhance nutritional care at every stage of life. Through inclusive, focused education, its incorporation into primary healthcare could improve health outcomes across the country. The study findings will be evidence-based information for the public health experts, stakeholders, and policymakers in order to execute such interventions in governmental and primary settings.

Ethical consideration

We obtained ethical clearance from the Institutional Review Board/Ethics Review Committee of the Department of Public Health at Northern University

Bangladesh (NUB) to conduct this study, following the Declaration of Helsinki.[42] The study is approved under the number NUB/DPH/EC/2024/30.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.